Grace Manor Care Center

In the surveyor’s words

From the most serious findings on record at Grace Manor Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 19, 2023

  Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of neurocognitive disorder with Lewy bodies (type of progressive dementia that leads to a decline in thinking, reasoning and independent function), was admitted to the facility on [DATE]. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after helping the resident into the sitting position on the edge of bed. […]

• Actual harm, isolatedF550Sep 16, 2021

  Based on interviews and record review, the facility failed to ensure four residents (#5, #18, #28 and #129) of 10 residents had the right to a dignified existence out of 16 sample residents. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely for Resident #5, #18, #28 and #129. The feelings of dehumanization and being treated in an undignified manner were evidenced by the residents' interviews. Resident #5, who was totally dependent on two staff with transfers and toilet use, said, I wet myself frequently. It usually happens in the morning when it is very hard to get some help. I felt very uncomfortable and embarrassed. […]

• No harm, potential for more than minimal, patternF880Apr 21, 2026

  Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units.Specifically, the facility failed to:-Ensure staff followed the correct dwell time when using disinfectant to clean resident rooms and was not sprayed near resident's personal hygiene items; -Ensure housekeeping staff performed hand hygiene appropriately when cleaning resident rooms; and,-Ensure staff changed gloves after moving from dirty to clean task during wound care. Findings include: I. […]

• No harm, potential for more than minimal, patternF761Apr 11, 2024

  Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of two medication carts and one of one medication rooms. Specifically the facility failed to: -Ensure medications were not loose in medication carts; and, -Ensure expired medications were not stored with current medications in the medication storage room. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised November 2020, was received from the director of nursing (DON) on 4/10/24 at 2:40 p.m. […]

• No harm, potential for more than minimal, patternF880Jan 11, 2023

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure hand hygiene was performed during medication administration. Findings include: I. Professional reference Centers for Disease Control and Prevention (CDC). Hand Hygiene in Healthcare Settings: Hand Hygiene Guidance. Reviewed January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html retrieved on 1/24/23. […]