Grace Nursing Home

In the surveyor’s words

From the most serious findings on record at Grace Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 5, 2024

  Based on interviews and record reviews, the facility failed to protect a resident's right to be free from neglect for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for neglect. The facility failed to ensure an effective system was in place for staff to identify whether a resident was out of the facility on pass or missing, which resulted in Resident #1 being left outside overnight without required care. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 08/26/2024 at 5:44 p.m., when Resident #1, a severely cognitively impaired resident who required extensive assistance, self-propelled outside the facility without staff knowledge. From 5:44 p.m. until the next morning at 8:15 a.m., staff assumed the resident was out of the facility on pass with family. […]

• Actual harm, isolatedF600Jun 12, 2025

  Based on observation, interviews and record reviews, the facility failed to ensure each resident had the right to be free from neglect for 1 (#1) of 3 (#1, #2 and #3) sampled residents reviewed for neglect. S3CNA and S4CNA neglected Resident #1 when they failed to verify Resident #1's transfer status prior to transferring Resident #1, who required mechanical lift for transfer. This deficient practice resulted in actual physical harm on 05/13/2025 at approximately 12:30 p.m., when S3CNA and S4CNA transferred Resident #1, who required a mechanical lift, by using a draw sheet without verifying what type of transfer assistance Resident #1 required. Following the transfer, Resident #1 yelled out in pain and an x-ray of the left shoulder was ordered. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2023

  48912 Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly sealed and dated after opening; 2. Presence of expired food intended for use; and 3. Dietary staff wore a beard restraint while preparing food. There were a total of 109 out of 112 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility policy titled, Food Receiving and Storage revealed the following, in part; Policy: Food shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage 1. All foods stored in refrigerator or freezer are covered, labeled, and dated. 7. […]

• No harm, potential for more than minimal, widespreadF867Sep 11, 2023

  Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure: 1. CNA staff documented fall intervention tasks for 3 (#F52, #RF3 and #RF4) of 3 (#F52, #RF3 and #RF4) sampled residents reviewed for falls; and 2. Residents were free of significant medication errors for 1 (#F267) of 3 (#F89, #RF4 and #F267) residents reviewed for medication administration. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF867Sep 11, 2023

  Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure: 1. CNA staff documented fall intervention tasks for 3 (#F52, #RF3 and #RF4) of 3 (#F52, #RF3 and #RF4) sampled residents reviewed for falls; and 2. Residents were free of significant medication errors for 1 (#F267) of 3 (#F89, #RF4 and #F267) residents reviewed for medication administration. Findings: 1. […]