Grace Village Health Care Facility

In the surveyor’s words

From the most serious findings on record at Grace Village Health Care Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 24, 2024

  Based on observation, interview and record review, the facility failed to ensure foods were stored appropriately and not expired and failed to ensure dishes and equipment was clean and in good working condition in 1 of 1 kitchens and 1 of 1 kitchenette observed. This deficient practice had the potential to affect 46 of 46 residents who receive meals from the kitchen and/or were served from the kitchenette. Findings include: 1. During an observation of the kitchen on [DATE] at 9:50 A.M., with the Dietary Manager, the following was observed: in the refrigerator: 3 containers of drinks with a used by date of [DATE]. 2. […]

• No harm, potential for more than minimal, patternF677Mar 31, 2023

  Based on record review, observation and interview, the facility failed to ensure nail care was provided and ensure residents who required staff assistance for toileting were toileted timely to prevent further incontinence for 4 of 20 residents reviewed for ADL (Activities of Daily Living) care. (Resident 19,12, 24 and 29) Finding includes: 1.During a meal observation, on 3/23/2023 at 11:45 A.M., Resident 19 was observed using her fingers to feed herself. During an observation, on 3/23/2023 at 1:53 P.M., Resident 19 was observed with a dark substance under her finger nails. During an observation, on 3/27/2023 at 11:56 A.M., Resident 19 was observed with a dark substance underneath her fingernails. […]

• No harm, potential for more than minimal, patternF656Jan 11, 2022

  Based on observation, interview, and record review, the facility failed to develop and implement a personalized care plan for 4 of 16 residents whose care plans were reviewed. (Residents 7, 28, 11, and 34) Findings include: 1. During an interview on 1/5/2022 at 9:09 A.M., Resident 7 indicated he had an area on his left upper thigh which had a skin discoloration. He had spilled hot coffee on himself and had a blister. A continuous positive airway pressure ([CONDITION(S)]) machine was also observed sitting on his nightstand. He indicated he used it when he sleeps. A clinical record review was completed on 1/6/2022 at 2:19 P.M. […]

• No harm, potential for more than minimal, patternF812Jan 11, 2022

  Based on observation, interview and record review, the facility failed to ensure items in the freezer were dated/labeled and resealed after opening to prevent freezer burn and failed to ensure cooking utensils were clean and serving scoops were free of standing water for 1 of 1 kitchens observed. (Main Kitchen) This deficient practice had the potential to affect the 42 residents who received meals from the kitchen. Finding includes: During an observation of the kitchen on 1/4/2022 between 9:30 A.M. […]

• No harm, potential for more than minimal, patternF880Jan 11, 2022

  Based on observation, interview and record review, the facility failed to ensure infection control measures were implemented related to medication administration without hand hygiene and proper glove use for 1 of 2 staff observed during medication administration for 4 of 6 residents. (RN 10 and Residents 299, 16, 13 and 22) Findings include: 1. During an observation of medication administration, conducted on 1/05/2022 between 11:25 A.M. - 12:00 P.M., RN 10 was noted to administer scheduled eye drop medication to Resident 16 without washing her hands and donning gloves. 2. […]