Gracelen Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jan 19, 2023

  1. Based on observation, interview, and record review it was determined the facility failed to implement infection control measures for a resident with exposed blood and bloodborne pathogens including Viral Hepatitis C for 1 of 1 sampled resident (#52) reviewed for infection control. This failure resulted in an immediate jeopardy situation. Resident 52 walked throughout the facility with an open bleeding head wound, touched various surfaces in common areas and held a bloodstained blanket with bloodstained hands. This placed all residents and staff at risk to contract Viral Hepatitis C, a life-threatening virus. […]

• Actual harm, patternF867Jan 19, 2023

  Based on interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of dignity, quality of care, accidents, nursing services, staffing and infection control. This placed residents at risk for adverse consequences, injury and contracting infectious diseases and resulted in a hip fracture for Resident 41 and a worsening wound for Resident 27. Findings include: The facility's 8/15/22 Quality Assurance and Performance Improvement (QAPI) Plan identified the following goal for improvement: -To improve and maintain survey compliance for the rest of 2022 and on-going. The facility's 1/19/2023 survey identified the following: 1. […]

• Actual harm, isolatedF689Aug 28, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure equipment was properly secure to prevent falls for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in Resident 1 experiencing an avoidable fall, resulting with a fractured hip which required surgery. The facility identified the failed practice; an avoidable accident related to improper use of a shower gurney (a specialized piece of equipment designed to bathe individuals who are unable to sit upright during a shower). The facility removed the device from use until staff were trained, and competency was demonstrated. Corrective actions were completed on 1/17/25. This failed practice was identified as past noncompliance. […]

• Actual harm, isolatedF580Sep 21, 2023

  Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant change in condition and head injury for 2 of 3 sampled residents (#s 1 and 3) reviewed for change in condition. This resulted in delayed treatment for Resident 3's significant change in condition and placed residents at risk for unmet needs and delayed treatment. Findings include: 1. Resident 3 was admitted to the facility in 2021 with diagnoses including dementia and partial paralysis. Resident 3's Progress Notes revealed the following: - On 5/23/23: Witness 4 (Physician) assessed Resident 3 related to the resident's family report of pain during a bowel movement. […]

• Actual harm, isolatedF604Sep 21, 2023

  Based on interview and record reviewed it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#6) reviewed for use of physical restraints. This failure resulted in Resident 6 displaying signs of emotional distress and verbalizing feelings of having been raped. Findings include: The facility's Physical Restraint policy and procedure last updated 6/22/23, indicated the following: -Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. […]