Gracepointe Crossing Gables

In the surveyor’s words

From the most serious findings on record at Gracepointe Crossing Gables, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 8, 2025

  Based on observation, interview, and document review, the facility failed to ensure care-planned interventions for safety with hot beverages were consistently implemented to reduce the risk of accident and injury for 1 of 1 residents (R1) reviewed who required lids on their hot beverages. This resulted in actual harm for R1 who was served a cup of hot tea without a lid and spilled it onto herself causing multiple second-degree burns. However, the facility had taken multiple corrective action(s) prior to the onsite survey so these findings are issued at past non-compliance. Findings include: A United States (US) National Library of Medicine Burn Classification article, dated 9/2023, identified burns happen with the skin is exposed to heat sources such as flames or hot objects. […]

• Actual harm, isolatedF689Jun 24, 2025

  Based on interview and document review, the facility failed to provide safe transfers for 1 of 3 residents (R1) who required gait belts (transfer belt) for transfer and ambulation assistance. This resulted in actual harm when R1 was being ambulated without a gaitbelt, fell, and sustained a fracture of the shoulder. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of heart failure, acute respiratory failure, and muscle weakness. […]

• No harm, potential for more than minimal, patternF880Aug 13, 2026

  Based on observation, interview and document review the facility failed to ensure residents were given an opportunity to wash their hands prior to eating. This had the potential to affect any resident who chose to eat in the main dining room. In addition, the facility failed to follow enhanced barrier precautions (EBP) during transfer and care of 2 of 2 residents (R52, R9). This deficient practice had the potential to impact all residents who resided at the facility. Findings include: EBP: R52's Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact with diagnoses of multiple sclerosis, left hand contracture, and ataxia. […]

• No harm, potential for more than minimal, patternF804Sep 4, 2025

  Based on observation and interview, the facility failed to provide a palatable diet by serving cold food at a temperature over 40 degrees. This had the potential to affect 17 residents who resided in the memory care unit. Findings include:During observation on 9/3/25 at 12:10 p.m., the dietary aid (DA)-A on the first floor kitchenet had started to serve the assisted living facility (ALF). The nursing home residents were scheduled to be served starting at 12:30 p.m. The ALF and nursing home (NH) hot food was in the steam table, and the dessert for the ALF and NH was a fruit salad served in individual bowls on trays on top of the counter. Facility's temperature log indicated the fruit salad's temperature was 38 degrees at 11:50 am. […]

• No harm, potential for more than minimal, patternF880Sep 4, 2025

  Based on observation, interview and document review, the facility failed to ensure glucometers (a device used to monitor blood sugar levels) were appropriately disinfected between uses, for 1 of 4 residents (R85) in the sample who had a blood sugar check by a unit glucose meter. This had the potential to affect all four residents on 2nd Floor North unit who received scheduled blood sugar checks. In addition, the facility failed ensure personal protective equipment (PPE) was worn by staff while assisting 1 of 1 resident (R79) on contact precautions. […]