Gracewell, An Eventide Community

In the surveyor’s words

From the most serious findings on record at Gracewell, An Eventide Community, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804Oct 31, 2024

  Based on observation, policy review, resident, and staff interview, the facility failed to prepare food that conserved flavor, appearance, and palatable for a lunch meal. The facility reported a census of 71. Findings include: Interview on 10/28/24 at 11:39 AM, Resident #15 stated the food is often overcooked and burnt at times, especially the meat. Interview on 10/29/24 at 9:33 AM, Resident #45 stated the food is bland, just didn't taste good. They described the meat as tough and unable to cut it. During continuous observation on 10/30/24 starting at 9:25 AM, Staff G, Cook, placed 5 pans of chicken nuggets into the oven to bake. At 9:40 AM they placed a pan of fish fillets into the oven to bake. […]

• No harm, potential for more than minimal, patternF801Sep 21, 2023

  Based on staff interviews the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 73 residents. Findings include: On 9/18/23 at 9:29 AM Staff B, Dietitian, reported that she is at the facility one day a week. Staff B stated the facility did not currently have a Certified Dietary Manager (CDM) at the facility. Staff B stated the Administrator is covering as the kitchen manager at this time and Staff C did the ordering. Staff B stated the Administrator did not have a CDM certificate either. Staff B stated that she and the facility knew of the regulation about the need for a CDM. Staff B said it is not always possible to have a CDM, but the facility is actively taking steps to hire a CDM. […]

• No harm, potential for more than minimal, patternF812Sep 21, 2023

  Based on observation, staff interview, and policy review the facility failed to store and prepare food in accordance with professional standards. The facility reported a census of 73 residents. Findings include: On [DATE] from 9:29 AM through 10:10 AM during a continuous observation during the initial kitchen tour revealed: a. The two door refrigerator had beef base chicken base, and gluten free bread open and undated. b. The dry storage had two packages of hamburger buns best if used by [DATE], one package of white sandwich bread best if used by [DATE], seven packages of white dinner rolls best if used by [DATE], one package of white dinner rolls best if used by [DATE], a large storage container of chocolate candy open and undated, a large storage container of graham cracker crumble open… […]

• No harm, potential for more than minimal, patternF880Sep 21, 2023

  Based on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing adequate hand hygiene when assisting 4 of 8 residents reviewed (Residents #23, #68, #70, and #174). Finding include: 1. Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 5, indicating severe cognitive impairment. On 9/20/23 at 7:20 AM observed Staff E, Registered Nurse (RN), give medications to Resident #23. Staff E completed hand hygiene and placed the blood sugar machine on a clean field. Staff E applied a glove to her right hand but not the left hand. Staff E used her left hand to support Resident #23's left hand index finger. […]

• No harm, potential for more than minimal, patternF584Jul 21, 2022

  Based on observations, facility policy review, clinical record review, resident, and staff interviews the facility failed to maintain a safe environment for 1 of 1 resident reviewed (Resident #44). The facility reported a census of 71 residents. Findings included: Resident #44's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #49 needed assistance of supervision from one staff member walking in her room and moving in her wheelchair. […]