King's Grant Lacy Health Center

In the surveyor’s words

From the most serious findings on record at King's Grant Lacy Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 16, 2026

  Based on observation, staff interviews, and facility document review, the facility staff failed to store, prepare and distribute food in the facility kitchen to prevent foodborne illnesses. The findings included: 1.The facility staff failed to discard out of date perishable food items and failed to label items when removed from the facility freezer. The kitchen contained out of date bread in the active food supply on two observations. The first observation had out of date bread dated 03/13/26 and the second observation had out of date bread of 4/7/26. On 4/14/2026 at 11:56 am, a walk through of the kitchen was conducted with the Dietary Director. Bread was observed placed on four trays in a separate area near the back of the kitchen containing sandwich breads and sandwich rolls. […]

• No harm, potential for more than minimal, isolatedF657Apr 16, 2026

  Based on staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 13 current residents, Resident #6.The findings included: Resident #6's CCP included the focus area full code. The clinical record included a provider order dated 01/17/2026 indicating the resident was a Do Not Resuscitate (DNR). Resident #6's diagnoses included dementia, Alzheimer's disease, and major depressive disorder. Section C (cognitive patterns) of Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/08/26 was coded 1/1/3 to indicate the resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. […]

• No harm, potential for more than minimal, isolatedF883Sep 14, 2023

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine to 2 of 5 sampled residents for immunizations in accordance with nationally recognized standards, Residents #12 and #13. The findings included: 1. For Resident #12, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV20) or a pneumococcal polysaccharide vaccine 23 (PPSV23) following admission to the facility. […]

• No harm, potential for more than minimal, isolatedF578Sep 30, 2021

  Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement policies and procedures relating to DNR (do not resuscitate) status for two (2) of 30 facility residents (Resident #12 and Resident #26). The findings include: The facility staff failed to ensure Resident #12's and Resident #26's code status was correctly marked, outside the residents' room, according to the facility's process. The facility's process is that residents with an active DNR will have a blue dot sticker placed beside the resident's name that is posted on the nameplate sign outside of the resident's room. Resident #26's clinical record included a minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE]. […]