Grace Home Inc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when:1. Clear measuring cups had cracks in them.2. Two green and one brown colored cutting boards were observed with deep cuts, scratches and scoring. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain professional standards of quality for 10 of 32 sampled residents (4, 5, 8, 11, 13, 14, 15, 23, 24, and 28) when: 1. Resident 15 had a specialty mattress (perimeter mattress or raised perimeter mattress refers to a mattress designed with a raised edge or bolster [a long pillow or cushion] along the sides to prevent falls) on her bed without a physician order or care plan in place. This failure of not having a physician order or implementing a comprehensive care plan for Resident 15 had the potential to place Resident 15's safety at risk and her specific needs not being met. 2. The facility failed to obtain a physician order for a specialty mattress for one of six sampled residents (Resident 4) when a pressure reducing mattress was replaced with a perimeter mattress. [...]

Inspectors wroteBased on observation and interview, the facility failed to have a Registered Nurse (RN) in the facility at least 8 consecutive hours in a day. This failure had the potential to put Residents' safety at risk and their specific needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure storage of medications when: 1. Medication room was propped open and unattended by authorized staff. This failure had the potential to place facility at risk for unauthorized access to medication room and possible drug diversion. 2. Resident 5's Hydrocortisone 2.5% topical cream was beyond the discard date. This failure had the potential for residents to receive expired medications that were no longer effective.

Inspectors wroteBased on observation, interview and record review the facility failed to label stored food and properly clean the kitchen for 31 of 33 Residents (Resident 1, 2, 3, 5, 6, 7, 8, 9, 10, 12, 13, 14,15,16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33) who eat food from the facility when: 1. Pastrami was not labeled with a thaw date after being moved from the freezer to the refrigerator. 2. The quaternary ammonium sanitizer solution used to clean the food preparation surfaces after breakfast tested at 150 ppm (parts per million), below the targeted 200-400 ppm. 3. Staff failed to document the dishwashing machine temperature log, prior to the start of washing, at each meal, to ensure proper sanitation of all dishware and trays. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise a comprehensive care plans for four of 12 residents (Resident 1, 4, 7 and 11) when: 1. Resident 1's Care Plan did not identify oxygen treatment interventions when oxygen was ordered by the physician. 2. Resident 4's mattress was changed to a specialty perimeter mattress and the care plan did not reflect this change. 3. Resident 7 was reassigned to another room after Resident 7's spouse passed away on 9/25/24. 4. Resident 11's care plan did not reflect assessment and interventions to address a change of condition in which Resident 11 was no longer able to ambulate (walk) without assistance. . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pureed turkey recipe for four of 31 sampled residents' (Resident 11, 14, 15, and 20) on a pureed (smooth textured food without lumps that does not require chewing, holds shape on a spoon and is not sticky) diet when water was substituted for turkey or chicken stock. This failure had the potential to decrease the food's flavor and nutritive value (providing and containing the nourishment needed for growth, health, and well-being) for all four residents on a pureed diet, and could have led to decreased intake and unexpected weight loss, which may further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow it's own infection prevention program designed to provide a safe and sanitary environment for three of eleven sampled residents when: 1. Resident 29 and Resident 31's urinals were hanging inside their trash can at bedside. 2. LVN 2 did not perform cleaning of Resident 13's inhaler and bedside table when Resident 13's inhaler was placed on top of bedside table before and after use. These failures had the potential risk in the development and transmission of communicable diseases and infections for Residents 13, 29, and 31.

Inspectors wroteBased on observation and staff interview during the survey period from 3/4/25 through 3/7/25, the facility failed to ensure each bedroom had 80 square feet of usable living space for residents in three of 14 rooms (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]). This failure to provide the residents in rooms 4, 6 and 7 with 80 square feet of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessment was reflective of the resident's status for 1 of 1 sampled residents when Resident 24's diagnosis of hip fracture was not recorded in Minimum Date Set (MDS) Section I. This failure had the potential for Resident 24 not to receive necessary care and services by nursing staff and put Resident 24 at risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 12 residents (Resident 15), when Resident 15 had a specialty mattress (perimeter mattress or raised perimeter mattress refers to a mattress designed with a raised edge or bolster [a long pillow or cushion] along the sides to prevent falls) on her bed without a care plan in place. This failure of not implementing an individualized care plan for Resident 15 had the potential to place Resident 15's safety at risk and her specific needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in the kitchen when there was no air gap (a space provided to prevent unsanitary water from flowing back into the sink) under the three-compartment food preparation sink. This failure placed 32 of 32 residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for nine of 16 sampled residents (Resident 3, 7, 9, 11, 13, 20, 28, 31 and 32) when: 1. Resident 13 and Resident 32's medications were administered late. This failure placed Resident 13 at risk for subtherapeutic effects (level too low to produce the intended medical effect) of the medication and Resident 32 at risk for increased anxiety (feeling of fear, dread and uneasiness). 2. Residents 3, 7, 9, 11, 13, 20, 28, 31 and 32 meal trays were served without a Licensed Nurse (LN) verifying the food served was the diet prescribed by the physician. This failure had the potential for residents to receive an incorrect diet and not meeting their nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for four of eight sampled residents (Resident 6, 7, 11 and 33) when a copy of the Physician Orders for Life-Sustaining Treatment (POLST) forms (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) were incomplete and readily available as part of the residents' medical record. These failures had the potential risk for Residents 6, 7, 11 and 33's end-of-life care decisions to not be followed in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when Licensed Vocational Nurse (LVN) 1 failed to properly disinfect (to clean something in order to destroy bacteria) resident-shared blood pressure (BP) cuffs (a device used to measure blood pressure) prior to and after use on four of eight residents (Resident 11, 32, 20 and 1). This failure placed Residents 11, 32, 20 and 1 at risk for the development and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident for 3 of 14 rooms (rooms [ROOM NUMBER]) when there were two residents in a room that did not meet the square footage requirement. This failure to provide the residents in rooms 4, 6 and 7 with 80 square feet of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of eight sampled residents (Resident 7) when Resident 7's urinary catheter (flexible tube inserted into the bladder to drain urine) bag was not covered and visible to residents and visitors while Resident 7 was in her room. This failure had the potential to violate Resident 7's privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage and labeling of medications for one of one medication cart when a a bubble pack of pantoprazole (a medication to help decrease the amount of acid in the stomach) 40 mg (milligrams - unit of measure), with an expiration date of 5/31/23, was found in the medication cart. This failure had the potential to allow use of an expired medication which could compromise the health of the facility residents.