A list of the most recent deficiencies for A Grace Sub Acute and Skilled Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-28 | 2024-01-29 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-30 | 2023-07-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-12 | 2022-06-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-18 | 2022-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-13 | 2022-06-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-13 | 2022-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-13 | 2022-05-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-13 | 2022-05-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-05-13 | 2022-05-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-13 | 2022-05-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-13 | 2022-05-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-13 | 2022-05-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-13 | 2022-05-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-13 | 2022-05-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-13 | 2022-05-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-13 | 2022-05-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-13 | 2022-05-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-13 | 2022-05-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-13 | 2022-05-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-10 | 2022-03-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-10 | 2022-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-17 | 2021-04-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-03-17 | 2021-04-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Establish methods for sharing information. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-14 | 2019-08-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-06-07 | 2019-06-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-07 | 2019-06-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-07 | 2019-06-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-07 | 2019-06-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-07 | 2019-06-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-07 | 2019-06-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-07 | 2019-06-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-07 | 2019-06-26 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-06-07 | 2019-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-07 | 2019-06-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-28 | 2018-07-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-04 | 2018-06-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-05-04 | 2018-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-04 | 2018-06-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-05-04 | 2018-06-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-05-04 | 2018-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-04 | 2018-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-04 | 2018-06-15 | N |
