A list of the most recent deficiencies for Grace Village Health Care Facility. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-17 | 2023-06-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Develop a communication plan. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-17 | 2023-06-01 | 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 | 2023-04-17 | 2023-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-17 | 2023-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-31 | 2023-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-31 | 2023-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-31 | 2023-04-26 | 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 | 2023-03-31 | 2023-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-31 | 2023-04-26 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-25 | 2022-03-15 | 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 | 2022-01-25 | 2022-03-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-25 | 2022-03-15 | 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 | 2022-01-25 | 2022-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-25 | 2022-03-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-01-11 | 2022-02-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-11 | 2022-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-11 | 2022-02-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-11 | 2022-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-02-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-11 | 2022-02-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-11 | 2022-02-07 | 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 | 2022-01-11 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-11 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-11 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-14 | 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 | 2019-08-13 | 2019-09-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-13 | 2019-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-13 | 2019-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-13 | 2019-09-25 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-07-12 | 2019-08-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-12 | 2019-08-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-12 | 2019-08-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-12 | 2019-08-09 | 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 | 2019-07-12 | 2019-08-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-12 | 2019-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-12 | 2019-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-09 | N |
