A list of the most recent deficiencies for Gracewell, An Eventide Community. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-10-21 | 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 | 2023-09-21 | 2023-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-10-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-21 | 2023-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-21 | 2023-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-21 | 2023-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-21 | 2023-09-27 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-09-21 | 2023-09-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-21 | 2022-08-21 | 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 | 2022-07-21 | 2022-08-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-21 | 2022-08-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-21 | 2022-08-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-21 | 2022-08-21 | 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 | 2022-07-21 | 2022-08-21 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-22 | 2022-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-22 | 2022-07-25 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-22 | 2022-07-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-22 | 2022-07-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-22 | 2022-07-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-23 | 2021-09-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-23 | 2021-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-23 | 2021-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-23 | 2021-09-23 | 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 | 2021-08-23 | 2021-09-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-23 | 2021-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-23 | 2021-09-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-24 | 2021-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-24 | 2021-08-31 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-24 | 2021-08-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-24 | 2021-08-24 | N |
