A list of the most recent deficiencies for Grace Brethren Village. 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 and implement an infection prevention and control program. | Health | 2023-12-07 | 2023-12-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-01 | 2023-08-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-01 | 2023-08-28 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-03-31 | 2022-05-06 | 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 | 2022-03-31 | 2022-05-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-31 | 2022-05-06 | 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 | 2022-03-31 | 2022-05-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-31 | 2022-05-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-03-31 | 2022-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-31 | 2022-05-06 | 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 | 2022-03-31 | 2022-05-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-31 | 2022-05-06 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-30 | 2022-05-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-07 | 2021-10-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-27 | 2020-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-27 | 2020-04-15 | 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 | 2020-02-27 | 2020-04-15 | 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 | 2020-02-27 | 2020-04-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-27 | 2020-04-15 | 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 | 2020-02-27 | 2020-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-27 | 2020-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-27 | 2020-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-27 | 2020-04-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-25 | 2020-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-04-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-25 | 2020-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-04-15 | N |
