A list of the most recent deficiencies for Gracelen Care Center. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-21 | 2023-11-10 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-21 | 2023-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-11-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-21 | 2023-11-10 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-09-21 | 2023-11-10 | Y |
| 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 | 2023-01-19 | 2023-03-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-19 | 2023-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-19 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-19 | 2023-03-10 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-19 | 2023-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-19 | 2023-03-10 | 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 | 2023-01-19 | 2023-03-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-19 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-19 | 2023-03-10 | 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 | 2023-01-19 | 2023-03-10 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-19 | 2023-03-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-19 | 2023-03-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-19 | 2023-03-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-19 | 2023-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-19 | 2023-03-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-19 | 2023-03-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-19 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-19 | 2023-03-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-19 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-03-10 | Y |
| 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 | 2023-01-10 | 2023-03-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-10 | 2023-03-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-25 | 2022-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-08-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-19 | 2022-07-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-19 | 2022-07-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-19 | 2022-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-19 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-19 | 2022-07-08 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-19 | 2022-07-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-21 | 2022-03-12 | 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 | 2022-01-21 | 2022-03-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-21 | 2022-03-12 | 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 | 2022-01-21 | 2022-03-12 | 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 | 2022-01-21 | 2022-03-12 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-21 | 2022-03-12 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-21 | 2022-03-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-21 | 2022-03-12 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-21 | 2022-03-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-21 | 2022-03-12 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-01-11 | 2022-03-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-12 | 2021-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-30 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-12 | 2021-08-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-13 | 2021-06-01 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-04-13 | 2021-06-01 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2021-04-13 | 2021-06-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-13 | 2021-06-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-13 | 2021-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-13 | 2021-06-01 | Y |
| 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 | 2021-04-13 | 2021-06-01 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Develop a communication plan. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-05 | 2018-08-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-05 | 2018-07-17 | N |
