Inspection Reports for
Grace Assisted Living – Fairview Lakes

.217.04 Resident's Appeal of Involuntary Discharge: the facility did not provide written notices of discharge when Residents #2, #3, and #4 were discharged on 3/8/24 and 2/11/24 (previously cited not indicated).

.310.01.c. Medication Distribution: the facility did not maintain the medication refrigerator containing insulin within the required temperature range; temperatures were out of range 14 times in March 2023 and as low as 30 degrees F, with specific readings of 37, 50, and 52.5 degrees recorded on survey dates.

.630. Training requirements for facilities admitting residents with a diagnosis of dementia, mental illness, developmental disability, or traumatic brain injury: six of ten staff personnel records reviewed lacked evidence of specialized training to care for these residents, confirmed by the Memory Care House Manager.

.405.03 Telephone: facility had an unsecured oxygen cylinder in the Med. Room off of the nurses station sitting on the floor just inside the door (NFPA 99, 11.6.2.3).

.405.02.c Prohibited Applications: relocatable power taps were used to power a small refrigerator in the Administrator's office and two washing machines in the laundry room, which are prohibited applications.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility had non-operational emergency lighting in corridors and lacked documentation for testing/inspecting three alcohol-based hand rub dispensers each time they are refilled (NFPA 101, 7.9.3.1.1 and 8.7.3.3).

.250.10.b Heating, Ventilation, and Air-Conditioning (HVAC): facility had double-sided fireplaces in the front lobby/dining room and TV room without safety barriers.

.152.03.a.ii. Policies of Acceptable Admissions: the facility did not arrange for services when they required Resident #1’s family to provide a one to one sitter to provide supervision after the resident displayed suicide ideation, and also required Resident #27’s family to provide a one to one sitter after the resident experienced a high number of falls.

.152.03.a.iii. Policies of Acceptable Admissions: the facility did not provide personnel, appropriate in numbers and with appropriate knowledge and skills to provide services, including lack of staff awareness of Resident #1’s behavior plans and insufficient staff to meet the needs of residents who sustained multiple falls and required care.

.154.02. Response of Staff to Emergencies: the facility did not ensure staff knew how to evacuate Resident #20 in case of an emergency, lacked sufficient staff to transfer the resident safely, and did not have the resident’s wheelchair available or know where to obtain one.

.154.04.a. Provided Care and Services by Staff: staff were not adequately trained to perform peri-care for uncircumcised males, including Residents #19 and #26, resulting in redness, rash, and buildup of cream in the peri area.

.215.08.b. Investigation within Thirty Days: the administrator did not complete thorough investigations for incidents and accidents, including multiple falls and possible neglect, often recapping caregiver documentation without further inquiry.

.215.08.f. Notification to Licensing Agency within One Business Day: the facility did not notify the Licensing Agency of reportable incidents such as falls resulting in hospitalization or emergency room visits for Residents #2 and #24.

.215.08.g. Identify and Monitor Patterns: the administrator did not implement effective interventions to prevent recurrent falls for residents with patterns of falling, including Residents #27, #7, #19, #4, and #24.

.300.02. Licensed Nurse: the facility nurse did not complete change of condition assessments for residents after falls or significant health changes, including Residents #4, #6, #9, #24, and #25.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure all medication orders were followed, including Resident #6 not receiving morphine as ordered and Resident #23 not receiving oxygen as ordered.

.320.01. Use of NSA: the facility did not ensure residents’ Negotiated Service Agreements provided accurate and updated instructions for care, including mobility, wound care, and emergency evacuation for multiple residents.

.330. REQUIREMENTS FOR FACILITY RECORDS: the facility did not maintain accurate records when Resident #27's family member signed a form declining a COVID-19 test after the resident had passed away, and a current resident's family member was required to sign the same form during the survey.

.450. REQUIREMENTS FOR FOOD AND NUTRITIONAL CARE SERVICES: the facility did not meet Idaho Food Code standards, with ice machines containing pink and black mold-like substance, worn cutting boards, unclean juice machines and coffee machine, and smudged walk-in refrigerators and freezers.

.520-04 Inadequate Care - Supervision: the facility failed to provide appropriate supervision and sufficient staffing to prevent recurrent falls and meet daily care needs for multiple residents, resulting in inadequate care, injuries, and unmet needs in toileting, grooming, medication administration, and peri-care.

.335.02 Standard Precautions: the facility did not follow standard precautions as provided in the CDC guidelines, including allowing visitation without face coverings, lack of mask requirements for staff and residents, no screening process for visitors or staff, residents allowed non-essential outings without isolation, and inadequate social distancing in dining and activity areas.

.520-09 Inadequate Care - Safe Living Environment: the facility failed to provide a safe living environment for residents by not implementing infection control measures during the COVID-19 pandemic, including staff working while symptomatic, inconsistent mask use, inadequate screening of staff and visitors, lack of social distancing, and failure to implement policies to control infections, resulting in 26 residents contracting COVID-19 and multiple deaths.

.221.01.a Conditions for Termination of the Admission Agreement: the facility provided Resident #1 and Resident #3 an immediate discharge without appropriate justification; Resident #1 was discharged for language barriers and three falls without time to determine if interventions were effective, and Resident #3 was discharged after following a visitor outside a secured unit.

.250.09 Ventilation: during the survey, a pungent sewer odor was noted in the memory care unit by room 27; interviews confirmed the odor was an ongoing issue.

.305.02.b Current Medication Orders and Treatment Orders: the facility did not implement Resident #8 and #15's mechanical soft diet and #14's thickened liquids; Resident #11's treatment order for BiPAP, daily blood sugar check, daily weights, and humidifier for oxygen was not implemented; the facility did not clarify with the physician to implement or hold a blood pressure medication for Resident #3.

.451 Menu and Diet Planning: both the assisted living and memory care unit did not train their kitchen staff how to prepare therapeutic diets according to the Idaho diet manual.

.451.03 Therapeutic Diets: both the assisted living and memory care unit did not have therapeutic diet menus available in the facility; this included diets for low concentrated sweets, pureed foods, no added salt, and mechanical soft foods.

.630.02 Mental Illness: nine of nine employees who worked with residents diagnosed with mental illness did not have specialized training; the facility administrator confirmed on 8/24/18 that staff did not receive mental illness training.

.630.03 Developmental Disability: six of six employees who worked with residents diagnosed with developmental disability did not have specialized training; the facility administrator confirmed on 8/24/18 that staff did not receive developmental disability training.

.640 Continuing Training Requirements: two of four employees who had been working at the facility longer than a year did not have eight hours of continuing education training; the facility administrator confirmed on 8/24/18 that three staff did not receive eight hours of annual continuing education training.

.730.02 Work Records: the facility's as-worked schedule did not document personnel who were in training, regional staff, and maintenance personnel who were at the facility; the facility did not include position titles for all employees on the as-worked schedules.

.221.01.a Conditions for termination of the admission agreement: the facility failed to provide Resident #1 with written, 30-day notice of discharge.

.215 Requirements For A Facility Administrator: the facility operated without an administrator for 15 days.

.215.09 Identify and Monitor Patterns of Incidents and Accidents: the administrator did not identify and monitor patterns related to incidents and accidents and develop interventions to prevent further falls for Residents #6 and #13, who had numerous falls.

.215.14 Notification to Licensing and Certification Unit: the facility failed to notify Licensing and Certification within 3 business days of a change in administrator.

.300.01 Licensed Professional Nurse (RN): caregivers were passing medications without proper delegation.

.305.02.a Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents had all medications as ordered for Residents #1, 2, 3, 6, 8, 9 and 10.

.305.02.b Current Medication Orders and Treatment Orders: the facility nurse did not ensure Residents #2 and #5 received mechanical soft diets as ordered, did not clarify oxygen orders for Resident #8, or clarify Resident #4 and #5's diet orders. Resident #7's crush order for medications was not implemented.

.305.03 Resident Health Status: the facility nurse did not document the status of Residents #2, 4, 5 and 8's wounds; wounds were not staged or documented as improving bi-weekly.

.310.04.a Psychotropic or Behavior Modifying Medication: the facility failed to attempt non-drug interventions prior to requesting medications for Residents #5, 6, and 11.

.320.01 Use of Negotiated Service Agreement: NSA's did not reflect residents' current needs, including care specifics for Residents #2, 4, and 8.

.350.02 Administrator or Designee Investigation Within Thirty Days: the administrator did not complete a thorough investigation on 12 of 16 reviewed incident/accidents.

.630.01 Dementia: 5 of 10 employees did not have dementia training.

.630.02 Mental Illness: 9 of 10 employees did not have mental illness training.

.630.03 Developmental Disability: 10 of 10 employees did not have developmental disability training.

.630.04 Traumatic Brain Injury: 10 of 10 employees did not have traumatic brain injury training.

.711.14 Discharge Information: the facility failed to document the disposition of residents' belongings who were discharged.

.215.01 Administrator Responsibility: the administrator did not ensure records were complete and accurate.

.250.10 Plumbing: residents' toilet seats were loose and/or broken.

.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to complainants within 30 days.

.600.05 Supervision: the facility administrator did not appropriately supervise staff to ensure residents' care needs were met.

.600.06.a Sufficient Personnel: the facility administrator did not schedule sufficient staff during meal times.

.711.08.a Care Notes: the facility staff did not document when Resident #5 received the incorrect therapeutic diet.