Inspection Reports for
Grace Independent and Assisted Living

.405.01.a. Electrical Installations and Equipment: extension cords and multiple plug adapters (MPAs) are prohibited; Room 173 used two 3-1 MPAs and Room 105 used one MPA to supply power to devices/appliances.

.405.02. Prohibited Applications: relocatable power taps (RPTs) are prohibited with the use of medical devices; Room 136 used an RPT to supply power to the oxygen concentrator.

.405.03. Medical Gases: no policy or procedure in accordance with NFPA 99, Chapter 11, Section 11.5 on elimination of ignition sources and misuse of flammable substances for residents using medical respiratory therapy such as oxygen.

.410. Requirements for Emergency Actions and Fire Drills: emergency egress and relocation drills were not documented with an evacuation point and the emergency plan fails to specify the designated point of assembly, contrary to NFPA 101, Chapter 33, Section 33.7.3.3.

.300.01 Licensed Registered Nurse (RN): the facility RN did not complete all required nursing assessments for residents, with quarterly assessments overdue for Residents #2, #4, and #9.

.404 Fire and life safety standards: the facility emergency disaster plan does not designate the drill point, drills do not demonstrate the evacuation point, no documented resident training on disaster plan roles, and the 2-hour separation door would not fully close and latch.

.405.03 Medical gases: no documented annual inservice for staff on the risks associated with oxygen.

.155. Emergency preparedness requirements: the facility disaster plan did not cover emergency events such as flood, earthquake, or high wind and did not specifically address COVID-19. The plan is not being followed as written, including lack of screening questions, no separation during communal dining, and no documented assembly point.

.155.01 Relocation agreements: the facility disaster relocation agreement is with one location dated 6/18/2014. Agreements must be with at least two separate locations and reviewed annually.

.404 Fire and life safety standards: sprinkler riser spar box and main riser lack a wrench as required; no documentation for annual rated assembly door testing; no documentation for inspection of electric fire dampers every four years; laundry room blocked electric fire damper open with spoons, impeding operation.

.405.01.a Electrical installations and equipment: multiple plug adapters and extension cords are prohibited but were found in rooms 158, 170, 103, and 163.

.405.04 Prohibited applications: no documentation of annual fireplace inspection due in April 2020; previous inspection dated 2019.

.405.03 Telephone: oxygen transfill room fan is not operational and exhausting; four unsecured liquid oxygen cylinders stored in the transfill room, which must be secured.

.404 Fire and life safety standards: no documentation for staff and residents' roles during emergencies; no annual training on oxygen risks; fire rated assembly doors by room 119 do not fully self-close and latch, leaving a gap; no documentation of 90-minute emergency light test, only 40 minutes documented; kitchen door entering dining room does not fully self-close and latch.

.335.03 Reporting of Individual with an Infectious Disease: the facility did not report individuals with an infectious disease to the local health district authority. Two staff members tested positive for COVID-19, and the facility did not inform the health district. The facility also failed to test all staff and residents and notify families as directed (complaint investigation).

.215.01 Administrator Responsibility: the facility administrator failed to ensure the facility's policy for medication and diabetic protocols were implemented, resulting in missed doses of Novolog and failure to notify the physician or follow required procedures.

.305.02.b Current Medication Orders and Treatment Orders: residents were not assisted to take their medications according to physician's orders, including missed Novolog doses, failure to provide prescribed diets, and lack of required weighing for a resident with Congestive Heart Failure (previously cited 4/19/18).

.402 Fire and life safety standards for buildings housing seventeen or more residents: no ashtray of safe design in designated smoking areas, staff smoking area used metal cans as ashtrays, no ashtrays for residents, over 80 cigarette butts found on grounds, resident rooms using oxygen were not posted with no smoking signs, and oxygen transfilling room lacked proper labeling.

.405.01.b. Electrical Installations and Equipment: two multi-plug adapters in resident room #158, a multi-plug adapter with relocatable power tap creating a daisy chain in resident room #138, a multi-plug adapter by television in resident room #140, and a zip extension cord with multi-plug adapter in resident room #116.

.405.05. Structure, Maintenance, Equipment to Assure Safety: missing documentation for emergency lighting testing including 30 second monthly tests for March, April, and June 2018 and the 90 minute annual test; last known annual test was 3/27/17.

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not implement Resident #3 or Resident #7's sliding scale insulin as ordered, resulting in numerous documented insulin errors in March and April 2018.

.320.01. Use of Negotiated Service Agreement: residents' NSAs did not clearly reflect their needs, including missing directions for visually impaired residents, outdated medication self-administration status, lack of hospice recommendations, and wound care requirements (previously cited 8/18/2017).

.215.09 Identify and Monitor Patterns of Incidents and Accidents: the administrator did not have a method for monitoring patterns of incidents and accidents to develop interventions to prevent recurrences, including residents who exited the building unsupervised.

.225.01 Evaluation for Behavior Management: the facility did not evaluate residents' behaviors, including wandering and sexually inappropriate behaviors.

.225.02 Intervention: the facility did not develop interventions for residents' behaviors and behavior plans contained irrelevant behaviors and interventions.

.250.14 Secure Environment: the facility did not provide a secured exterior and interior environment despite having cognitively impaired residents who attempted to leave.

.305.02.a Current Medication Orders and Treatment Orders: the facility lacked a sliding scale insulin order for a resident and hospice orders differed from administered medications.

.305.03 Resident Health Status: nursing assessments were not conducted when residents experienced changes in physical or mental health status.

.320.01 Use of Negotiated Service Agreement: NSAs did not clearly reflect residents' needs or include necessary interventions.

.350.02 Administrator or Designee Investigation Within Thirty Days: investigations were not completed for residents exiting unsupervised, missing money, or alleged mistreatment.

.350.05 Facility Notification to Appropriate Agencies: adult protection was not notified of resident mistreatment allegations or missing money.

.350.07 Notification of Licensing and Survey Agency Within Twenty-Four Hours: the facility failed to notify Licensing and Certification of reportable incidents such as falls and elopements.

.711.01 Ongoing Resident Care Records: documentation of behaviors, interventions, and their effectiveness was inconsistent and incomplete.

.711.08.c Care Notes: unusual events, including a resident leaving the facility at night, were not documented.

.730.02.a Work Records: work records did not document times worked by staff including administrator, nursing, kitchen, and maintenance.

.730.02.b Work Records: work records did not contain first and last names of employees.

.520-04 Inadequate Care - Supervision: the facility failed to provide a safe living environment and adequate supervision for residents with cognitive impairment who left the facility unsupervised, resulting in inadequate care.

.405.05 Structure, Maintenance, Equipment to Assure Safety: communication wires running through six 2-inch conduit pipes have gaps creating penetrations in the ceiling of the Mechanical/Electrical room that would not resist smoke passage; a 3 by 4 inch penetration exists in the two-hour firewall above the ceiling in the Mechanical/Electrical room.

.415.01 Maintenance of Equipment and Systems: emergency lighting was not operational in the exit hallway next to room 171, between fire doors and room 164, between rooms 105 and 107, and between rooms 103 and 104.

.415.05 Automatic Fire Extinguishing System Service and Testing: missing escutcheon rings at fire sprinklers in both closets in room 175, bedroom closet room 169, and bedroom closet room 153.

.221.04 Written Notice of Discharge: the facility did not provide an emergency discharge notice to Resident #2.

.221.04.h Written Notice of Discharge: the facility provided a discharge notice without all pertinent information for Resident #4.

.305.02.b Current Medication Orders and Treatment Orders: the facility did not ensure residents had medications as ordered; Resident #4 did not have pain medications available for five days.

.320 Requirements For The Negotiated Service Agreement: the facility did not develop an interim care plan to include instructions for Resident #2's use of a specific walker.

.405.05 Structure, Maintenance, Equipment to Assure Safety: smoke seal installations at doors by rooms 121/129 (by kitchen) and 101/102 were not installed correctly, obstructing fire door latches.