Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
145% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services requirements, specifically to evaluate whether the facility provided medications to meet the needs of residents as ordered.
Findings
The facility failed to ensure pharmacy services met the needs of one sampled resident when prescribed seizure medications were not available and thus not administered as ordered due to delays in pharmacy delivery and authorization processes, potentially compromising resident health and safety.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Report Facts
Dates medications not administered: 5
Medication orders dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Verified medications were not administered due to pharmacy delivery delay |
| Consultant Pharmacist | Consultant Pharmacist | Explained delay in medication delivery due to controlled substance regulations and authorization issues |
Inspection Report
Routine
Census: 22
Deficiencies: 12
Date: Oct 18, 2024
Visit Reason
The inspection was a routine regulatory survey of A Grace Sub Acute & Skilled Care to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate call devices for residents, incomplete baseline care plans, incomplete physician orders, improper medication administration, failure to attempt alternatives before using bed rails, inaccurate controlled drug accountability, failure of the consultant pharmacist to identify medication irregularities, unnecessary medications, medication errors during administration, food safety violations, infection prevention lapses, and environmental maintenance issues.
Deficiencies (12)
Failure to provide appropriate staff call device for Resident 81, risking delayed assistance.
Failure to complete baseline care plans within 48 hours of admission for Residents 66 and 25.
Incomplete physician orders and failure to monitor intake/output for Residents 25, 35, 75, 93, and 98.
Failure to attempt alternatives prior to use of side rails for 18 sampled and 77 nonsampled residents.
Failure to ensure accurate accountability and documentation of controlled drugs for Residents 35, 39, and 85.
Consultant pharmacist failed to identify and report medication irregularities for Residents 5 and 93.
Residents 35 and 98 received unnecessary or improperly administered medications.
Medication error rate of 5.56% observed during medication administration for Residents 67 and 93.
Food safety violations including expired and undated food items, and improper thermometer sanitation.
Infection prevention failures including dirty oxygen concentrator filters, improper PPE use, and improper urinary drainage bag placement.
Resident 1 did not have a working call system within reach in the bathroom and bathing area.
Cracked walls near Resident 28's bathroom door and toilet area not repaired, posing safety and sanitary risks.
Report Facts
Medication error rate: 5.56
Residents affected by side rails deficiency: 95
Unaccounted controlled drugs: 16
Calcium acetate doses not given with meals: 35
Bananas with black spots: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Interviewed regarding Resident 81 call button, medication administration, and insulin order. |
| DON | Director of Nursing | Confirmed multiple findings including call button issues, medication irregularities, infection control lapses, and side rail use. |
| NS M | Nurse Supervisor | Interviewed about baseline care plan completion and call device assessment. |
| MDSC | Minimum Data Set Coordinator | Confirmed medication documentation errors and baseline care plan deficiencies. |
| LVN D | Licensed Vocational Nurse | Confirmed blood pressure taken on arm with AV fistula and lack of intake/output monitoring. |
| DS | Dietary Supervisor | Observed and interviewed regarding food safety violations and meal preference issues. |
| CP | Consultant Pharmacist | Interviewed about failure to identify medication irregularities and recommendations. |
| CNA F | Certified Nursing Assistant | Observed placing urinary drainage bag on bed, confirmed infection risk. |
| RN J | Registered Nurse | Observed not wearing gown during enhanced barrier precautions medication pass. |
| LVN C | Licensed Vocational Nurse | Observed improper lidocaine patch application and medication administration. |
| Resident 1 | Reported call button was out of reach. | |
| Resident 28 | Reported cracked walls in bathroom area. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to complete a Morse Fall Scale assessment after a resident's fall.
Complaint Details
The complaint investigation confirmed the facility did not complete the required Morse Fall Scale assessment after Resident 1's witnessed fall on 5/10/24.
Findings
The facility failed to complete a Morse Fall Scale after a witnessed fall of Resident 1 on 5/10/24, which could compromise the identification of fall risk factors and implementation of interventions. The facility's policy requires completion of the Morse Fall Scale after each fall, but no documentation was found for this incident.
Deficiencies (1)
Failure to complete a Morse Fall Scale assessment after a resident's fall.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN A | Licensed Nurse | Interviewed regarding the fall incident and failure to complete Morse Fall Scale. |
| LN B | Licensed Nurse | Confirmed the facility's requirement to complete Morse Fall Scale after falls and absence of documentation for Resident 1's fall. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to accurately complete the Fall Morse Scale assessments for Resident 1, which is critical for assessing fall risk and developing appropriate care plans.
Complaint Details
The complaint investigation found that the facility did not accurately complete fall risk assessments for Resident 1 following an unwitnessed fall on 9/13/2023. The assessments on 9/29/2023 and 11/15/2023 failed to document the fall history, which was confirmed by the Director of Nursing and the Minimum Data Set Nurse during interviews.
Findings
The facility failed to ensure that the Fall Morse Scale was completed accurately for Resident 1 on 9/29/2023 and 11/15/2023, not reflecting the resident's fall on 9/13/2023. This failure potentially compromises the development and implementation of resident-centered fall prevention care plans.
Deficiencies (1)
Failure to accurately complete the Fall Morse Scale assessments for Resident 1 on 9/29/2023 and 11/15/2023, not accounting for a fall on 9/13/2023.
Report Facts
Deficiencies cited: 1
Fall Morse Scale score: 40
Fall Morse Scale score: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified that the Fall Morse Scale assessments were not completed accurately for Resident 1 on 9/29/2023 and 11/15/2023 | |
| Minimum Data Set Nurse (MDSN) | Confirmed the inaccurate completion of Resident 1's Fall Morse Scale assessments and the failure to account for the fall on 9/13/2023 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide care and treatment according to physician orders for Resident 1, specifically related to the wearing of a hand splint, a knee brace, and provision of Restorative Nursing Assistant (RNA) services.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's care. The findings confirmed that the physician orders were not followed or documented correctly, and RNA services were inconsistently provided. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to ensure Resident 1 received proper treatment as ordered by the physician. The left hand splint and right knee brace orders were not followed or documented properly, and RNA services were provided less frequently than ordered with incomplete documentation. These failures had the potential to compromise Resident 1's health and well-being.
Deficiencies (3)
Physician order for the wearing of a hand splint was not followed or documented.
Physician order for the wearing of a knee brace was not followed or documented.
RNA services were not provided as ordered and refusals were not documented.
Report Facts
RNA services documented: 8
RNA services documented: 3
Date of physician order for hand splint and knee brace: 2023
Date of physician order for RNA services: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | Licensed Vocational Nurse | Interviewed regarding transcription errors and documentation failures for hand splint and knee brace orders |
| RNA B | Restorative Nursing Assistant | Interviewed regarding RNA service provision and documentation, acknowledged missing entries and refusals |
| ADON | Assistant Director of Nursing | Interviewed and confirmed orders were not transcribed correctly and documentation was incomplete |
| DON | Director of Nursing | Reviewed physician orders and RNA treatment records, confirmed missing documentation and lack of refusal documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 30, 2023
Visit Reason
The inspection was conducted due to a complaint filed by Resident 1 regarding missing personal items including chips, sodas, and baby wipes, and the facility's failure to resolve this grievance.
Complaint Details
The complaint was substantiated as the facility did not act on Resident 1's grievance filed on 5/2/23 regarding missing chips, sodas, and baby wipes. The grievance recommended securing Resident 1's items in a locked closet with a key, but this was not done.
Findings
The facility failed to resolve the grievance for Resident 1 about missing items, as the recommended actions to secure the resident's belongings in a locked closet with a key were not implemented. Interviews and observations confirmed the items were missing and the closet remained unlocked without a key for the resident.
Deficiencies (1)
Failure to resolve Resident 1's grievance about missing personal items and to implement recommended measures to secure belongings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Clerk A | Business Office Clerk | Reviewed Resident 1's grievance and confirmed no action was taken on the complaint. |
Inspection Report
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 15
Date: May 13, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for increased antipsychotic medication dose, failure to reasonably accommodate resident needs, failure to protect resident health information, medication administration errors, failure to monitor and clarify medication orders, failure to provide appropriate care to prevent contractures, failure to provide timely pain management, failure to provide appropriate dialysis care, failure to ensure controlled medication accountability, failure of the consultant pharmacist to identify medication irregularities, failure to ensure appropriate use of psychotropic medications, medication errors with administration and storage, failure to provide emergency dental care, failure to follow proper food handling and sanitation practices, and failure to implement infection prevention and control practices.
Deficiencies (15)
Failed to obtain informed consent for increased dose of antipsychotic medication for one resident.
Failed to reasonably accommodate resident's needs when call light was out of reach.
Failed to protect residents' personal health information by leaving computer monitor unattended.
Licensed nurses failed to check food trays for correct diets before serving residents and medication orders lacked clarity.
Failed to provide appropriate care to prevent contractures by not applying heel protectors or splints as ordered.
Failed to provide timely assessment and intervention for pain.
Failed to ensure dialysis site dressing was removed as ordered.
Failed to ensure controlled medications were fully accounted for and controlled drug sign-in/sign-out sheets were incomplete.
Consultant pharmacist failed to identify and report irregular medication orders during monthly medication regimen review.
Failed to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications; lacked specific behavior indication for use.
Medication errors including administering wrong form of aspirin, incorrect eye drop administration, wrong medication given, improper measurement of laxative, and administering multivitamin with minerals instead of multivitamin only.
Failed to ensure proper medication storage and labeling including missing temperature logs, mislabeled insulin pens, unlabeled and undated medication vials, expired medications not removed, and unattended feeding formula bags.
Failed to assist and provide emergency dental care for a resident with dental pain.
Failed to follow proper sanitation and food handling practices including uncovered food in freezer, unlabeled and undated pitcher of liquid, and wet food service equipment.
Failed to implement infection prevention and control practices including improper hand hygiene, improper PPE use, lack of Covid-19 screening, and improper storage of irrigation syringe.
Report Facts
Medication error rate: 15.63
Controlled medication unaccounted: 18
Missing signatures: 40
Medication administration observation count: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Named in medication administration errors, medication storage deficiencies, and dialysis dressing observation. |
| LVN L | Licensed Vocational Nurse | Named in medication accountability and medication order clarification findings. |
| DON | Director of Nursing | Named in multiple interviews related to medication errors, infection control, and care findings. |
| MD | Medical Director | Named in interview regarding informed consent and medication indications. |
| RN B | Registered Nurse | Named in pain assessment and infection control observations. |
| CNA K | Certified Nursing Assistant | Named in infection control observation related to isolation gown use. |
| DSD/IP | Director of Staff Development/Infection Preventionist | Named in infection control practice interviews. |
| CP | Consultant Pharmacist | Named in medication regimen review findings. |
Inspection Report
Routine
Deficiencies: 15
Date: Jun 3, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, informed consent, abuse reporting, resident assessments, care planning, restorative nursing services, gastrostomy tube management, behavioral health care, pharmaceutical services, medication administration, medication storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, obtain informed consent for psychotropic medication, timely report abuse allegations, notify ombudsman of resident transfers, accurately assess residents' conditions, develop and implement comprehensive care plans, provide restorative nursing services, manage gastrostomy tubes properly, ensure behavioral health follow-up, accurately account for controlled substances, monitor psychotropic medication side effects, prevent medication errors, store medications properly, label and store resident food safely, and maintain infection control practices.
Deficiencies (15)
Failed to maintain resident privacy for two residents when their lower bodies were exposed to public view.
Failed to obtain informed consent for psychotropic medication for one resident.
Failed to timely report suspected abuse following an allegation for one resident.
Failed to notify the Long Term Care Ombudsman in writing of hospital transfers for four residents.
Failed to accurately code the minimum data set (MDS) for seven residents, resulting in inaccurate assessments.
Failed to develop and implement individualized comprehensive care plans for four residents, including failure to revise care plans and implement interventions.
Failed to provide appropriate restorative nursing services to maintain or improve range of motion for four residents.
Failed to ensure appropriate treatment and management of gastrostomy tube for one resident, including failure to replace obstructed tube timely.
Failed to ensure behavioral health care and psychiatric follow-up for two residents with behavior problems.
Failed to ensure accurate accounting of controlled substance medications for seven residents.
Failed to ensure residents were free from unnecessary psychotropic drugs and lacked proper monitoring for side effects.
Medication error rate of 5.56% observed during medication administration for one resident, including improper nebulizer medication mixing.
Failed to ensure medications and biologicals were properly stored and labeled, including expired medications in emergency kit, unrefrigerated medications, undated injectable pen, and expired nutritional supplement.
Failed to properly store, label, and date food brought by family for one resident, risking food contamination.
Failed to implement infection prevention and control practices including use of undated gastrostomy syringe, unlabeled distilled water, outdated nebulizer tubing, and suction tubing touching the floor.
Report Facts
Medication error rate: 5.56
Controlled substance discrepancies: 7
Residents affected by deficiencies: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Director H | Admission Director | Confirmed privacy curtain should have been used to protect resident privacy. |
| Director of Staff Development | Director of Staff Development | Confirmed staff should have used privacy curtain to protect resident privacy. |
| Nurse Supervisor K | Nurse Supervisor | Confirmed no informed consent for psychotropic medication was obtained. |
| Certified Nursing Assistant I | Certified Nursing Assistant | Confirmed privacy curtain should have been used during care to protect resident privacy. |
| Social Services Director G | Social Services Director | Acknowledged failure to notify ombudsman of hospital transfers and lack of psychiatric referral follow-up. |
| Minimum Data Set Coordinator M | Minimum Data Set Coordinator | Confirmed inaccurate resident assessments and discontinued restorative nursing program. |
| Licensed Vocational Nurse F | Licensed Vocational Nurse | Confirmed care plans were missing or not revised for residents. |
| Director of Nursing | Director of Nursing | Acknowledged multiple deficiencies including care plan issues, medication monitoring, and medication storage. |
| Registered Nurse J | Registered Nurse | Observed gastrostomy tube obstruction and food storage issues. |
| Licensed Vocational Nurse Q | Licensed Vocational Nurse | Administered nebulizer medications incorrectly by mixing routine and PRN medications. |
| Licensed Vocational Nurse B | Licensed Vocational Nurse | Identified expired medications in emergency kit. |
| Licensed Vocational Nurse D | Licensed Vocational Nurse | Observed medication storage issues including unrefrigerated medications and expired nutritional supplement. |
| Licensed Vocational Nurse C | Licensed Vocational Nurse | Observed medication storage issues including unrefrigerated medications. |
| Licensed Vocational Nurse P | Licensed Vocational Nurse | Confirmed suction tubing should not touch the floor. |
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