Inspection Reports for Gracy Woods I Nursing Center
12021 Metric Blvd, Austin, TX 78758, TX, 78758
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
26.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
663% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for Gracy Woods Nursing Center.
Findings
The facility was found deficient in developing and implementing comprehensive, person-centered care plans, specifically failing to update a resident's care plan after a fracture diagnosis. Additionally, the facility failed to ensure nurse aides had completed required skill performance checklists, placing residents at risk of inadequate care.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including updating care plans after significant changes such as fractures.
Failed to ensure nurse aides who have worked more than 4 months were trained and competent; missing Nurse Aide Curriculum skill performance checklists for 13 nurse aides.
Report Facts
Residents affected: 1
Residents affected: 13
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 12, 2025
Visit Reason
An abbreviated survey was initiated due to an Immediate Jeopardy (IJ) identified on 09/12/2025 related to the facility's failure to prevent elopement of a cognitively impaired resident.
Findings
The facility failed to ensure adequate supervision and preventive measures to stop Resident #1 from eloping, resulting in the resident being missing for 26 hours. Immediate Jeopardy was identified but later removed; however, the facility remained out of compliance at a lower severity level while monitoring the effectiveness of corrective actions.
Deficiencies (1)
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically failing to prevent Resident #1 from eloping.
Report Facts
Residents affected: 1
Staff trained in elopement assessments: 16
Staff participated in elopement drill: 39
Residents with elopement risk assessments completed: 93
Residents identified as elopement risk: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding Resident #1's whereabouts and elopement risk | |
| LVN B | Interviewed about Resident #1's admission and cognitive status | |
| CNA C | Interviewed about Resident #1's behavior and elopement risk | |
| RN D | Conducted Resident #1's admission and assessment | |
| Administrator | Administrator (ADM) | Notified of Immediate Jeopardy and involved in corrective actions |
| Director of Nursing | Director of Nursing (DON) | Involved in education and implementation of elopement prevention measures |
| Medical Director | MD | Interviewed regarding Resident #1's elopement risk and involved in follow-up |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 31, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident rights, environment, pharmaceutical services, food safety, and infection control at Gracy Woods Nursing Center.
Findings
The facility failed to reasonably accommodate the communication needs of residents with limited English proficiency, maintain a homelike environment due to damaged bedroom walls, ensure proper pharmaceutical services including narcotic documentation and medication cart management, maintain food safety standards including proper labeling, dating, and use of facial hair restraints in the kitchen, and implement effective infection prevention and control practices including hand hygiene and sanitization during wound care.
Deficiencies (5)
Failed to provide reasonable accommodations for residents with limited English proficiency, resulting in communication barriers.
Failed to maintain a homelike environment due to damaged and unkept bedroom walls for residents.
Failed to document controlled medications properly and remove discontinued medications from medication carts.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date food products and failure of Dietary Manager to wear facial hair restraint.
Failed to implement infection prevention and control program effectively, including failure of staff to perform hand hygiene and sanitize surfaces during wound care.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: Many
Residents affected: 3
Staff affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA A | Named in medication administration and narcotic documentation deficiencies | |
| LVN C | Named in infection control deficiencies related to wound care sanitization | |
| CNA A | Named in infection control deficiencies related to hand hygiene | |
| Dietary Manager | Named in food safety deficiencies related to facial hair restraint and food labeling | |
| DON | Director of Nursing | Interviewed regarding communication, infection control, and medication administration |
| Administrator | Administrator | Interviewed regarding staff training and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with pharmaceutical services regulations, specifically to ensure accurate acquiring, receiving, dispensing, and administering of medications for residents.
Findings
The facility failed to provide pharmaceutical services as required, specifically failing to ensure that Resident #1 received prescribed ciprofloxacin-dexamethasone ear drops according to physician orders from 07/04/2025 through 07/09/2025. This failure posed a risk of decreased health status and quality of life for the resident.
Deficiencies (1)
Failure to provide prescribed ciprofloxacin-dexamethasone ear drops to Resident #1 as ordered by the physician from 07/04/2025 through 07/09/2025.
Report Facts
Dates medication not administered: 6
Medication order start date: Jul 4, 2025
Medication order end date: Jul 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Received and faxed the medication order for Resident #1 on 07/03/2025 |
| MA B | Medication Aide | Reported no ear drops available for Resident #1 and communicated issues with medication availability |
| LVN C | Licensed Vocational Nurse | Checked medication cart and confirmed no ear drops available; described protocol for medication orders and communication |
| ADON | Assistant Director of Nursing | Described medication order and delivery process and was unaware of medication unavailability for Resident #1 |
| NP | Nurse Practitioner | Provided orders for Resident #1's antibiotic ear drops and noted lack of communication from facility about medication delivery issues |
| DON | Director of Nursing | Outlined expectations for medication order follow-up and communication; noted failure in notifying about medication non-delivery |
| LVN D | Licensed Vocational Nurse | Described medication order process and expectations for communication when medication is not delivered |
| ADM | Administrator | Unaware of specific medication ordering timeframes; expected staff to contact NP if medication issues arose |
Inspection Report
Routine
Census: 84
Deficiencies: 20
Date: Feb 28, 2025
Visit Reason
Routine inspection of Gracy Woods Nursing Center to assess compliance with regulatory standards including resident care, medication administration, infection control, facility maintenance, and staff training.
Findings
The facility had multiple deficiencies including failure to maintain a safe, clean, and homelike environment; incomplete investigation of resident grievances; misappropriation of resident property; incomplete and inaccurate care plans; unsafe medication administration practices; inadequate infection control practices; insufficient staff training on key regulatory topics; and failure to maintain essential equipment in safe operating condition.
Deficiencies (20)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 of 24 resident rooms, including peeling wallpaper, missing drawer covers, torn privacy curtains, broken blinds, and holes in walls.
Failed to fully investigate and address Resident #36's grievance report of missing personal property including laptops, wallet, DVDs, and food items, and did not assist in replacing identification and bank cards.
Failed to ensure Resident #36 was free from misappropriation of property when he was forced to leave his room due to bed bug infestation and returned to find missing items.
Failed to timely report suspected abuse, neglect, or theft involving Resident #36's missing property to proper authorities.
Failed to develop and implement comprehensive person-centered care plans for 5 residents, including failure to update diet and medication orders, reflect refusals of assistance with personal refrigerated items, and accurately document code status and colostomy use.
Failed to ensure Resident #47 did not have an insulin needle on her bedside table and Resident #70 had a power strip with a fan plugged in on the floor.
Failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and medication carts were locked; insulin pens lacked pharmacy labels; medications were left unattended on medication carts; and residents had unauthorized medications at bedside.
Failed to provide pharmaceutical services to meet the needs of residents, including allowing medication aides to prepare medications and licensed nurses to administer medications they did not prepare, and discarding partial doses of medication mixtures.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including lack of hand soap at kitchen handwashing station, dish racks and juice lines on the floor, undated and improperly stored food items, uncovered resident trays, and unclean ice machine without cleaning log.
Failed to enact a policy regarding use and storage of foods brought to residents by family and visitors, resulting in spoiled and expired food in residents' personal refrigerators and incomplete temperature logs.
Failed to dispose of garbage and refuse properly, with dumpster door left open and trash on the ground outside the dumpster.
Failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, with one of two washing machines and one of two dryers inoperable.
Failed to maintain an infection prevention and control program, including improper hand hygiene by staff, failure to wear gowns and change gloves during medication administration, and urinary catheter bags touching the floor.
Failed to provide bedrooms that assure full visual privacy for each resident, with Resident #66 lacking a privacy curtain.
Failed to provide effective communications training as mandatory training for 16 employees.
Failed to provide education on resident rights and facility responsibilities to properly care for residents for 9 employees.
Failed to provide mandatory training on infection prevention and control program standards, policies, and procedures for 7 staff members.
Failed to provide training on the facility's Quality Assurance and Performance Improvement (QAPI) program for 16 employees.
Failed to provide training in compliance and ethics program's standards, policies, and procedures for 16 employees.
Failed to provide mandatory behavioral health training for 15 employees.
Report Facts
Resident census: 84
Insulin pens without pharmacy label: 7
Insulin pens in medication cart: 11
Laundry staff without food handler certificate: 6
Residents reviewed for care plans: 21
Residents reviewed for infection control: 21
Employees reviewed for training: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Administered medications to Residents #69, #67, and #40 without proper hand hygiene; supervised medication aide preparing medications |
| MA D | Medication Aide | Prepared medications for Resident #69; left medication cart unlocked with medications unattended |
| LVN J | Licensed Vocational Nurse | Administered medication via PEG tube to Resident #66 without wearing gown and contaminated gloves |
| DON | Director of Nursing | Provided multiple interviews regarding care plan issues, infection control, medication administration, and staff training |
| MM | Maintenance Manager | Aware of missing privacy curtain for Resident #66; responsible for maintenance issues |
| Administrator | Facility Administrator | Provided multiple interviews regarding grievance investigation, maintenance issues, medication policies, and staff training |
| LVN KK | Licensed Vocational Nurse | Interviewed regarding Resident #74's care and catheter care |
| LVN H | Licensed Vocational Nurse | Interviewed regarding medication self-administration and Resident #72's care |
| CNA C | Certified Nursing Assistant | Interviewed regarding Resident #74 and Resident #21 dialysis folder |
| DS | Dietary Supervisor | Interviewed regarding food safety and staff training |
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #36's missing property and dialysis communication sheets |
| CNA F | Certified Nursing Assistant | Interviewed regarding Resident #36's independence and missing items |
| LVN GG | Licensed Vocational Nurse | Reviewed for training compliance |
| RN HH | Registered Nurse | Reviewed for training compliance |
| RN II | Registered Nurse | Reviewed for training compliance |
| LVN JJ | Licensed Vocational Nurse | Reviewed for training compliance |
| SW | Social Worker | Reviewed for training compliance and involved in grievance investigation |
Inspection Report
Routine
Census: 84
Deficiencies: 20
Date: Feb 28, 2025
Visit Reason
Routine inspection of Gracy Woods Nursing Center to assess compliance with regulatory requirements including resident care, safety, infection control, medication administration, and facility environment.
Findings
The facility was found deficient in multiple areas including maintenance issues in resident rooms, incomplete and inaccurate care plans, failure to provide privacy curtains, improper medication administration practices, inadequate infection control practices, failure to maintain equipment, insufficient staff training in multiple required areas, and food safety violations.
Deficiencies (20)
Facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 of 24 resident rooms, including peeling wallpaper, missing drawer covers, torn privacy curtains, broken blinds, and holes in walls.
Facility failed to ensure Resident #36's grievance regarding missing personal property was fully investigated and resolved, and did not assist in replacing identification and bank cards.
Facility failed to ensure Resident #36 was free from misappropriation of property when he was forced to leave his room due to bed bugs and returned to find items missing.
Facility failed to maintain communication and coordination with dialysis facility for Resident #21, resulting in missing dialysis communication sheets.
Facility failed to develop and implement comprehensive person-centered care plans for 5 residents, including failure to update diet and medication orders, reflect refusals of assistance, and update code status and colostomy care.
Facility failed to ensure Resident #47 did not have an insulin needle on her bedside table and Resident #70 had a power strip with a fan plugged in, creating hazards.
Facility failed to ensure all drugs and biologicals were stored in locked compartments with proper labeling and medication carts were locked; medications were left unattended on medication carts; Resident #72 had medicated ointment at bedside; Resident #84 had cough syrup at bedside.
Facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition; one washer and one dryer in laundry were inoperable.
Facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including lack of hand soap at kitchen handwashing station, dish racks and juice lines on floor, undated and spoiled food items, uncovered resident trays, and unclean ice machine.
Facility failed to maintain medical records that were complete and accurately documented for Residents #69 and #74, including failure to update physician orders and care plans to reflect current diet, medication, and code status.
Facility failed to ensure Resident #66 had a privacy curtain to provide full visual privacy.
Facility failed to maintain infection prevention and control program, including failure of LVN A to perform proper hand hygiene when administering medications, failure of LVN J to wear gown and change gloves during peg tube medication administration, and failure to keep Resident #74's urinary catheter bag off the floor.
Facility failed to provide sufficient support personnel with appropriate competencies and skills for food and nutrition service, including failure of six dietary staff to have Texas Food Handler Certificates.
Facility failed to enact a policy regarding use and storage of foods brought to residents by family and visitors, resulting in spoiled and expired food in residents' personal refrigerators and incomplete temperature logs.
Facility failed to provide effective communications training as mandatory training for 16 staff members.
Facility failed to provide education on resident rights and facility responsibilities to properly care for residents for 9 staff members.
Facility failed to provide mandatory training on the facility's Quality Assurance and Performance Improvement (QAPI) program for 16 staff members.
Facility failed to provide mandatory training on infection prevention and control program standards, policies, and procedures for 7 staff members.
Facility failed to provide mandatory training on compliance and ethics program's standards, policies, and procedures for 16 staff members.
Facility failed to provide mandatory behavioral health training for 15 staff members.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 2
Insulin pens without pharmacy label: 7
Insulin pens total: 11
Medication carts unlocked: 2
Dietary staff without food handler certificate: 6
Residents affected: 2
Residents affected: 1
Staff without effective communications training: 16
Staff without resident rights training: 9
Staff without QAPI training: 16
Staff without infection control training: 7
Staff without compliance and ethics training: 16
Staff without behavioral health training: 15
Inspection Report
Routine
Deficiencies: 1
Date: Jul 26, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically reviewing compliance with infection control protocols during peri care for residents.
Findings
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple CNAs not changing gloves or washing hands appropriately during peri care for two residents, potentially placing residents at risk of disease transmission. The Director of Nursing confirmed the breaches and emphasized the need for education and adherence to facility policies.
Deficiencies (1)
Failure to maintain an infection prevention and control program, including improper glove use and hand hygiene by CNAs during peri care for Residents #1 and #2.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in infection control breach for not changing gloves or washing hands during peri care. | |
| CNA B | Named in infection control breach for not changing gloves or washing hands during peri care. | |
| CNA C | Named in infection control breach for not washing hands or changing gloves appropriately during peri care. | |
| DON | Director of Nursing | Confirmed infection control breaches and emphasized need for education and adherence to policies. |
Inspection Report
Deficiencies: 1
Date: May 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically focusing on the safe and appropriate provision of respiratory care, including tracheostomy care, tracheal suctioning, and infection control measures related to oxygen equipment.
Findings
The facility failed to ensure that Resident #1's nasal cannulas and tubing were properly stored when not in use, posing a risk of cross-contamination and infection. Observations and interviews revealed that the tubing was hanging on a wheelchair handle instead of being stored in a bag as required by facility policy and infection control procedures.
Deficiencies (1)
Failure to ensure Resident #1's nasal cannulas and tubing were properly stored when not in use, risking cross-contamination and illness.
Report Facts
Residents reviewed for respiratory care: 5
Residents affected: 1
Oxygen flow rate: 2
Dates of nurse's notes reviewed: 7
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted as an annual survey of Gracy Woods Nursing Center to assess compliance with regulatory requirements, including care planning and pharmaceutical services.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for one resident and failed to provide ordered pain medications for a resident with malignant cancer, resulting in an Immediate Jeopardy that was later removed after corrective actions. The facility also failed to ensure pharmaceutical services met residents' needs, particularly regarding medication availability and administration.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable objectives and timeframes.
Failed to provide safe, appropriate pain management for a resident requiring such services, including failure to administer ordered pain medications leading to an Immediate Jeopardy.
Failed to provide pharmaceutical services to meet the needs of each resident, including failure to provide ordered pain medications for three consecutive months.
Report Facts
Medication not administered: 25
Medication not administered: 16
Medication not administered: 20
Medication not administered: 17
Medication not administered: 38
Medication not administered: 4
Medication not administered: 10
Medication not administered: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Reported resident crying from pain and inability to receive pain medication; called NP for alternative medication |
| DON | Director of Nursing | Responsible for medication ordering and ensuring residents receive medications; acknowledged failure in pain medication provision |
| Administrator | Aware of pain medication issues and Immediate Jeopardy; involved in corrective action planning | |
| RN A | Registered Nurse | In-serviced on pain management and assessment; described pain assessment procedures |
| RN B | Registered Nurse | In-serviced on pain assessment and management; described individualized pain assessment |
| LVN B | Licensed Vocational Nurse | In-serviced on pain assessment; described methods to assess pain in verbal and nonverbal residents |
| LVN C | Licensed Vocational Nurse | In-serviced on pain management; described evaluating individual resident needs for pain |
| LVN D | Licensed Vocational Nurse | In-serviced on pain management; described assessing pain in verbal and nonverbal residents |
| CMA A | Certified Medication Aide | In-serviced on medication management and reporting medication availability and refusals |
| CMA B | Certified Medication Aide | In-serviced on medication ordering and reporting medication availability and refusals |
| CMA C | Certified Medication Aide | In-serviced on medication availability and reporting |
| CMA D | Certified Medication Aide | In-serviced on medication ordering and reporting medication availability and refusals |
| CMA E | Certified Medication Aide | In-serviced on medication ordering and reporting medication availability and refusals |
| RN C | Registered Nurse | In-serviced on pain control maintenance and medication ordering |
| LVN F | Licensed Vocational Nurse | In-serviced on medication management and reporting medication availability |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 1, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, privacy, dignity during dining, and food safety standards in the facility.
Findings
The facility was found deficient in promoting residents' dignity during dining by not serving meal trays simultaneously to residents at the same table, failing to ensure privacy during care for residents, and not properly labeling, dating, and sealing food items in the kitchen. These deficiencies posed risks to residents' dignity, privacy, and health.
Deficiencies (3)
Failed to treat residents with respect and dignity by not serving meal trays at the same time to residents at the same table.
Failed to ensure resident privacy during care by leaving doors open and privacy curtains not pulled, exposing residents.
Failed to store, prepare, distribute, and serve food in accordance with professional standards by not labeling, dating, and sealing food items in the refrigerator, freezer, and dry storage.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 7
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Interviewed regarding dining tray policy and failure to serve residents simultaneously |
| KS E | Kitchen Staff | Interviewed regarding dining tray policy and food labeling, dating, and sealing |
| CK F | Kitchen Staff | Interviewed regarding dining tray policy and food labeling, dating, and sealing |
| DON | Director of Nursing | Interviewed regarding dining tray policy and resident privacy during care |
| Nurse A | Nurse | Interviewed regarding dining tray policy and resident privacy during care |
| Administrator | Facility Administrator | Interviewed regarding dining tray policy, resident privacy, and food labeling policies |
| CNA B | Certified Nursing Assistant | Interviewed regarding privacy violation during care |
| CNA C | Certified Nursing Assistant | Interviewed regarding privacy violation during care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was conducted due to complaints of abuse and neglect involving two residents at Gracy Woods Nursing Center, specifically allegations of verbal abuse by a CNA towards Resident #1 and physical abuse by Resident #3 towards Resident #2.
Complaint Details
The complaint investigation substantiated that CNA A verbally abused Resident #1 by calling him dumb and making inappropriate comments during care on 3/7/24. Resident #3 was found to have hit Resident #2 on the foot four times on 3/2/24, causing pain and fear. Resident #2 was hospitalized following the incident due to a UTI and blood pressure drop, unrelated to the abuse. CNA A was suspended pending further investigation. Resident #3 was moved to another hall to prevent further incidents.
Findings
The facility failed to protect residents from abuse, with confirmed incidents including a CNA verbally abusing Resident #1 and Resident #3 physically hitting Resident #2. Investigations confirmed the allegations, and corrective actions such as suspension of the CNA and relocation of Resident #3 were taken. The facility policies on abuse and resident rights were reviewed.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical and verbal abuse.
Report Facts
Residents reviewed for abuse/neglect: 7
Residents affected: 2
Times Resident #3 hit Resident #2: 4
Days to move Resident #3: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in verbal abuse finding towards Resident #1 and subject of investigation and suspension | |
| RN A | Registered Nurse | Conducted assessment and responded to Resident #2's call light after incident |
| ADM | Administrator | Overheard CNA A's verbal abuse and initiated investigation |
| CNA B | Certified Nursing Assistant | Interviewed regarding knowledge of abuse and resident checks |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding abuse and neglect involving two residents at the facility, specifically allegations that a CNA verbally abused Resident #1 and that Resident #3 physically hit Resident #2.
Complaint Details
The complaint investigation confirmed that CNA A verbally abused Resident #1 by calling him dumb and making inappropriate comments during care on 3/7/24. Resident #3 was found to have hit Resident #2 on the foot four times on 3/2/24, causing pain and fear. Resident #2 was hospitalized following the incident with a UTI unrelated to the abuse. CNA A was suspended pending further investigation. Resident #3 was moved to another hall to prevent further incidents.
Findings
The facility failed to protect residents from abuse, with confirmed incidents including a CNA calling Resident #1 dumb and Resident #3 hitting Resident #2 on the foot multiple times. Investigations confirmed the allegations, and appropriate actions such as suspension of the CNA and relocation of Resident #3 were taken.
Deficiencies (1)
Failure to protect residents from all types of abuse including verbal and physical abuse.
Report Facts
Residents reviewed for abuse/neglect: 7
Residents affected: 2
Times Resident #3 hit Resident #2: 4
Days to move Resident #3: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in verbal abuse finding against Resident #1 and placed on suspension |
| RN A | Registered Nurse | Conducted assessment and responded to Resident #2's call light after incident |
| ADM | Administrator | Overheard CNA A's verbal abuse and initiated investigation |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 26, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding neglect, wound care, nutrition, infection control, and staff competencies at Gracy Woods Nursing Center.
Complaint Details
The complaint investigation revealed substantiated neglect and inadequate wound care, nutrition, infection control, and staff competency issues leading to resident harm including infections, sepsis, and death.
Findings
The facility failed to ensure residents #71, #85, and #87 received appropriate wound care, nutritional supplements, and infection prevention measures, resulting in infections, sepsis, and death of Resident #71. Staff failed to perform proper hand hygiene and wound care techniques, and there were deficiencies in staff competencies and training. The facility implemented a plan of removal and re-education but remained out of compliance at a scope of pattern and severity of potential for more than minimal harm after the immediate jeopardy was removed.
Deficiencies (6)
Failed to ensure residents were free from neglect and received nutritional supplements to promote wound healing, resulting in infections and death.
Failed to perform proper wound care including hand hygiene and changing gloves between wounds, risking cross contamination.
Failed to wash hands with soap and water after handling feces, risking infection transmission.
Failed to perform hand hygiene while serving lunch to multiple residents.
Failed to maintain an effective infection prevention and control program, including proper wound care and hand hygiene.
Failed to ensure nursing staff had appropriate competencies and skills for wound care and infection control.
Report Facts
Weight loss: 42
Braden scale score: 9
White blood cell count: 22
Albumin level: 1.7
Number of residents with significant weight loss: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TLVN S | Wound Care Nurse | Named in wound care deficiencies including failure to perform hand hygiene and cross contamination. |
| RN I | Registered Nurse | Named in wound care deficiencies and training issues. |
| TLVN T | Wound Care Nurse | Named in wound care deficiencies and training issues. |
| DON | Director of Nursing | Named in interviews regarding wound care, nutrition, infection control, and staff training. |
| LD | Licensed Dietitian | Named in interviews regarding nutrition interventions and failures. |
| MDSN | MDS Nurse | Named in interviews regarding weight loss monitoring and communication failures. |
| ADM | Administrator | Named in interviews regarding oversight and staff training. |
| LVN M | Licensed Vocational Nurse | Named in hand hygiene deficiency after handling feces. |
| CNA L | Certified Nursing Assistant | Named in staff training and infection control interviews. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jan 26, 2024
Visit Reason
The inspection was conducted based on complaints and concerns related to residents' rights, dignity, safety, nutrition, wound care, infection control, and environmental hazards.
Complaint Details
The complaint investigation revealed multiple failures in resident care including dignity, privacy, nutrition, wound care, infection control, and environmental safety. Immediate Jeopardy was identified related to neglect in wound care and nutrition leading to infections and death.
Findings
The facility failed to ensure residents' dignity, privacy, safety, nutritional status, wound care, infection control, and environmental safety. Specific failures included improper wound care, lack of nutritional interventions, failure to prevent infections, inadequate hand hygiene, and unsecured hazardous chemicals.
Deficiencies (10)
Facility failed to ensure residents' right to a dignified existence and privacy during care.
Facility failed to ensure a resident could reach his call device, risking unmet needs.
Facility failed to maintain a safe, clean, comfortable, and homelike environment, including maintenance issues and cleanliness.
Facility failed to protect residents from neglect related to wound care and nutritional supplementation, resulting in infections, sepsis, and death.
Facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to order nutritional supplements and prevent infections.
Facility failed to ensure the environment was free from accident hazards, including unsecured housekeeping carts and unlocked shower rooms with accessible chemicals.
Facility failed to ensure nursing staff had appropriate competencies and skills for wound care, including failure to perform hand hygiene and proper wound care techniques.
Facility failed to provide enough food/fluids to maintain a resident's health, including failure to implement dietitian recommendations and speech therapy interventions, resulting in significant weight loss and death.
Facility failed to provide pharmaceutical services to meet residents' needs, including failure to remove expired medication administration supplies.
Facility failed to provide and implement an infection prevention and control program, including failure to prevent infections, improper hand hygiene, and cross contamination during wound care.
Report Facts
Weight loss: 42
Braden scale score: 9
Number of residents on 200 hall: 30
Number of residents on 300 hall: 12
Expired dressing kits: 4
Expired IV supplies: 2
Number of residents with significant weight loss: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TLVN S | Wound Care Nurse | Named in wound care deficiencies and failure to perform hand hygiene and proper wound care techniques. |
| DON | Director of Nursing | Named in multiple interviews regarding wound care, infection control, and staff training. |
| ADM | Administrator | Named in interviews regarding facility oversight, infection control, and staff training. |
| RNC | Regional Nurse Consultant | Named in interviews regarding supervision and training of nursing staff. |
| LD | Licensed Dietitian | Named in interviews regarding nutritional interventions and failure to implement recommendations. |
| MDSN | MDS Nurse | Named in interviews regarding weight loss monitoring and communication failures. |
| LVN M | Licensed Vocational Nurse | Named in hand hygiene deficiency related to feces handling. |
| CNA E | Certified Nursing Assistant | Named in environmental safety deficiency related to unsecured housekeeping cart. |
| CNA D | Certified Nursing Assistant | Named in hand hygiene deficiency and environmental safety deficiency. |
| CNA L | Certified Nursing Assistant | Named in staff training and hand hygiene interviews. |
| RN I | Registered Nurse | Named in wound care and infection control training and observations. |
| TLVN T | Wound Care Nurse | Named in wound care training and observations. |
| RN R | Registered Nurse | Named in wound care and infection control training. |
| CNA P | Certified Nursing Assistant | Named in infection control and hand hygiene training. |
| LVN N | Licensed Vocational Nurse | Named in infection control and hand hygiene interviews. |
| RN J | Registered Nurse | Named in infection control and hand hygiene interviews. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards of care related to dialysis services for residents requiring such treatments.
Findings
The facility failed to ensure current active physician's orders for the type or frequency of dialysis treatments were in place for three of four residents reviewed for dialysis, and failed to ensure orders for monitoring the dialysis access site were in place for one resident. These failures could place residents at risk of severe blood loss, infection control complications, and hospitalization.
Deficiencies (2)
Failure to ensure current active physician's orders for the type or frequency of dialysis treatments for Resident #1, Resident #2, and Resident #3.
Failure to ensure physician's orders were in place for monitoring the dialysis access site for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding expectations for dialysis orders and monitoring. | |
| DON | Interviewed regarding nurses' responsibility to ensure proper physician orders for dialysis treatments and monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to concerns about a resident (R#1) who eloped twice within 24 hours and was discharged against medical advice (AMA) without proper assessment or consultation with medical staff.
Complaint Details
The complaint investigation focused on Resident #1 who eloped twice within a 24-hour period and was discharged AMA without assessment or consultation with the facility MD or NP. Immediate Jeopardy was identified on 08/22/2023 and removed on 08/24/2023. The facility remained out of compliance at a lower severity level due to ongoing corrective system evaluation.
Findings
The facility failed to ensure adequate supervision to prevent accidents and failed to protect the resident from abuse and neglect. The resident eloped twice, was discharged AMA without physician or nurse practitioner approval, and the facility did not follow proper protocols for elopement risk assessment, discharge, and supervision. Immediate Jeopardy was identified but later removed, with the facility remaining out of compliance at a lower severity level.
Deficiencies (2)
Failure to protect resident from abuse, neglect, misappropriation of property, and exploitation.
Failure to ensure adequate supervision to prevent accidents for one resident who eloped twice and was discharged AMA without proper assessment or orders.
Report Facts
Duration of resident stay: 52
PHQ-9 score: 11
MSE score: 12
Elopement incidents: 2
Time resident was missing after first elopement: 2.5
Time resident was missing after second elopement: 1.75
Date Immediate Jeopardy identified: Aug 22, 2023
Date Immediate Jeopardy removed: Aug 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported resident's exit seeking behavior and communication with ADM on 08/10/2023. |
| LVN A | Licensed Vocational Nurse | Observed resident's exit seeking behavior and communicated with NP for orders after first elopement. |
| RN 2 | Registered Nurse | Administered wander guard with resident's permission and conducted Q15-minute checks after first elopement. |
| ADM | Administrator | Made decisions regarding AMA discharge without consulting MD or NP; communicated with corporate office. |
| DON | Director of Nursing | Reported not being informed of AMA discharge and lack of physician orders for AMA. |
| NP | Nurse Practitioner | Ordered labs, wander guard, and Q15-minute checks after first elopement; not informed of AMA discharge until after the fact. |
| MD | Medical Doctor | Not informed of AMA discharge until after the fact. |
| Maintenance Manager | Maintenance Manager | Confirmed door alarms and wander guard alarms were functioning properly. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to accurately document medical records for Resident #1, specifically related to a fall, subsequent hospital visit, hip fracture, transfer to another facility for therapy, and readmission.
Complaint Details
The complaint investigation focused on Resident #1's medical record accuracy after an unwitnessed fall on 06/29/23, subsequent hospitalizations, and transfers. The Director of Nursing (DON) and LVN A confirmed expectations and procedures for documentation were not met. The DON provided education to nursing staff on 02/06/23 regarding transfer and discharge documentation.
Findings
The facility failed to ensure Resident #1's medical chart included nursing documentation of his fall, hospital visit, hip fracture, transfer to another skilled nursing facility, and readmission. Nursing documentation was missing from 03/17/23 until 07/14/23, which could lead to errors in care and treatment.
Deficiencies (1)
Failure to safeguard resident-identifiable information and maintain accurate medical records for Resident #1, including documentation of fall, hospital visit, hip fracture, transfer, and readmission.
Report Facts
Residents reviewed for accurate medical records: 3
Date of Resident #1's accident/incident report: Jun 29, 2023
Date of Resident #1's quarterly MDS assessment: May 15, 2023
Date of Resident #1's quarterly care plan revision: May 16, 2023
Date range of missing nursing documentation: No nursing documentation from 03/17/23 until 07/14/23.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided interview statements about Resident #1's fall, hospitalizations, transfers, and documentation expectations. | |
| LVN A | Licensed Vocational Nurse | Documented the incident report for Resident #1's fall and provided interview about nursing documentation practices. |
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