Grace Assisted Living II, LLC

Based on the documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review date of April 20, 2021. No documentation of further review was available for the Compliance Officer to review. 2. In an interview, E1 acknowledged that the polices and procedures were not reviewed at least once every three years and updated as needed.

Based on documentation review, observation, and interview, the licensee implemented a change without an approval or amended license issued by the Department. Findings include: 1. A review of Department records revealed the facility was licensed for five residents. 2. During the environmental inspection of the facility, the Compliance Officer observed three resident bedrooms. The bedrooms contained a combined four beds available for residents. The Compliance Officer observed one bedroom not available for use by residents. 3. A review of Department records revealed no notification from the facility of the modification of the floor plan to reduce the number of residents or resident bedrooms. 4. In an interview, E2 reported the current non-resident bedroom was used for live-in staff. E2 acknowledged the facility was licensed for a capacity of five but only had enough resident beds for four residents.