Grace Assisted Living LLC

A certification complaint, prompted by #CO40168, was completed on 5/29/25. A deficiency was cited. Based on record review and staff interview, the facility (residence) failed to ensure allegations of abuse were thoroughly investigated affecting one member (resident) (#1) and two former residents (#2, #3).Findings include:1. Record ReviewThe residence' s Abuse, Neglect, and Exploitation policy, dated 11/1/13, read in part: All observations and actions are recorded in the resident record and/or on other forms as indicated by facility policies and procedures. An investigation will be carried out and will be documented according to regulations, requirements, and/or facility policy and procedures. If an employee was involved, the suspected employee would be suspended pending the outcome of the investigation. The employee would not be allowed to return to the facility or to interact with the resident until the investigation was completed. Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia.An investigation report dated 5/17/25, read that "The facility has received a report regarding an allegation of abuse between a caregiver (Staff #2) and a resident (former Resident #3). The incident occurred on 5/16/25, around 9:30 a.m., when an [external health representative] who administered [former Resident #2' s] insulin overheard shouting and what sounded like a slap between [Staff #2] and [former Resident #3]. Administrative staff were away from the facility at this time."The internal investigation revealed that the facility interviewed six residents, a staff member from the external health representative company, and one facility staff member. Former Resident #2' s interview revealed that he admitted to having claimed to have been hit by Staff #2 before. Former Resident #3' s interview revealed that she had witnessed both verbal and physical abuse between Staff #2 and former Resident #3 on several occasions. Two resident interviews revealed that they had witnessed yelling between Staff #2 and former Resident #3 before. However, the facility concluded the alleged abus..

A licensure complaint, prompted by #CO40167, was completed on 5/29/25. Deficiencies were cited. Based on interview and record review, the residence failed provide therapeutic diets when the diet is prescribed by the resident' s practitioner, affecting one of three sample residents (#3). Findings include:Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia.A written practitioner' s order, dated 5/22/25, directed the residence to provide a thickened liquid diet.The resident' s care plan, dated 5/22/25, revealed that the resident required a thickened liquid diet.On 5/27/25 at approximately 3:00 p.m., the speech language pathologist stated she expected the residence to follow practitioner' s and her instruction that former Resident #3 be given thickened liquid once the order was received on 5/22/25.On 5/28/25 at 4 p.m., Staff #1 and the administrator stated they were aware that former Resident #3' s practitioner prescribed a therapeutic diet. On 5/28/25 at approximately 4:04 p.m., Staff #1 stated that the residence did not receive a prescription from.. Based on record review and interview, the residence failed to promptly notify the residents' responsible parties regarding the residents' change from baseline status affecting one (#3) former resident.Findings include: Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia.An incident report dated 11/18/24, read that former Resident #3 had a fall which resulted in her right knee swelling, and she could not straighten her knee, and later was taken to the emergency room. It also read that the former resident' s case manager and residence staff were notified.A progress note dated 11/20/24 read that former Resident #3 was discharged from the hospital. A progress note dated 11/22/25, read that former Resident #3 asked for pain medication and her practitioner prescribed pain medication. Later that day a progress note read that former Resident #3 did not have any strength, not able to sit straight, eyes not focusing and was taken to the hospital. A pro.. Based on record review, observation, and interview, the residence failed to investigate allegations of neglect in accordance with regulation and written policy, affecting one resident (#1) and two former residents (#2, #3). Findings include:1. Record ReviewThe residence' s Abuse, Neglect, and Exploitation policy, dated 11/1/13, read in part: All observations and actions are recorded in the resident record and/or on other forms as indicated by facility policies and procedures. An investigation will be carried out and will be documented according to regulations, requirements, and/or facility policy and procedures. If an employee was involved, the suspected employee would be suspended pending the outcome of the investigation. The employee would not be allowed to return to the facility or to interact with the resident until the investigation was completed. Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia.An investigation report dated 5/17/25, re..

A relicensure survey revisit was completed on 10/23/24 for all previous deficiencies cited 10/27/22. The residence is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally