Grace Assisted Living, LLC

Based on record review and interview, the manager failed to ensure that a resident has a written service plan that is reviewed and updated at least once every six months for a resident receiving personal care services and at least once every three months for a resident receiving directed care services for three of nine residents sampled. Findings Include: 1 . A review of R2's medical record revealed R2's service plan was last reviewed and updated on November 8th, 2024. R2 is directed care and would need to have the service plan reviewed and updated every 3 months. 2 . A review of R4's medical record revealed R4's service plan was last reviewed and updated on September 20, 2024. R4 is personal care and would need to have the service plan reviewed and updated every 6 months. 3 . A review of R8's medical record revealed R8's service plan was last reviewed and updated on November 19th, 2024. R8 is directed care and would need to have the service plan reviewed and updated every 3 months. 4 . In an interview, E1 acknowledged R2's, R4's, and R8's medical records did not have their service plans reviewed and updated according to their level of care.

Based on observation, record review, and interview, the manager failed to ensure a caregiver or assistant caregiver documents the services provided in the resident's medical record for nine out of nine residents sampled. The Department was provided false and misleading information. Findings Include: 1. The Compliance Officer observed E1 writing something on a piece of paper and went to look. The Compliance Officer observed E1 filling out activities of daily living (ADL) for R1. The Compliance Officer requested the ADL sheets. 2. A review of R1's medical record revealed a service plan last updated January 3rd, 2025. The service plan shows the level of care as directed and includes various services such as incontinence care, fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 3. A review of R1’s April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 4. A review of R2's medical record revealed a service plan last updated November 8th, 2024. The service plan shows the level of care as directed and includes various services such as incontinence care, fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 5. A review of R2’s April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 6. A review of R3's medical record revealed a service plan last updated July 10th, 2024. The service plan shows the level of care as supervisory and includes various services such as fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 7. A review of R3’s April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 8. A review of R4's medical record revealed a service plan last updated September 20th, 2024. The service plan shows the level of care as personal and includes various services such as fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 9. A review of R4’s April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 10. A review of R5's medical record revealed a service plan last updated June 10th, 2024. The service plan shows the level of care as supervisory and includes various services such as fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 11. A review of R5's April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 12. A review of R6's medical record revealed a service plan last updated January 3, 2025. The service plan shows the level of care as personal and includes various services such as incontinence care, fluid encouragement, brushing teeth, skin care, skin checks, showering, and cleaning nails. 13. A review of R6's April ADL showed no documentation of services provided from April 5th, 2025, to April 16th, 2025. 14. A review of R7's medical record revealed a serv

Based on observation and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed a door leading to the backyard with an alert. Opening the door revealed that the alert was not functioning. E1 attempted to set off the alert by opening the door twice. 2. In an interview, E1 acknowledged the door leading to the backyard had an alert that was not functioning and would not alert employees of the egress of a resident to the backyard.

Based on record review and interview, the manager failed to ensure that medication administration to a resident was documented in the resident's medical record for nine out of nine residents sampled. Findings Include: 1. A review of R1's medical record revealed signed medication orders dated February 19th, 2025. Medication listed: Quetiapine, Sertraline, and Trazodone. 2. A review of R1's Medication Administration Record (MARs) revealed no medication administration between April 5th, 2025, and April 16th, 2025. 3. A review of R2's medical records revealed signed medication orders dated February 19th, 2025. Medication listed: Hydrochlorothiazide, Amlodipine, Aspirin, Mirtazapine. 4. A review of R2's MARs revealed no medication administration between April 5th, 2025, and April 16th, 2025. 5. A review of R3's medical records revealed signed medication orders dated February 19th, 2025. Medication listed: Aspirin, Furosemide, Metoprolol, Venlafaxine, Carbidopa-Levodopa, Gabapentin, Trazodone, and Melatonin. 6. A review of R3's MARs revealed no medication administration between April 5th, 2025, and April 16th, 2025. 7. A review of R4's medical records revealed signed medication orders dated February 19th, 2025. Medications listed: Sertraline, furosemide, buspirone, and Trazodone. 8. A review of R4's MARs revealed no medication administration between April 5th, 2025, and April 16th, 2025. 9. A review of R5s medical records revealed signed medication orders dated February 19th, 2025. Medications listed: Levothyroxine, Amlodipine Besylate, Divalproex, Ibuprofen, Omeprazole, and Atorvastatin. 10. A review of R5's MARs revealed no medication administration between April 5th, 2025, and April 16th, 2025. 11. A review of R6's medical records revealed signed medication orders dated February 21st, 2025. Medications listed: Donepezil, Alprazolam, Mirtazapine, Quetiapine, and Trazodone. 12. A review of R6's MARs revealed no medication administration between April 5th, 2025 and April 16th, 2025. 13. A review of R7's medical records revealed signed medication orders dated December 30th, 2024. Medication listed: Sertraline, Xarelto, Atorvastatin, Donepezil, Memantine, and Gabapentin. 14. A review of R7's MARs revealed no medication administration between April 5th, 2025 and April 16th, 2025. 15. A review of R8's medical records revealed signed medication orders dated February 19th, 2025. Medication listed: Lantus insulin and Lispro insulin. 16. A review of R8's MARs revealed no medication administration between April 5th. 2025 and April 16th, 2025. 17. A review of R9's medical records revealed signed medication orders dated December 30, 2025. Medication listed: Aspirin, Farxiga, Valsartan, Metformin, Atorvastatin, Quetiapine and Trazodone. 18. A review of R9's MARs revealed no medication administration between April 5th. 2025 and April 16th, 2025. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, R5's, R6's, R7's, R8's, R9's medication administration record sh

Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed an unlocked cabinet in the kitchen, opening the cabinet revealed medication. E1 attempted multiple times to lock the cabinet but failed to do so. The lock mechanism appeared to be worn down. 2. In an interview, E2 acknowledged that the medication was not stored in a locked cabinet.