Grace Extended Residential Assisted Living

The facility failed to ensure wastewater and sewage were discharged into an approved sewage system.

The facility failed to have documented evidence that direct care staff had completed all required continuing education.

The facility failed to keep appropriate written records showing all prescribed medications and treatments that residents missed.

The facility failed to include a section addressing sheltering arrangements in the emergency preparedness and response plan.

The facility failed to include a section addressing transportation in the emergency preparedness and and response plan.

The facility's plan failed to include the location of a current list of the facility's resident population.

The facility failed to search the employee misconduct registry and nurse aide registry before hiring to determine if the individual is unemployable.

The facility failed to have sufficient staff to ensure safe evacuation of the facility in the event of emergency.

The facility failed to review the plan at least annually to reflect changes in information, within 30 days following a disaster, within 30 days after a drill, and within 30 days after a change in rule or policy.

The facility failed to train all staff in emergency and evacuation procedures prior to their assuming any job responsibilities.

The facility failed to ensure that all employees providing services were screened for tuberculosis within two weeks of employment and annually.

The facility failed to ensure that a registered nurse properly assessed and documented that a task being provided to resident qualified as a health maintenance activity (HMA), or the facility failed to ensure that a resident met the criteria to receive assistance with a non-delegated HMA task.

The facility failed to provide a bedroom of the required size and/or arrangement in compliance with licensing standards for assisted living facilities of this type.

The facility failed to maintain the building free of accumulations of dirt, rubbish, dust, and hazards.

The facility failed to ensure an annual inspection was conducted by the local fire marshal.

The facility failed to ensure that a registered nurse followed the Board of Nursing rules when performing an assessment on a resident for a non-delegated health maintenance activity, to develop an overall understanding of the resident's health status or the facility failed to ensure that a registered nurse reassessed and documented a resident's status appropriately and within the required timeframes.

The facility failed to ensure that the service plan was approved and signed by the resident or a person responsible for the resident's health care decisions, or that it was updated annually and upon a significant change in condition, based upon an assessment of the resident, or that care was provided to the resident based upon that assessment.

The facility failed to ensure lighting levels were in compliance with licensing standards for assisted living facilities and the Illumination Engineering Society of North America.

The facility failed to ensure metal or other approved waste baskets were provided in all areas where smoking is and permitted.

The facility failed to screen all residents, staff, and people who come to the facility.

The facility failed to ensure that a licensed person or a trained, authorized, and delegated person administered medications according to physician's orders.

The facility failed to provide and/or maintain portable fire extinguishers in compliance with licensing standards for assisted living facilities and NFPA 10.

The facility failed to include a section addressing health and medical needs in the emergency preparedness and response plan.

The facility failed to post the telephone number of the managing local ombudsman and the Ombudsman Program.

The facility failed to keep current and complete personnel records

The facility failed to ensure the fire alarm and smoke detection system was in compliance with licensing standards for assisted living facilities.

The facility failed to ensure the required sprinkler system was inspected, tested, and maintained in compliance with NFPA 25.

The facility failed to include a section addressing evacuation in the emergency preparedness and response plan.

The facility failed to ensure the smoke detectors were to be tested for sensitivity as required. The facility failed to provide all required fire alarm documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation, must be available for examination by DADS.

The facility failed to train all staff in reporting abuse and neglect prior to their assuming any job responsibilities.

The facility failed to ensure that a registered nurse properly delegated a task (not considered a health maintenance activity) to a personal care staff person in accordance with the Board of Nutrition rules.

The facility failed to include a section addressing warning in the emergency preparedness and response plan.

The facility failed to have written policies for the control of communicable diseases including tuberculosis (TB) screening in employees and residents.

The facility failed to conduct and document a risk assessment for potential emergencies or disasters.

The facility failed to have a COVID-19 response plan.

The facility failed to provide a written contract with a fire alarm firm to perform inspections, testing, and system maintenance at least every six months.

The facility failed to ensure that all operable windows had insect screens.

The facility failed to include a section addressing communication in the emergency preparedness and response plan.

The facility failed to ensure the building and structure complied with other applicable chapters of the Life Safety Code, NFPA 101.

The facility inappropriately admitted or retained residents whose needs could not be met.

The facility failed to ensure fire drills were conducted and documented to be in compliance with licensing standards for assisted living facilities.