Grace Village Assisted Living & Memory Care

The facility failed to administer medications as ordered by a licensed practitioner for three residents during medication passes on 06/10/25 and 06/11/25. Specifically, staff administered incorrect strengths of calcium and vitamin D supplements and a discount store brand multivitamin instead of the prescribed medications. This resulted in a medication error rate of 12%.

The facility failed to administer medications as ordered by a licensed practitioner for 3 out of 4 residents observed during medication passes on 06/10/25 and 06/11/25. Specifically, staff failed to correctly administer supplements for calcium, vitamin D, cholesterol, and eye health. This resulted in a medication error rate of 12%.

The facility failed to ensure a resident with Alzheimer's dementia was free from physical abuse. Multiple staff members witnessed staff member C slapping the resident across the face during a period of combative behavior while providing personal care.

The facility failed to ensure a resident with Alzheimer's dementia was free from physical abuse. Multiple staff members witnessed a staff member (Staff C) slapping the resident across the face during a period of combative behavior while providing care.

The facility failed to provide adequate personal care, leaving residents in incontinence briefs for extended periods of time. Interviews revealed that residents were often found with soaking wet briefs and bed linens, and some residents wore the same brief through multiple shifts without being changed.

The facility failed to provide adequate personal care, specifically regarding incontinence management. Staff left residents in soiled incontinence briefs for extended periods, resulting in residents being found soaking wet and bed linens being soiled during shift changes.

The facility failed to provide adequate supervision for two residents with a history of falls. Specifically, no additional safety interventions were ordered or implemented to minimize the risk of future falls for these residents.

The facility failed to provide adequate supervision for two residents with a history of falls. Specifically, no additional safety interventions were ordered or implemented to minimize the risk of future falls for these residents.