Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grace Home Inc. during CMS and state inspections, most recent first.
Food contact surfaces were found in poor condition when cracked measuring cups and cutting boards with deep cuts, scratches, and scoring were observed in the kitchen. The CDM and RDNC stated these items were not in good repair and needed replacement because cracked or scored equipment could not be properly cleaned and sanitized, and the facility policy required food to be prepared in a clean and safe manner with cutting boards in good condition.
The facility failed to obtain physician orders for specialty mattresses for two residents and did not implement care plans, compromising their safety. Additionally, LVNs did not follow proper medication administration protocols, using only one identifier and not explaining medications, leading to potential errors. The DON acknowledged these lapses in adherence to facility policies.
The facility did not have an RN on duty for the required eight consecutive hours. The DON, the only RN scheduled, left at 11 a.m. for time off, leaving the Director of Staff Development, an LVN, to cover. The Administrator was unaware of the requirement, and no waiver was in place. The DON acknowledged the importance of RN presence but did not prioritize it in staffing plans.
The facility failed to secure the medication storage room, leaving it propped open and unattended, which could lead to unauthorized access. Additionally, a resident's Hydrocortisone cream was found expired but not removed, contrary to facility policy. LVNs and the DON acknowledged these issues.
The facility failed to label stored food properly, maintain appropriate sanitizer concentration, and document dishwashing machine temperatures. Pastrami was found without proper labeling, the sanitizer solution was below the required concentration, and dishwashing logs were incomplete, risking cross-contamination and foodborne illness.
The facility failed to update care plans for several residents, leading to potential deficiencies in care. A resident's care plan lacked oxygen treatment interventions despite a physician's order. Another resident's care plan did not reflect the use of a specialty mattress, while a third resident's care plan was outdated regarding room assignment after a spouse's passing. Additionally, a resident's care plan inaccurately stated their mobility status, not reflecting the need for a stand lift with two-person assistance.
The facility did not follow the prescribed pureed turkey recipe for residents on a pureed diet, using water instead of turkey or chicken stock. This substitution was observed during a kitchen inspection and confirmed by the RD and DSS, who emphasized the importance of following recipes to maintain flavor and nutritional value. The failure to adhere to the recipe could affect resident intake and nutritional status.
The facility failed to follow its infection prevention program, leading to potential risks of infection. Two residents' urinals were improperly stored in trash cans, and an LPN did not clean a bedside table or use a barrier during medication administration for another resident. The Infection Preventionist and DON acknowledged these practices could lead to contamination and infection.
The facility did not meet the required 80 square feet of living space per resident in rooms 4, 6, and 7, with each resident having only 76.56, 76.05, and 76.05 square feet respectively. The Administrator was aware of this issue. Despite the deficiency, the rooms were observed to meet the residents' needs, providing adequate privacy, storage, and space for care and mobility.
A facility failed to record a resident's hip fracture diagnosis in the MDS, despite it being documented in other medical records. The resident, who had Parkinson's Disease and a recent hip surgery, was observed in a wheelchair with a boot. Interviews with staff confirmed the omission, which could affect the care provided, as the MDS is essential for assessing and planning resident care.
A facility failed to implement a care plan for a resident with a specialty perimeter mattress, designed to prevent falls, despite the resident's severe cognitive impairment and need for full assistance with ADLs. The absence of a care plan was confirmed through staff interviews and record reviews, highlighting a breach in the facility's policy on comprehensive person-centered care plans.
Food Contact Surfaces Not Maintained in Safe Condition
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional standards when cracked clear measuring cups were observed in the kitchen during a concurrent observation and interview with the CDM. The CDM stated the cracked measuring cups did not look okay, that any equipment with uncertainty or compromise should be thrown out, and that she would discard the cups because she did not want open areas or cracks that could allow plastic particles into residents' food. The CDM also stated she had been instructed by the RD that equipment starting to crack needed to be thrown out, and that equipment not in good repair created a risk of cross contamination and could lead to food-borne illness. The RDNC later stated measuring cups needed to be continuously looked at and replaced, and that items with cracking needed to be replaced for food safety and sanitation. Two green cutting boards and one brown cutting board were also observed in the kitchen with deep cuts, scratches, and scoring during a concurrent observation and interview with the CDM. The CDM stated the green cutting boards were concerning and that cutting boards with deep grooves could be a concern for food safety and sanitary reasons. The CDM stated equipment not in good repair caused a risk of cross contamination and could lead to food-borne illness. The RDNC stated cutting boards with deep cuts needed to be replaced, and that items with deep cuts, scratches, and scoring needed to be replaced for food safety and sanitation. The facility policy titled Food Preparation stated employees would prepare food in a clean and safe manner to protect residents from foodborne illness and that cutting boards with deep cuts should be discarded immediately.
Deficiencies in Mattress Orders and Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of quality by not obtaining physician orders or implementing care plans for specialty mattresses for two residents. Resident 15 had a perimeter mattress on her bed without a physician order or care plan, which was necessary due to her severe cognitive impairment and spastic movements. Similarly, Resident 4 had a specialty mattress without a physician order, despite having conditions such as cerebral palsy and epilepsy that necessitated such equipment for safety and comfort. The facility also failed to adhere to proper medication administration protocols. LVNs used only one identifier before administering medications to several residents and did not explain the medications being given. This practice was observed with multiple residents, including those with severe cognitive impairments, increasing the risk of medication errors. Additionally, LVN 2 signed the Electronic Medical Record for medications that were administered by another nurse, further compromising the accuracy of medical records. Furthermore, LVN 1 administered medications to a resident without proper identification, explanation, or providing water afterward. This oversight in medication administration procedures was acknowledged by the DON, who confirmed that the facility's policies and procedures were not followed. These deficiencies highlight significant lapses in the facility's adherence to established protocols for resident care and safety.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours in a day, as required. On the day in question, the Director of Nursing (DON), who was the only RN scheduled, left the facility at 11 a.m. for scheduled time off. The Director of Staff Development, who covered for the DON, was a Licensed Vocational Nurse and not an RN. Observations later in the day confirmed that there was no RN present in the facility. Interviews with the Administrator and the DON revealed a lack of awareness and oversight regarding the requirement for an RN to be present for eight consecutive hours. The Administrator admitted to being unaware of this requirement and confirmed that no waiver was in place to excuse the absence of an RN. The DON acknowledged the importance of having an RN on duty to supervise staff and ensure compliance with standards but admitted that this requirement was not prioritized in their staffing plan.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a survey. On two separate occasions, the medication storage room at the nursing station was found propped open and unattended, allowing potential unauthorized access. Licensed Vocational Nurses (LVNs) acknowledged the issue, noting that the room should always be locked to prevent unauthorized access to medications, which could lead to potential harm. The Director of Nursing (DON) confirmed that the medication room must be locked to prevent risks to residents and staff. Additionally, the facility did not properly manage medication expiration dates. Resident 5's Hydrocortisone 2.5% topical cream was found to be beyond its discard date, yet it remained on the medication storage counter. LVN 3 and the Pharmacist Consultant both recognized that the expired medication should be removed and destroyed, as it may no longer be effective. The facility's policy and procedure on medication storage, dated 2007, mandates that outdated medications be immediately removed and disposed of according to proper procedures.
Deficiencies in Food Labeling, Sanitization, and Dishwashing Procedures
Penalty
Summary
The facility failed to adhere to proper food labeling and storage procedures, as observed during a survey. Packages of frozen pastrami were found in the refrigerator without a pull date or a new use-by date label. The Dietary Services Supervisor (DSS) acknowledged that the facility does not always place pull date labels if the food is intended for a specific meal, which is contrary to the facility's policy requiring all food removed from the freezer to be labeled with a pull date and a new use-by date. This oversight could lead to the use of food past its optimal flavor or nutritive value. Additionally, the facility did not maintain the appropriate concentration of quaternary ammonium sanitizer solution used for cleaning food preparation surfaces. The solution tested at 150 ppm, below the targeted 200-400 ppm, which is necessary to ensure effective sanitation. The Dietary Aide (DA) confirmed that the solution was used after breakfast without being tested, and the concentration was too low to effectively kill bacteria, posing a risk of cross-contamination. Furthermore, the facility failed to document the dishwashing machine temperature log prior to washing at each meal. The dishwasher, which operates at a low temperature, relies on chemical sanitizers to sanitize dishes. However, the staff did not check the dishwasher temperature or sanitation concentration levels before washing, which could result in inadequate sanitation and potential cross-contamination. The DSS confirmed that the dishwasher temperature and sanitation level should be checked between every meal to ensure proper sanitation.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans for four residents, leading to potential deficiencies in care. For Resident 1, the care plan did not include oxygen treatment interventions, despite a physician's order for oxygen therapy due to COPD. This omission was identified during interviews and record reviews, where staff acknowledged that the care plan should have been updated to reflect the physician's order to ensure patient-centered care. Resident 4's care plan was outdated and did not reflect the use of a specialty perimeter mattress, which was observed in the resident's room. The care plan still mentioned the use of bolsters, which the facility no longer used. The Director of Staff Development admitted to not having received care plan training and acknowledged the care plan was not updated to reflect the current equipment used for the resident's safety. Resident 7's care plan was not updated to reflect a change in room assignment after the passing of the resident's spouse, who was previously noted as a caregiver. The care plan still indicated that the resident shared a room with the spouse. Similarly, Resident 11's care plan was not updated to reflect a significant change in mobility status, as the resident was no longer able to ambulate without assistance. The care plan inaccurately stated that the resident could ambulate with one-person assistance and a walker, despite the resident requiring a stand lift with two-person assistance.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to adhere to the prescribed pureed turkey recipe for four residents on a pureed diet, substituting water for turkey or chicken stock. This substitution was observed during a kitchen inspection where the cook prepared pureed turkey with water instead of the required stock, which is essential for maintaining the food's flavor and nutritive value. The Registered Dietician and Dietary Service Supervisor both confirmed that the recipe should have been followed to ensure the food's taste and nutritional content, which are crucial for resident intake and preventing weight loss. Interviews with kitchen staff revealed that the use of water instead of stock could alter the food's consistency and flavor, potentially leading to decreased resident intake and increased risk of choking. The facility's policies and job descriptions emphasize the importance of following standardized recipes to conserve nutritional value and ensure palatability. The failure to follow the recipe as outlined in the facility's procedures and job descriptions was identified as a deficiency, with potential implications for the residents' nutritional status.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention program, resulting in potential risks for the development and transmission of communicable diseases among residents. Specifically, two residents' urinals were observed hanging inside their trash cans at bedside, which could lead to contamination and infection. The Infection Preventionist acknowledged awareness of this practice and its potential to cause infection due to contact with trash. The Director of Nursing also recognized the risk of hand contamination and potential infection from urinals hanging inside trash cans. Additionally, a Licensed Vocational Nurse did not follow standard precautions during medication administration for another resident. The nurse placed the resident's inhaler on the bedside table without cleaning the table or using a barrier, and did not clean the inhaler lid after use. The Infection Preventionist confirmed that standard precautions require cleaning of bedside tables before and after use, and the facility's policy mandates the use of barriers and cleaning with hydrogen peroxide wipes to prevent bacterial transmission.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that each bedroom had the required 80 square feet of usable living space per resident in three of the 14 rooms surveyed. Specifically, rooms 4, 6, and 7 were identified as having less than the minimum space requirement for two residents, with each resident having only 76.56, 76.05, and 76.05 square feet respectively. During an interview, the Administrator acknowledged awareness of this deficiency. Despite the space shortfall, the rooms were observed to meet the residents' needs, providing reasonable privacy, adequate closet and storage space, and sufficient room for nursing care and mobility. The report notes that the health and safety of the residents would not be adversely affected by the continuance of this waiver.
Failure to Record Hip Fracture in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically by not recording a diagnosis of hip fracture in the Minimum Data Set (MDS) Section I for a resident. This oversight was identified during a survey when the resident, who had a history of Parkinson's Disease and a recent hip fracture with surgical correction, was observed in a wheelchair with a boot on her right foot. The resident was alert but confused, and her MDS assessment did not reflect the hip fracture diagnosis, which was documented in other medical records, including a doctor's visit note and a quarterly interdisciplinary team care conference. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON)/MDS Coordinator, confirmed the omission of the hip fracture diagnosis in the MDS. The DON acknowledged that the hip fracture should have been captured in the MDS, as it was a significant change affecting the resident's activities of daily living. The failure to accurately document the resident's condition in the MDS had the potential to impact the care and services provided to the resident, as the MDS is a critical tool for assessing and planning resident care.
Failure to Implement Care Plan for Specialty Mattress
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a specialty mattress on her bed without a care plan in place. This deficiency was identified during a review of the resident's records and interviews with staff. The resident, who was admitted with a diagnosis of unspecified disorder of psychological development and unspecified dementia, had a specialty perimeter mattress designed to prevent falls. However, there was no care plan documented for this mattress, which is essential for guiding staff on the specific care required for the resident. The resident's Minimum Data Set assessment indicated severe cognitive impairment, and progress notes highlighted contractures and advanced cognitive decline, requiring full assistance with activities of daily living. Despite these needs, the facility's Director of Staff Development and Director of Nursing were unaware of the mattress's presence and the lack of a care plan. The Certified Nursing Assistant noted the importance of a care plan for the mattress, especially given the resident's condition, but confirmed that no such plan was in place. The facility's policy on comprehensive person-centered care plans was not followed, as confirmed by the Director of Nursing. The policy requires that care plans include measurable objectives and timetables to meet residents' needs, reflecting recognized standards of practice. The absence of a care plan for the specialty mattress meant that the resident's specific needs were not being met, and staff were not adequately informed on how to provide appropriate care, potentially compromising the resident's safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 194 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anberry Nursing And Rehabilitation Center | 7.4 mi | ★★★★★ | 13 | 0 |
| Main West Postacute Care | 10.8 mi | ★★★★★ | 1 | 0 |
| North Starr Postacute Care | 11 mi | ★★★★★ | 14 | 0 |
| Brandel Manor | 11.1 mi | — | 0 | 0 |
| Covenant Village Care Center | 11.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Grace Home Inc..
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.