Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Nursing Home during CMS and state inspections, most recent first.
Failure to provide nail care and personal hygiene assistance: A cognitively intact resident with a self-care deficit and need for ADL support had long, dirty fingernails with black substance under several nails, and the nails were observed to extend past the fingertips. The resident said he had asked more than once for his nails to be cleaned and trimmed, and an LPN confirmed they should have been cleaned and trimmed; the DON stated nursing staff were responsible for keeping non-diabetic residents' nails cleaned and trimmed.
A resident with a G-tube, dysphagia, and GERD had an order for continuous enteral feeding and peg flushes, but the pump was found off and not running during observation. The flush bag was also not labeled with an opened date and time, and an LPN and the DON confirmed the pump should have been running continuously as ordered.
A facility failed to provide safe respiratory care for two residents. One resident’s portable O2 tubing was not labeled with the date last changed, and her O2 was running at 3 L/min despite an order for 2 L/min PRN; an LPN confirmed both issues. Another resident’s pre-filled water reservoir connected to the O2 concentrator was not labeled with the open date, and an LPN confirmed it should have been dated.
Expired medications and supplements were found in medication room MR2 during an observation with an LPN, including Senna Liquid and multiple bottles of Adult Vitamin Tablets with expired dates. The LPN confirmed the items were expired and stated they should not be kept in the medication storage room. The DON stated nurses are responsible for checking expiration dates and confirmed there should be no expired medications or supplements in the medication room.
Two CNAs transferred a resident with severe cognitive impairment and multiple medical conditions using a draw sheet instead of the required mechanical lift with two-person assistance, as specified in the care plan. The improper transfer resulted in the resident sustaining a displaced fracture of the left humerus, requiring emergency evaluation and ongoing pain management.
A resident with severe cognitive impairment and dependent on staff for transfers was injured when two CNAs, unfamiliar with her care needs, transferred her without using the required Hoyer lift, resulting in a fractured arm. The DON and Administrator, after internal investigation, did not report the incident as neglect to the State Survey Agency within the required timeframe, contrary to facility policy.
A resident with severe cognitive impairment and multiple mobility-related diagnoses was transferred between bed and wheelchair by two CNAs using a draw sheet, rather than the required Hoyer lift with two staff as specified in the care plan. Both CNAs did not verify the resident's transfer requirements in the electronic system before performing the transfer, and the DON confirmed the care plan was not followed.
A resident with severe cognitive impairment and a PEG tube had a care plan that did not match current physician's orders for enteral feeding and NPO status. The care plan listed incorrect water flush rates and allowed snacks between meals, which conflicted with the NPO order. Both an LPN and the DON confirmed the care plan was not updated to reflect the resident's current needs.
Expired medications were found on a medication cart, including eye drops without expiration dates and a nasal inhaler past its expiration date. An LPN confirmed the oversight, and the DON stated that staff nurses were responsible for checking expiration dates.
The facility failed to maintain an effective infection prevention and control program. A resident with wounds was transferred without Enhanced Barrier Precautions, and another with a urinary catheter lacked necessary precautions. Additionally, an LPN did not follow hand hygiene protocols during wound care, and a CNA used improper technique during catheter care.
A resident with cognitive intactness and significant medical conditions experienced a lack of dignity when staff failed to empty his urinal in a timely manner. The urinal, containing 400 cc of urine, was left at the bedside from early morning through breakfast and lunch, despite the resident's request for it to be emptied. Staff, including the CNA and DON, confirmed the oversight and acknowledged the disrespectful nature of serving meals with the urinal present.
A resident, who was cognitively intact, reported being physically assaulted by his roommate, who had a history of aggressive behaviors and cognitive impairment. Despite the facility's policy on abuse prevention, no additional staff training or interventions were implemented following the incident. The resident was moved to another room, and the aggressor was sent for evaluation, but no further actions were taken to address the deficiency.
A facility failed to refer a resident with a new mental health diagnosis for a PASRR Level II evaluation. The resident, initially diagnosed with Depression, was later diagnosed with Brief Psychotic Disorder, but the facility did not update the PASRR or request a Level II evaluation. The social worker acknowledged the oversight, and the DON was unaware of the requirement.
A resident, who was cognitively intact, was found with medications left at her bedside by an LPN, who did not observe her taking them. The resident did not have physician orders to self-administer medications. The DON confirmed that medications should not be left at the bedside for residents unable to self-administer.
A facility failed to label oxygen tubing and humidifier bottles with the date of last change for a resident with chronic respiratory conditions, as required by their policy. Staff confirmed the oversight, acknowledging that equipment should be changed and labeled every seven days.
The facility failed to store and prepare food under sanitary conditions, as a package of block cheese was found improperly labeled and dated in the walk-in cooler. Staff confirmed that the cheese should have been labeled with a discard date and used within 7 days of opening, in accordance with the facility's policy. This deficiency was acknowledged by the Dietary Manager and the Administrator.
The facility did not make survey results from the past three years, including recent complaint surveys, accessible to residents, family members, and the public. Observations showed no survey results displayed at the entrance or dining area. The administrator confirmed the binder with survey results was kept in his office and not available for public view, acknowledging that these should have been accessible.
A resident with severe cognitive impairment was left outside overnight without care due to staff assuming she was out on pass with family. The facility's ineffective system for tracking residents' whereabouts led to the resident not receiving necessary care and medications, resulting in hospitalization for multiple health issues.
The facility did not post the required contact information for state agencies and advocacy groups, nor did it provide information on how residents can file complaints with the State Survey Agency. This was confirmed during facility tours and an interview with staff, indicating non-compliance with regulations.
A resident was left outside in a wheelchair for over 14 hours after another resident opened a door, allowing her to exit. The facility failed to report this neglect incident to the state agency within the required 24-hour period, as confirmed by the administrator. The resident was found with wet clothes and a red bottom, indicating neglect.
A resident with severe cognitive impairment suffered a skin tear and bruising when their arm became caught in an assist bar during a care procedure. The facility failed to conduct an entrapment risk assessment or obtain informed consent for the use of assist bars, which were installed at the family's request. Staff interviews confirmed the absence of formal procedures for assessing risk or obtaining consent for assist bars, which were used on resident beds.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure a resident who required assistance with ADLs received the necessary services to maintain good grooming and personal hygiene. Resident #23 was admitted with diagnoses including COPD, chronic diastolic CHF, and depression, and his quarterly MDS showed a BIMS of 15, indicating he was cognitively intact. His care plan identified a self-care deficit related to needing assistance with ADLs and personal hygiene, with interventions to assist with ADLs as needed and provide personal hygiene assistance. Observations showed Resident #23's fingernails were long and dirty. On one observation, the fingernails were noted to be long and dirty, and on a later observation they were still long with a black substance under 6 fingernails and measured approximately 0.5 cm past the fingertip on all 10 fingers. The resident stated he had asked more than once for his nails to be cleaned and trimmed and said he wanted them cleaned and trimmed. An LPN observed and confirmed the nails were long and dirty and should have been cleaned and trimmed. The DON stated nursing staff were responsible for keeping non-diabetic residents' nails cleaned and trimmed and expected all staff to keep each resident's nails cleaned and trimmed.
Enteral Feeding Pump Off and Flush Bag Unlabeled
Penalty
Summary
Resident #102, who was admitted with diagnoses including Gastrostomy, Dysphagia, Disturbances of Salivary Secretion, and Gastro-Esophageal Reflux Disease, had a physician order for Peptamin 1.5 at 60 mL/hr continuously every 24 hours with peg flushes via an auto flush system. During an observation in the resident’s room, the resident was found sitting upright in a wheelchair and asleep, and the enteral feeding pump was noted to be off and not running. Further inspection showed the feeding flush bag was not labeled with an opened date and time. An LPN later confirmed that the pump was not on or running and that the flush bag should have been labeled with an opened date and time. The DON also confirmed that the resident’s feedings were to be administered continuously as ordered and that the pump should not have been off.
Respiratory Equipment Not Properly Labeled and Oxygen Flow Not Per Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #39 by not following the physician-ordered oxygen therapy. Resident #39 had been recently re-admitted with a diagnosis of pneumonitis due to inhalation of food and vomit. On observation, she was sitting upright in her wheelchair in the dining room using a portable oxygen tank and nasal cannula, but the oxygen tubing was not labeled with the date last changed. The resident’s current order directed oxygen at 2 L/min per nasal cannula or mask as needed, yet the portable oxygen was observed running at 3 L/min. An LPN confirmed both that the tubing was not labeled with the date last changed and that the oxygen was being administered at the wrong flow rate. The facility also failed to ensure proper labeling of respiratory equipment for Resident #68. She had diagnoses including pulmonary fibrosis, interstitial pulmonary disease, emphysema, COPD, and sleep apnea, and her most recent BIMS score was 13, indicating she was cognitively intact. During observation, her pre-filled water reservoir connected to the oxygen concentrator was not labeled with the open date. An LPN confirmed the bottle was not labeled with the open date and should have been. The facility policy stated that pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every 30 days, and that the bottle and tubing should be labeled with the current date upon opening.
Expired Medications and Supplements Found in Medication Room
Penalty
Summary
Drugs and biologicals in medication storage were not maintained in accordance with accepted professional principles because expired medications and supplements were found in medication room MR2. During an observation with an LPN, surveyors found one bottle of Senna Liquid 8.8 mg/5 ml with an expiration date of 04/2025, one bottle of Adult Vitamin Tablets with an expiration date of 05/2025, one bottle of Adult Vitamin Tablets with an expiration date of 07/2025, two bottles of Adult Vitamin Tablets with an expiration date of 09/2025, and one bottle of Adult Vitamin Tablets with an expiration date of 10/2025. The LPN confirmed the items were expired and stated expired medications and supplements should not be kept in the medication storage room. The DON later stated nurses are responsible for checking medication expiration dates and confirmed there should be no expired medications or supplements in the medication room.
Failure to Verify Transfer Status Results in Resident Injury
Penalty
Summary
Two certified nursing assistants (CNAs) failed to verify the required transfer method for a resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance, as documented in her care plan. Both CNAs were unfamiliar with the resident's specific needs and did not consult the electronic kiosk or care plan to confirm the appropriate transfer method. Instead, they transferred the resident using a draw sheet, both from bed to wheelchair and later from wheelchair back to bed, without using the required Hoyer lift. The resident, who had significant medical conditions including Parkinson's Disease, a history of falls, a left artificial knee joint, and a right below-knee amputation, was also severely cognitively impaired and unable to advocate for herself. After being transferred back to bed by the CNAs, the resident yelled out in pain. An x-ray was ordered, revealing a closed displaced fracture of the proximal end of her left humerus. She was subsequently sent to the emergency room for evaluation and treatment, and upon return, continued to experience pain and required her arm to be immobilized in a sling. Interviews with the involved CNAs confirmed that neither had checked the resident's care plan or the electronic system to verify the required transfer assistance prior to performing the transfer. Both CNAs admitted they should have checked the resident's transfer status. The Director of Nursing and other staff confirmed that the resident's care plan clearly indicated the need for a Hoyer lift with two-person assistance for all transfers, and that the staff did not follow this plan, resulting in the resident's injury.
Failure to Timely Report Suspected Neglect Following Resident Injury During Transfer
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe after a resident sustained an injury during a transfer. According to facility policy, all alleged violations involving neglect must be reported immediately, but not later than two hours if serious bodily injury is involved, or within 24 hours if not. In this case, a resident with severe cognitive impairment, dependent on staff for transfers, was transferred from a wheelchair to bed by two CNAs who did not verify the required method of transfer. The resident, who required a Hoyer lift with two staff assist per her care plan, was instead transferred using a draw sheet, resulting in her yelling out in pain and later being diagnosed with a fractured left humerus. Interviews with the CNAs involved revealed that neither was familiar with the resident's specific transfer needs and neither checked the care plan or system to confirm the appropriate transfer method prior to the incident. Both CNAs acknowledged that they should have verified the resident's transfer requirements. The Director of Nursing (DON) and Administrator were notified of the incident on the day it occurred, and an internal investigation determined that the injury resulted from improper transfer technique, which was not in accordance with the resident's care plan. Despite these findings, the Administrator did not report the incident to the State Survey Agency, as required by facility policy and regulation. Both the DON and Administrator stated they did not initially consider the incident to be neglect, viewing it instead as a mistake. As a result, the required notification to the State Survey Agency was not made, constituting a failure to report suspected neglect in a timely manner.
Failure to Follow Care Plan for Dependent Transfer
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident who required assistance with transfers. The resident, who had diagnoses including Parkinson's Disease, unspecified osteoarthritis, a history of falls, a left artificial knee joint, and a right below-knee amputation, was assessed as severely cognitively impaired and dependent for chair/bed transfers. The care plan specified that the resident required a Hoyer lift with two staff for all transfers. However, on the day in question, two CNAs who were unfamiliar with the resident's needs transferred her between bed and wheelchair using a draw sheet instead of the required Hoyer lift. Both CNAs confirmed in interviews that they did not check the resident's care plan or the electronic system to verify the required transfer method before performing the transfer. The Director of Nursing confirmed that the resident was not transferred according to her plan of care and that staff are expected to verify the required assistance level if they are unsure. The CNAs involved stated they should have checked the system or asked for guidance but did not do so prior to transferring the resident. This failure to follow the established care plan resulted in the resident not receiving care as planned for her specific needs.
Care Plan Not Updated to Reflect Current Physician's Orders
Penalty
Summary
The facility failed to develop and maintain a comprehensive, person-centered care plan that accurately reflected a resident's current physician's orders. Specifically, the care plan for a resident with diagnoses including dysphagia following cerebral infarction and a gastrostomy did not match the active physician's orders regarding enteral feeding and water flush rates. The physician's orders specified Glucerna 1.5 at 60 cc/hr via PEG with a 40 ml/hr flush and an NPO diet, but the care plan listed a 60 ml/hr water flush and included an intervention to allow snacks between meals, which contradicted the NPO order. During interviews, both an LPN and the DON confirmed that the care plan did not accurately reflect the current physician's orders. The discrepancies were identified through review of the resident's clinical record, MDS assessment indicating severe cognitive impairment, and direct comparison of the care plan with the physician's orders. The staff acknowledged that the care plan should have been updated to align with the resident's current medical needs and orders.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles, specifically regarding the availability of expired medications for administration. During an observation of Med Cart 1, it was found that a bottle of lubricant eye drops and another bottle of eye drops, both dated from August 2024, had no expiration dates, and a nasal inhaler with an expiration date of August 17, 2024, was still present. An LPN confirmed that eye drop medications should only be used for 30 days and acknowledged that the expired nasal inhaler should have been removed but was not. The Director of Nursing stated that staff nurses were responsible for checking medication carts for expired medications and that nurses administering medications should check expiration dates before use. He confirmed that the eye drops were beyond their 30-day use period and the nasal inhaler was expired and should have been discarded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #107, staff did not implement Enhanced Barrier Precautions (EBP) during a transfer, despite the resident having wounds that required such precautions. The Certified Nursing Assistant (CNA) involved admitted to not wearing gloves or a gown during the transfer, which was confirmed by the Director of Nursing (DON) as a high-contact activity necessitating EBP. Resident #271, who had an indwelling urinary catheter, was not provided with EBP measures upon admission. There was no signage or personal protective equipment (PPE) available at the resident's door, which was acknowledged by both the Licensed Practical Nurse (LPN) and the DON. The DON confirmed that EBP should have been implemented for residents with urinary catheters. Additionally, the facility's staff failed to adhere to proper hand hygiene protocols during wound care for Resident #107. The LPN performing the wound care did not use hand sanitizer or wash hands between glove changes, which was contrary to the facility's hand hygiene policy. Furthermore, improper infection control techniques were used during catheter care for Resident #35, as the CNA cleaned the catheter tubing in the wrong direction, which was acknowledged as incorrect by both the CNA and the DON.
Failure to Maintain Resident Dignity by Timely Urinal Management
Penalty
Summary
The facility failed to ensure that a resident's right to a dignified existence was upheld, as evidenced by the improper handling of a urinal in the resident's room. Resident #50, who is cognitively intact and has diagnoses including the acquired absence of both legs above the knee, anxiety, and PTSD, reported that his urinal was not emptied in a timely manner. Despite having meals in his room, the urinal containing 400 cc of urine was left at his bedside from 6:00 a.m. and remained there through breakfast and lunch, which the resident found disrespectful. Observations and interviews confirmed that the urinal was not emptied by staff during their shifts, even though it was in plain sight and should have been addressed. The CNA responsible for Resident #50 acknowledged that the urinal had not been emptied during her shift and confirmed that meals were served with the urinal present. The Director of Nursing also confirmed the oversight and agreed that serving meals with a urinal at the bedside was disrespectful to the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which constitutes a deficiency in ensuring residents' rights to be free from abuse. Resident #28, who was cognitively intact with a BIMS score of 15, reported being physically assaulted by his roommate, Resident #100, who also had a history of aggressive behaviors and a BIMS score of 8, indicating cognitive impairment. The incident occurred when Resident #28 was awakened by Resident #100 punching and elbowing him, causing fear and distress. This incident was reported to an LPN, who confirmed the assault with Resident #100. Despite the facility's policy on abuse prevention, there were no additional staff training or interventions implemented following the incident. The Director of Nursing and the Administrator were informed of the altercation, and while Resident #28 was moved to another room and Resident #100 was sent to the emergency room for evaluation, no further actions were taken to address the deficiency. The lack of further interventions or staff in-service training highlights the facility's failure to adequately prevent and respond to resident-to-resident abuse.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. Resident #11 was admitted with a diagnosis of Depression and later received an additional diagnosis of Brief Psychotic Disorder on 09/28/2023. However, the facility did not update the resident's Level I PASRR to include this new diagnosis, nor did they resubmit a request for a Level II evaluation and determination. During an interview, the social worker responsible for submitting PASRRs confirmed that a request should have been made following the new diagnosis but was not. The Director of Nursing was also unaware of the need to resubmit the Resident Review form for a PASRR Level II referral after the resident's new diagnosis. This oversight resulted in the facility's failure to comply with the required procedures for residents with mental health diagnoses.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure that nursing staff adhered to professional standards of quality by leaving medications at the bedside of a resident who did not have physician orders to self-administer medications. Resident #82, who was cognitively intact with a BIMS score of 13, was observed with seven pills in a medication cup and a 4-ounce cup of liquid supplement on her bedside table. The resident reported that an LPN had given her the medications and left the room without observing her take them. The LPN confirmed this account and acknowledged that the medications should not have been left at the bedside. The Director of Nursing also confirmed that medications should not be left at the bedside for residents unable to self-administer medications.
Failure to Label Oxygen Equipment in Accordance with Policy
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for a resident receiving oxygen therapy. Specifically, the facility did not label the oxygen tubing and humidifier bottle with the date they were last changed, as required by the facility's policy. The policy mandates that pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every seven days or when the water level becomes low. During an observation, it was noted that the oxygen tubing and humidifier bottle for a resident with chronic respiratory conditions were not labeled with the date of the last change. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the facility's policy was to change all oxygen tubing and humidifier bottles every seven days on Sunday, and that they should be labeled with the date of change. However, the staff acknowledged that the resident's equipment was not labeled as required. This oversight was identified during a survey, highlighting a deficiency in adhering to the facility's infection control procedures related to oxygen administration.
Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, as observed during a survey. During an initial tour of the facility's kitchen, a package of block cheese was found in the walk-in cooler, wrapped in plastic wrap, opened, and dated 08/24/2024, which was not in compliance with the facility's policy. The policy required all foods stored in the refrigerator or freezer to be covered, labeled, and dated, with refrigerated foods labeled and dated to ensure they are used prior to expiration, frozen, or discarded. Interviews with staff confirmed that the opened cheese should have been labeled with a discard date and used within 7 days of opening. The staff acknowledged the failure to comply with the policy, which was confirmed by the Dietary Manager and the Administrator.
Survey Results Not Accessible to Public
Penalty
Summary
The facility failed to ensure that all survey results from the past three years, including complaint surveys since the last annual survey, were accessible for residents, family members, legal representatives, and the public. On October 14, 2024, observations were made at the facility's entrance and dining area, revealing the absence of a binder or display of survey results. During an interview, the administrator confirmed that the survey results binder was not available for public view and was instead kept in his office. The administrator acknowledged that survey results from annual recertification surveys dated October 2023, October 2022, and October 2021, as well as complaint surveys from August 27, 2024, and September 5, 2024, should have been accessible to the public but were not.
Resident Neglect Due to Ineffective Tracking System
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a severely cognitively impaired resident being left outside overnight without necessary care. The resident, who required extensive assistance, self-propelled outside the facility without staff knowledge. Staff assumed the resident was out on pass with family, leading to a lack of care and medication administration for over 14 hours. The resident was found the next morning, lethargic and wet with urine, and was subsequently transferred to the hospital with conditions including Hypertensive Urgency, Hyponatremia, Dehydration, and Mild Acute Kidney Injury. The facility's system for tracking residents' whereabouts was ineffective, as staff failed to verify whether the resident was signed out on pass. Interviews revealed that staff relied on assumptions and information from the resident's roommate rather than checking the sign-out log or contacting the family. This oversight resulted in the resident not receiving incontinence care or medications as required by her care plan. The incident highlighted a breakdown in communication and procedure among the staff. Multiple staff members, including CNAs and LPNs, did not verify the resident's location, leading to neglect. The facility's policy on identifying neglect was not effectively implemented, as staff did not ensure the resident's safety and well-being, resulting in significant harm.
Failure to Post Required Contact Information for State Agencies
Penalty
Summary
The facility failed to post the names, addresses, and telephone numbers of all pertinent state agencies and advocacy groups, including the State Survey Agency, as well as a statement on how residents may file a complaint with the State Survey Agency. This deficiency was identified during a brief tour of the facility on September 3, 2024, at 2:00 p.m., where no such postings were observed. The issue was further confirmed during a subsequent tour on September 4, 2024, at 11:36 a.m., with staff member S8SS, who acknowledged the absence of the required postings. Additionally, an interview with S1ADM on the same day at 11:43 a.m. confirmed the lack of postings, indicating a failure to comply with regulations that ensure residents are informed about how to report suspected violations of state or federal nursing facility regulations.
Failure to Report Resident Neglect Incident
Penalty
Summary
The facility failed to report an alleged neglect incident involving a resident to the state survey agency within the required 24-hour timeframe. The incident involved a resident who was found outside the facility in a wheelchair, having been there for over 14 hours. The resident was discovered by staff at 8:30 a.m. after being outside since the previous evening. The facility's policy mandates that all alleged violations involving neglect be reported immediately, but no later than 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury. However, the facility administrator confirmed that the incident was not reported to the state agency. The incident began when another resident opened a door, allowing the resident in question to wheel herself out onto the patio and eventually get stuck between the fence and sidewalk. The resident remained outside overnight, and was found the next morning with wet clothes and a red bottom, indicating potential neglect. The facility's failure to report this incident in a timely manner constitutes a deficiency in adhering to their own policies and state regulations regarding the reporting of neglect.
Failure to Assess Entrapment Risk and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident was assessed for the risk of entrapment from bed rails and did not obtain informed consent for their use. The facility's policy on bed rails requires an interdisciplinary evaluation, assessment of alternatives, and informed consent before bed rails are used. However, for one resident with severe cognitive impairment, there was no documentation of an entrapment risk assessment or consent for the use of bed rails. The incident involved a resident with Alzheimer's Disease, Dementia, and Generalized Muscle Weakness, who required moderate staff assistance for bed mobility. During a routine care procedure, the resident's arm became caught in the assist bar, resulting in a skin tear and bruising. The staff involved did not realize the resident's arm was caught until after the injury occurred. The facility's incident investigation confirmed the lack of assessment and consent for the use of assist bars, which were used at the request of the resident's family. Interviews with facility staff revealed that there was no formal process for assessing entrapment risk or obtaining consent for the use of assist bars, which were considered different from bed rails. The facility did not perform risk assessments or obtain consents for the assist bars, which were used on resident beds. The staff acknowledged the absence of these procedures, and the facility's Director of Nursing confirmed that no other interventions were considered before the installation of the assist bars.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Slaughter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Zachary Manor Nursing And Rehabilitation Center | 5.3 mi | ★★★★★ | 9 | 0 |
| The Lodge At Lane | 5.5 mi | ★★★★★ | 0 | 0 |
| Villa Feliciana Chronic Disease | 7.5 mi | ★★★★★ | 7 | 0 |
| Louisiana War Veterans Home | 7.5 mi | ★★★★★ | 0 | 0 |
| River Oaks Nursing & Rehabilitation Center Llc | 9.2 mi | ★★★★★ | 2 | 0 |
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