Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Essentia Health Grace Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and a history of wandering eloped from the facility, and care plans for three residents at risk for elopement lacked interventions for exit-seeking behaviors and did not specify how often to test wanderguard batteries. Staff only checked device placement, not battery function, and the facility's policy did not address monitoring or battery testing frequency as recommended by the manufacturer.
A resident with a history of falls and medical conditions requiring assistance was injured due to the facility's failure to implement care plan interventions. The resident fell during a bathroom transfer when a nursing assistant did not use a required gait belt, resulting in a nasal bone fracture and forehead laceration. Staff interviews confirmed the oversight, highlighting the importance of adhering to care plans for resident safety.
A facility failed to implement proper PPE practices for a resident under Enhanced Barrier Precautions, designed to prevent the spread of multidrug-resistant organisms. Staff only used gloves during high-contact activities, despite CDC guidance requiring gowns and gloves. Misunderstandings about PPE requirements were revealed, and gowns were not readily available, leading to the deficiency.
A resident with diabetes mellitus received insulin without the pen being primed, contrary to manufacturer's instructions. The RN administering the insulin acknowledged the oversight. Interviews with the consultant pharmacist and DON confirmed the importance of priming to ensure accurate dosage, as outlined in the manufacturer's package insert and facility policy.
Failure to Assess and Intervene for Elopement Risk and Inadequate Wanderguard Battery Testing
Penalty
Summary
The facility failed to adequately assess and implement interventions for residents at risk for elopement, specifically for one resident who was cognitively impaired with a history of dementia, anxiety disorder, and wandering behaviors. This resident had a documented history of elopement and exit-seeking behaviors, including pounding on doors and standing at exit doors, but the care plan did not include interventions for these behaviors or document the reasons for the resident's attempts to leave the facility. The care plan also lacked specific guidance on how often to check the battery of the resident's wanderguard tag, a device intended to alert staff if the resident attempted to leave the premises. Additionally, the facility failed to follow manufacturer recommendations for testing the batteries of wanderguard tags for three residents identified as at risk for elopement. While staff checked the physical placement of the wanderguard devices every shift, there was no evidence that the batteries were tested weekly as required by the manufacturer. Instead, maintenance staff tested the batteries monthly, and there was no documentation of these checks. Interviews with staff and the DON revealed a lack of awareness regarding the recommended frequency for battery testing and an absence of documentation or policy guidance on this matter. The facility's elopement prevention policy did not provide adequate direction on monitoring and managing residents at risk for elopement or specify how often wanderguard batteries should be tested. Multiple staff interviews confirmed that interventions for exit-seeking behaviors were not included in the care plans, and the focus was primarily on door security rather than addressing the underlying causes of residents' attempts to leave. The deficiency was further evidenced by an incident in which a resident successfully eloped from the facility and was found outside, as well as another incident where the same resident attempted to leave again shortly after.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement care plan interventions for a resident who required the use of a transfer belt during transfers, resulting in a fall and significant injury. The resident, who had intact cognition and required assistance with various activities of daily living, was identified as being at risk for falls due to a history of falls with injury, chronic cardiac conditions, and other health issues. Despite these risks, staff did not use a transfer belt during a transfer to the bathroom, leading to the resident falling and sustaining a bilateral nasal bone fracture and a forehead laceration. The incident occurred when a nursing assistant was assisting the resident in the bathroom. The resident, who had been experiencing episodes of dizziness and vagal responses, stood up from the toilet without a gait belt and fell forward over her walker, landing face-first on the floor. The nursing assistant had not used a gait belt, which was a requirement per the resident's care plan, and this oversight contributed to the resident's fall and subsequent injuries. Interviews with staff revealed that the use of a gait belt was a standard procedure for residents requiring assistance with transfers, especially those with a history of vagal responses. However, the nursing assistant involved in the incident admitted to forgetting to use the gait belt. The facility's investigation confirmed that the care plan was not followed, and the lack of a gait belt during the transfer was a critical factor in the resident's fall and injuries.
Inadequate PPE Use for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate donning and doffing of personal protective equipment (PPE) practices for a resident under Enhanced Barrier Precautions (EBP), which are designed to reduce the transmission of multidrug-resistant organisms. The deficiency was observed during interactions with a resident who required extensive assistance with activities of daily living, including toileting and dressing, and had a catheter due to bladder outlet obstruction. Despite the presence of a sign on the resident's door indicating the need for gown and glove use during high-contact activities, staff members, including an occupational therapy assistant and a nursing assistant, only used gloves while assisting the resident with toileting, contrary to the Centers for Disease Control and Prevention (CDC) guidance. Interviews with staff, including the infection preventionist and the director of nursing, revealed a misunderstanding of the EBP requirements, with staff believing that gowns were only necessary when working with the resident's catheter. The facility's policy on Standard and Transmission Based Precautions indicated that gowns should be worn to protect skin and prevent soiling of clothing during activities likely to generate splashes or sprays of body fluids. However, gowns were not readily available in or outside the resident's room, and staff did not adhere to the expected PPE protocols, leading to the deficiency.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of insulin using a Novolog insulin pen for a resident with diabetes mellitus. The resident, who had intact cognition, was prescribed Novolog Flex Pen U-100 to be administered subcutaneously three times daily. During a medication pass, a registered nurse (RN) prepared and administered the insulin without priming the pen as per the manufacturer's instructions. The RN acknowledged the oversight and confirmed awareness of the requirement to prime the pen to ensure accurate dosage. Interviews with the consultant pharmacist and the director of nursing highlighted the importance of priming the insulin pen to deliver the correct dosage. The manufacturer's package insert and the facility's medication administration policy both emphasized the necessity of performing an airshot before each injection to remove air bubbles. The failure to prime the insulin pen was a deviation from these guidelines, resulting in a significant medication error for the resident.
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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.
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Nursing homes near Graceville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Traverse Care Center | 16.8 mi | ★★★★★ | 7 | 0 |
| Fairway View Neighborhoods | 17.1 mi | ★★★★★ | 1 | 1 |
| Browns Valley Health Center | 19.2 mi | ★★★★★ | 7 | 1 |
| Wilmot Care Center Inc | 23.2 mi | ★★★★★ | 0 | 0 |
| West Wind Village | 24.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.