GRACE ASSISTED LIVING LLC

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 5/29/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 5/29/25. The facility is in compliance with all deficiencies that were cited.

A certification complaint, prompted by #CO40168, was completed on 5/29/25. A deficiency was cited.

Based on record review and staff interview, the facility (residence) failed to ensure allegations of abuse were thoroughly investigated affecting one member (resident) (#1) and two former residents (#2, #3). Findings include:1. Record ReviewThe residence's Abuse, Neglect, and Exploitation policy, dated 11/1/13, read in part: All observations and actions are recorded in the resident record and/or on other forms as indicated by facility policies and procedures. An investigation will be carried out and will be documented according to regulations, requirements, and/or facility policy and procedures. If an employee was involved, the suspected employee would be suspended pending the outcome of the investigation. The employee would not be allowed to return to the facility or to interact with the resident until the investigation was completed. Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia. An investigation report dated 5/17/25, read that "The facility has received a report regarding an allegation of abuse between a caregiver (Staff #2) and a resident (former Resident #3). The incident occurred on 5/16/25, around 9:30 a.m., when an [external health representative] who administered [former Resident #2's] insulin overheard shouting and what sounded like a slap between [Staff #2] and [former Resident #3]. Administrative staff were away from the facility at this time."The internal investigation revealed that the facility interviewed six residents, a staff member from the external health representative company, and one facility staff member. Former Resident #2's interview revealed that he admitted to having claimed to have been hit by Staff #2 before. Former Resident #3's interview revealed that she had witnessed both verbal and physical abuse between Staff #2 and former Resident #3 on several occasions. Two resident interviews revealed that they had witnessed yelling between Staff #2 and former Resident #3 before. However, the facility concluded the alleged abuse was not true due to the 'staggering' evidence. On 5/27/25 at 10:05 a.m., the staff schedule was requested. The residence provided the staff schedule at 10:11 a.m. Staff #2's name was listed on the schedule for 5/16-5/19/25. On 5/27/25 at 3:55 p.m., the monitoring for Staff #2 was requested. At 4:11 p.m., the administrator created a template and provided a blank template the residence would use moving forward. On 5/28/25 the monitoring document was not provided or filled out as to how the residence monitored Staff #2 during her shift on 5/27/25. On 5/28/25 at 3:17 p.m., the schedule was again requested to be updated before the exit could take place. After questions were asked about Staff #2, Staff #1 crossed out Staff #2's name on 5/17, 5/18 and 5/19/25.2. InterviewOn 5/27/25 from 10:20 to 10:28 a.m., the administrator and Staff #1 were sharing their confusion with why schedules needed to be changed when staff leave for a few hours. They continued to explain that Staff #1 and Staff #3 live in the building, so they are always here; however there are some Sundays where Staff #1 is gone for hours to go to church. Though they continued to explain their confusion and hesitance to update the schedule they reluctantly added a few updates to the schedule. On 5/27/25 at 2:04 p.m., the local law enforcement department representative read the police report over the phone and confirmed that on 5/16/25, former Resident #3 reported that she had witnessed Staff #2 always yell at former Resident #3 and 'throw her around like a rag doll.'On 5/27/25 at 3:55 p.m., the administrator acknowledged that the investigation report submitted to the state department read that the residence would monitor Staff #2 for the next 30 days, however, when asked what monitoring looked like for Staff #2 the administrator asked for advice as to how the residence could monitor Staff #2. He continued to say he was not sure the best way to monitor the staff, asked how the state department would recommend monitoring to look and stated that he would create a template. On 5/28/25 at 12:54 p.m., Former Resident #3 confirmed that she had witnessed Staff #2 hit former Resident #3 on multiple occasions but she believed that the resident deserved it so she never told the other staff. Former Resident ##3 continued to state that these hits occurred in several places including the common rooms and that a former staff member had even witnessed the physical abuse. On 5/28/25 at 3:37 p.m., Staff #1 and the administrator acknowledged that though they reported to the state department that Staff #2 was not allowed on the premises until the investigation was over, the staff schedule given until this question was brought up, did reflect that Staff #2 worked 5/17-5/19/25. On 5/28/25 at approximately 3:45 p.m., the administrator confirmed that the monitoring in the internal investigation was not detailed and did not specify how monitoring would look for staff and how they would ensure that they protected the residents throughout the 30 days. He continued on to admit that the investigation failed to document the action steps taken when two residents claimed to either be a witness of abuse or to be a victim of abuse and agreed that the internal investigation looked like they did not follow up with in the report submitted to the state department. He admitted that the residence failed to document any follow up interviews that were attempted with each resident.

A licensure complaint, prompted by #CO40167, was completed on 5/29/25. Deficiencies were cited.

Based on record review and interview, the residence failed to promptly notify the residents' responsible parties regarding the residents' change from baseline status affecting one (#3) former resident. Findings include: Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia. An incident report dated 11/18/24, read that former Resident #3 had a fall which resulted in her right knee swelling, and she could not straighten her knee, and later was taken to the emergency room. It also read that the former resident's case manager and residence staff were notified. A progress note dated 11/20/24 read that former Resident #3 was discharged from the hospital. A progress note dated 11/22/25, read that former Resident #3 asked for pain medication and her practitioner prescribed pain medication. Later that day a progress note read that former Resident #3 did not have any strength, not able to sit straight, eyes not focusing and was taken to the hospital. A progress note dated 11/25/24, read that former Resident #3 was discharged from the hospital. A progress note dated 12/5/24, read that former Resident #3 had surgery on her broken right knee to fix her patella. A progress note dated 12/26/24, read that former Resident #3's daughter called the residence where the residence then informed her that former Resident #3 had a fall and had surgery. The note continued to read that the resident had continued to bend her knee and re-injured the knee and was scheduled for another surgery on 1/3/25. Progress notes with a date range from 11/18/24 to 12/26/24 read that the residence had only attempted to reach out to the sister only and had failed to attempt to contact former Resident #3's daughter who was listed as former Resident #3's emergency contact. A progress note dated 1/15/25 read that the residence called former Resident #3's case manager and informed her that they had the wrong number on file so the messages that were left to inform her from 11/18/24 to 1/15/25 went to someone else. On 5/27/25 at approximately 10:58 a.m., Staff #1 and the administrator stated the residence did not contact former Resident #3's daughter of the incident because they did not have her phone number until 12/16/24 and provided time-stamped face sheets that showed when the phone number was added. On 5/28/25 at approximately, 3:04 p.m., Staff #1 and the administrator confirmed that they believed a fall and broken patella was a change in condition. On 5/28/25 at approximately 3:10 p.m., the administrator stated that he expected that each emergency contact listed be notified when the residence cannot get ahold of a representative. Staff #1 and the administrator confirmed that they had only called the sister and did not attempt to contact former Resident #3's daughter. On 5/28/25 at 3:13 p.m., Staff #1 also confirmed that she recalled knowing former Resident #3's daughter contact information prior to 12/26/24 and recalled that she had conversations with her daughter back in 2019. She continued to say that she assumed the daughter's phone number had changed when she moved to another state, and did not remember why it was not updated in the contact information when the residence was initially informed of the phone number.

Based on record review, observation, and interview, the residence failed to investigate allegations of neglect in accordance with regulation and written policy, affecting one resident (#1) and two former residents (#2, #3). Findings include:1. Record ReviewThe residence's Abuse, Neglect, and Exploitation policy, dated 11/1/13, read in part: All observations and actions are recorded in the resident record and/or on other forms as indicated by facility policies and procedures. An investigation will be carried out and will be documented according to regulations, requirements, and/or facility policy and procedures. If an employee was involved, the suspected employee would be suspended pending the outcome of the investigation. The employee would not be allowed to return to the facility or to interact with the resident until the investigation was completed. Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia. An investigation report dated 5/17/25, read that "The facility has received a report regarding an allegation of abuse between a caregiver (Staff #2) and a resident (former Resident #3). The incident occurred on 5/16/25, around 9:30 a.m., when an [external health representative] who administered [former Resident #2's] insulin overheard shouting and what sounded like a slap between [Staff #2] and [former Resident #3]. Administrative staff were away from the facility at this time."The internal investigation revealed that the facility interviewed six residents, a staff member from the external health representative company, and one facility staff member. Former Resident #2's interview revealed that he admitted to having claimed to have been hit by Staff #2 before. Former Resident #3's interview revealed that she had witnessed both verbal and physical abuse between Staff #2 and former Resident #3 on several occasions. Two resident interviews revealed that they had witnessed yelling between Staff #2 and former Resident #3 before. However, the facility concluded the alleged abuse was not true due to the 'staggering' evidence. On 5/27/25 at 10:05 a.m., the staff schedule was requested. The residence provided the staff schedule at 10:11 a.m. Staff #2's name was listed on the schedule for 5/16-5/19/25. On 5/27/25 at 3:55 p.m., the monitoring for Staff #2 was requested. At 4:11 p.m., the administrator created a template and provided a blank template the residence would use moving forward. On 5/28/25 the monitoring document was not provided or filled out as to how the residence monitored Staff #2 during her shift on 5/27/25. On 5/28/25 at 3:17 p.m., the schedule was again requested to be updated before the exit could take place. After questions were asked about Staff #2, Staff #1 crossed out Staff #2's name on 5/17, 5/18 and 5/19/25.2. InterviewOn 5/27/25 from 10:20 to 10:28 a.m., the administrator and Staff #1 were sharing their confusion with why schedules needed to be changed when staff leave for a few hours. They continued to explain that Staff #1 and Staff #3 live in the building, so they are always here; however there are some Sundays where Staff #1 is gone for hours to go to church. Though they continued to explain their confusion and hesitance to update the schedule they reluctantly added a few updates to the schedule. On 5/27/25 at 2:04 p.m., the local law enforcement department representative read the police report over the phone and confirmed that on 5/16/25, former Resident #3 reported that she had witnessed Staff #2 always yell at former Resident #3 and 'throw her around like a rag doll.'On 5/27/25 at 3:55 p.m., the administrator acknowledged that the investigation report submitted to the state department read that the residence would monitor Staff #2 for the next 30 days, however, when asked what monitoring looked like for Staff #2 the administrator asked for advice as to how the residence could monitor Staff #2. He continued to say he was not sure the best way to monitor the staff, asked how the state department would recommend monitoring to look and stated that he would create a template. On 5/28/25 at 12:54 p.m., Former Resident #3 confirmed that she had witnessed Staff #2 hit former Resident #3 on multiple occasions but she believed that the resident deserved it so she never told the other staff. Former Resident ##3 continued to state that these hits occurred in several places including the common rooms and that a former staff member had even witnessed the physical abuse. On 5/28/25 at 3:37 p.m., Staff #1 and the administrator acknowledged that though they reported to the state department that Staff #2 was not allowed on the premises until the investigation was over, the staff schedule given until this question was brought up, did reflect that Staff #2 worked 5/17-5/19/25. On 5/28/25 at approximately 3:45 p.m., the administrator confirmed that the monitoring in the internal investigation was not detailed and did not specify how monitoring would look for staff and how they would ensure that they protected the residents throughout the 30 days. He continued on to admit that the investigation failed to document the action steps taken when two residents claimed to either be a witness of abuse or to be a victim of abuse and agreed that the internal investigation looked like they did not follow up with in the report submitted to the state department. He admitted that the residence failed to document any follow up interviews that were attempted with each resident.

Based on interview and record review, the residence failed provide therapeutic diets when the diet is prescribed by the resident's practitioner, affecting one of three sample residents (#3). Findings include:Former Resident #3 was admitted to the residence on 11/15/16 with diagnoses including dementia, dysphagia, and schizophrenia. A written practitioner's order, dated 5/22/25, directed the residence to provide a thickened liquid diet. The resident's care plan, dated 5/22/25, revealed that the resident required a thickened liquid diet. On 5/27/25 at approximately 3:00 p.m., the speech language pathologist stated she expected the residence to follow practitioner's and her instruction that former Resident #3 be given thickened liquid once the order was received on 5/22/25. On 5/28/25 at 4 p.m., Staff #1 and the administrator stated they were aware that former Resident #3's practitioner prescribed a therapeutic diet. On 5/28/25 at approximately 4:04 p.m., Staff #1 stated that the residence did not receive a prescription from the pharmacy and therefore did not and could not purchase the thickened liquid powder for former Resident #3 to drink liquids from 5/22/25 to 5/24/25. On 5/29/25 at approximately 12:04 p.m., Staff #1 confirmed that the residence was still providing former Resident #3 thin liquids after receiving the order from the practitioner. She also stated that she was aware that the residence was responsible for purchasing items ordered by a practitioner, 'no matter what.' However, she said she was unaware that the residence could purchase thickened liquid from a department store without a prescription.

A recertification survey was completed on 10/23/24. No deficiencies were cited

A relicensure survey was completed on 10/23/24. No deficiencies were cited.

A recertification survey revisit was completed on 10/23/24 for all previous deficiencies cited 10/27/22. The facility is in compliance with all regulations surveyed.

A relicensure survey revisit was completed on 10/23/24 for all previous deficiencies cited 10/27/22. The residence is in compliance with all regulations surveyed.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally