House of Grace 3

Based on record review, the licensee did not comply with the section cited above as two (2) out of three (3) staff files did not contain proof of the required additional 20 hours of annual training, which poses/posed a potential health, safety, or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as six (6) out of six (6) resident files did not contain updated re-appraisals, which poses/posed a potential health, safety, or personal rights risk to persons in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven* Licensee will send report and retrain by 8/13/24. case.(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.(C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

Based on observation, the licensee did not comply with the section cited above in 2 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, water temperature taken in kitchen sink was measured to be 141 degrees F and was not prominetly identified by warning signs, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, staff #1 training record did not document required 6 hours of dementia care with 4 weeks of employment, the licensee did not comply with the section cited above in 1 out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, water temperatures in grooming faucets were above 120 degree F, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.