Earlier this month, at the first-ever meeting of NorCo Council's Gracedale Oversight Committee, it was learned that the home, which is currently operating with a Provisional II license, was cited by the state Department of Health on September 10 and again on September 24 with three deficiencies. Two of these were "G" level deficiencies, meaning there was actual harm to a resident.
There was little detail about these violations at the meeting, but the September 10 deficiencies are now posted on the Department of Health website.
The first violation involved a resident with dysphagia (difficulty swallowing), traumatic brain injury, and spastic hemiplegia (a neuromuscular condition that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body resulting in muscles on one side of the body). He has a swallowing problem and was placed on a special diet of soft food. Direct supervision is required when he eats.
On August 28, he began choking on a meal that was supposed to be pureed. Although he was supposed to be under supervision while eating, another resident slipped him part of a sandwich without notice by a nurse. He began to choke and the Heimlich maneuver failed. The resident had to be laid on his side and was subject to back thrusts until he spit out pieces of the sandwich. He was rushed to the hospital, where it was determined that he had acute respiratory failure with hypoxia from aspiration pneumonia. He remained in the hospital for four days.
Gracedale's nursing director admitted that the facility failed to provide adequae supervision.
The second violation occurred on August 22, and involves a resident suffering from ALS. Her medical plan requires that a gait belt be used when she is walking or moving from his wheelchair to a bed. A nurse's aide was assisting this resident in getting from his wheelchair to his bed when the resident began to cry and fall down. The nurse's aide had failed to use the required gait belt, but had the presence of mind to lower herself to the floor with the resident to break the fall and reduce injury. There is no indication that the resident suffered any harm.
Although one of these incidents is a "G" level deficiency, I'd agree that they pale in comparison to some of the other deficiencies found at Gracedale since Michelle Morton has been its Administrator. But deficiencies are still deficiencies, and even Executive Tara Zrinski concedes that the home will be in Provisional status a bit longer than had been hoped.
The details of the third incident are still unavailable for public review.
According to the CMS website, there is no indication that Gracedale was fined over either of these incidents.

