Inspection Reports for
Grace Caldwell Independent, Assisted Living & Memory Care

.404 Fire and life safety standards for existing buildings: the double doors from the kitchen to the main dining hall would not self-close because the right-hand door leaf strikes the locking mechanism of the left-hand door leaf, preventing closure. This is a repeat deficiency from a 6/3/2022 survey.

.405.02.c Prohibited applications: a coffee maker and a toaster were plugged into a relocatable power tap in Room 203.

.310.01.c. Medication Distribution System: the facility did not maintain the medication refrigerator temperatures between 38 and 45 degrees F, with documented out-of-range temperatures as low as 35 degrees on multiple occasions and no corrective action taken.

.215.08.f Notification to Licensing Agency within One Business Day: the facility did not notify Licensing and Certification within one business day when residents fell and required outside assessment; the nurse stated the facility was using an old reportable incident matrix and was unaware these incidents needed to be reported.

.330.09 Resident Admission and Discharge Register: the facility did not maintain an up-to-date admission and discharge register; the register inaccurately documented resident counts with discrepancies among the register, administrator statements, and electronic medical records.

.403 Fire and life safety standards: the facility lacked documentation for smoke detector sensitivity testing since initial construction in 2018, and kitchen doors with kick-down hold-open devices did not self-close, with door leaves interfering with each other, compromising corridor safety.

.155 Emergency preparedness requirements: disaster plan does not include all relevant facility risks such as a main rail transport line 0.3 miles away and lacks a plan addressing internal and external flood risks.

.155.02.b Written procedures: disaster plan does not include designated assembly points for emergencies.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: doors to hazardous areas such as laundry rooms were obstructed from fully self-closing; door to laundry by room 172 was chocked open with a wooden door wedge.

.415.02 Fuel-fired heating: no copy of annual fuel-fired heating inspection for furnaces on site; furnaces must be inspected at least annually.

.415.04 Fire alarm smoke detection system service and testing: no documentation of fire alarm inspection or sensitivity testing since initial construction.

.415.05 Automatic fire extinguishing system service and testing: missing escutcheon at main dining room west side ceiling; sprinkler heads loaded or painted requiring replacement; temporary construction cover over sprinkler pendant by room 134; no documented gauge or control valve inspections at fire riser on southeast side of building.

.335.01 Implementation of Policies: the facility allowed a caregiver to work on 8/14/20 and 8/15/20 after they had a nasal swab test for COVID-19, which was positive, on 8/14/20 from the hospital.

.335.02 Standard Precautions: the facility did not implement testing of all caregivers and residents after being instructed to do so by the local health department after residents and staff had positive cases of COVID-19. The facility did not isolate Resident #1 per CDC guidance after they returned from the hospital with a positive COVID-19 test result. Resident #1's caregivers were allowed to work with Resident #1 and then passed medications to all memory care residents during the same shifts.

.335.03 Reporting of Individual with an Infectious Disease: the facility did not implement mass testing on three separate occasions after being instructed to do so by the local health department when residents and staff had positive test results for COVID-19.

.405.06 Natural or man-made hazards: the facility did not have a suitable fence, railing or guard to provide protection for residents after construction began on the East side of the building, leaving a three foot immediate drop off into a construction trench outside of each exit door.

.520-09 Inadequate care - safe living environment: the facility failed to provide a safe living environment for Resident #1, who was legally blind, and potentially other residents by not installing proper barriers or developing an adequate safety plan after sidewalks were removed, resulting in Resident #1 falling into a construction trench and sustaining multiple injuries.

.405.03 Medical gases: Resident room #126 had two oxygen cylinders unsecured sitting on the floor.

.250.13.j. Resident sleeping rooms: Resident #7 resided in a room which did not have a door; the room had a half-wall approximately 5 feet tall and did not provide privacy.

.711.01. Ongoing resident care records: the facility's behavior tracking tool did not document the outcome for each intervention implemented, making it unclear which interventions were effective.