Inspection Reports for Grace Caldwell Independent, Assisted Living & Memory Care
ID, 83605
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Inspection Report
Life Safety
Deficiencies: 2
Mar 22, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Grace Assisted Living at Caldwell.
Findings
Two deficiencies were identified: the double doors from the kitchen to the main dining hall would not self-close due to a locking mechanism issue, and Room 203 had a coffee maker and toaster plugged into a relocatable power tap, which is prohibited.
Deficiencies (2)
| Description |
|---|
| Double doors leading from the kitchen into the main dining hall would not self-close due to the right-hand door leaf striking the locking mechanism of the left-hand door leaf. |
| Room 203 had a coffee maker and a toaster plugged into a relocatable power tap (RPT), which is a prohibited application. |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 7, 2024
Visit Reason
The inspection was conducted as a health care licensure and follow-up visit combined with a complaint investigation.
Findings
The facility failed to maintain the medication refrigerator temperature within the required range of 38 to 45 degrees Fahrenheit, with documented out-of-range temperatures occurring multiple times between December 2023 and March 2024 without corrective action.
Complaint Details
The visit included a complaint investigation component; however, substantiation status is not stated.
Deficiencies (1)
| Description |
|---|
| The facility did not maintain the temperatures in the medication refrigerator, which contained insulin, between 38 and 45 degrees F, with documented out-of-range temperatures on multiple occasions and no corrective action taken. |
Report Facts
Out-of-range temperature occurrences: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Morgan | Administrator | Named as the facility administrator who reviewed temperature logs monthly |
| Megan Rideout | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Jan 20, 2023
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation.
Findings
The facility failed to notify Licensing and Certification within one business day of resident falls requiring outside assessment and did not maintain an accurate admission and discharge register, with discrepancies in resident counts.
Complaint Details
The visit was triggered by a complaint investigation combined with a follow-up to verify compliance.
Deficiencies (2)
| Description |
|---|
| The facility did not notify Licensing and Certification within one business day when residents fell and required outside assessment or bedside x-rays. |
| The facility did not maintain an up-to-date admission and discharge register, with inconsistent resident counts across different records. |
Report Facts
Resident count discrepancy: 133
Resident count discrepancy: 122
Resident count discrepancy: 119
Resident count: 113
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Morgan | Administrator | Provided resident census information and statements regarding admission and discharge register accuracy. |
| Michael Oldfield | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 2
Jun 3, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, specifically regarding sensitivity testing of smoke detectors and the self-closing functionality of kitchen to dining room doors. Documentation for smoke detector sensitivity testing since initial construction in 2018 was not provided, and the kitchen doors did not self-close due to a malfunctioning hold-open device.
Deficiencies (2)
| Description |
|---|
| Facility could not produce documentation for sensitivity testing of smoke detectors since initial construction in 2018. |
| Doors from the kitchen to the main dining room were equipped with a kick-down hold open device preventing self-closing; doors did not self-close when released. |
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