Inspection Reports for Grace Village Assisted Living & Memory Care
501 River Bend Drive Granite Falls, NC 28630, Granite Falls, NC, 28630
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 11, 2025
Visit Reason
The Adult Care Licensure Section and the Caldwell County Department of Social Services conducted an annual survey and complaint investigation on 06/10/25 and 06/11/25, including two completed complaint investigations and two initiated complaint investigations.
Complaint Details
Two complaint investigations were completed, one complaint investigation was initiated on 05/30/25, and a second investigation was initiated by Caldwell County Department of Social Services on 06/06/25.
Findings
The facility failed to administer medications as ordered by a licensed practitioner for 3 of 4 residents observed during medication passes, with a medication error rate of 12%. Additionally, the facility failed to ensure 3 of 5 sampled residents had a written profile completed within 30 days of admission to the Special Care Unit and quarterly thereafter.
Deficiencies (2)
Failed to administer medications as ordered by a licensed practitioner for residents #3, #6, and #8 during medication passes on 06/10/25 and 06/11/25.
Failed to ensure 3 of 5 sampled residents (#5, #6, and #7) had a written profile completed within 30 days of admission to the Special Care Unit and quarterly thereafter.
Report Facts
Medication error rate: 12
Medication errors observed: 4
Residents with medication errors: 3
Residents without timely written profile: 3
Preservision Areds administration occurrences: 16
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The visit was conducted as a complaint investigation regarding allegations of physical abuse of a resident by a staff member at Grace Village Assisted Living and Memory Care.
Complaint Details
The complaint investigation substantiated that staff member C physically abused Resident #3 by slapping her face on 8/14/2024. The facility conducted an internal investigation and suspended the staff member. Multiple staff members provided witness statements confirming the abuse.
Findings
The facility was found to have a Type A1 violation for failing to ensure Resident #3 was free from physical abuse by staff member C, who was observed slapping the resident's face. Multiple staff statements and interviews confirmed the incident. The facility provided a plan of protection and an internal investigation was completed.
Deficiencies (1)
Failure to ensure Resident #3 was free from physical abuse by staff member C, who slapped the resident's face.
Report Facts
Dates of Visits: Visits occurred on 9/16, 9/18, 10/7, re-open 11/5, 11/20/2024 and 11/26/2024
Correction Date: Correction date for the Type A1 violation shall not exceed December 26, 2024
Resident Sample Size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named as the staff member who slapped Resident #3, causing the physical abuse violation | |
| Resident Care Coordinator | Interviewed regarding the incident and internal investigation | |
| Executive Administrator | Involved in internal investigation and plan of protection | |
| PCA staff member B | Witnessed the incident and provided interview | |
| Med-Tech staff member A | Witnessed the incident and provided interview |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Aug 14, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and complaint investigations from 08/06/24 through 08/09/24 and 08/13/24 through 08/14/24.
Complaint Details
The visit included complaint investigations related to personal care, supervision, medication administration, and resident rights.
Findings
The facility failed to provide adequate personal care and supervision, including timely incontinence care and fall prevention interventions, resulting in serious harm to residents. Additional failures included lack of timely health care referrals, medication administration errors, staff sleeping during shifts, unnecessary isolation of a resident, and malfunctioning call light systems.
Deficiencies (9)
Facility failed to ensure personal care was provided related to residents being left in incontinence briefs for extended periods of time.
Facility failed to provide supervision for residents with a history of falls, resulting in unabated A1 violation.
Facility failed to ensure referral and follow-up to meet acute health care needs for a resident related to delayed x-ray after a fall.
Facility failed to ensure all current medication orders were reviewed and signed by the physician at least every six months for 2 residents.
Facility failed to administer medications as ordered for 2 residents related to an anti-seizure medication and allergy eye drops.
Facility failed to ensure medications were administered within one hour before or after the prescribed time for 2 residents related to alprazolam, doxycycline, and insulin.
Facility failed to ensure resident rights were maintained for 29 residents when 3rd shift staff were found sleeping during their shift and failed to provide routine care for residents on unnecessary isolation and with malfunctioning call light.
Facility failed to ensure accurate and timely documentation of controlled substances for 2 residents with orders to treat anxiety and pain.
Facility failed to ensure electronic medication administration records were accurate for 1 resident related to inaccurate documentation of seizure medication.
Report Facts
Fall occurrences: 3
Fall occurrences: 2
Medication doses: 2
Medication doses: 50
Medication doses: 99
Medication doses: 17
Medication doses: 30
Medication doses: 12
Medication doses: 7
Medication doses: 5
Medication doses: 17
Medication doses: 2
Medication doses: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Coordinator | Named in multiple findings related to supervision, medication administration, and isolation. | |
| Resident Care Coordinator | Named in multiple findings related to supervision, medication administration, and isolation. | |
| Administrator | Administrator | Named in multiple interviews related to supervision, medication administration, and resident rights. |
| Medication Aide | Medication Aide | Named in findings related to medication administration errors and staff sleeping. |
| Personal Care Aide | Personal Care Aide | Named in findings related to personal care, supervision, and staff sleeping. |
| Hospice Registered Nurse Supervisor | Hospice RN Supervisor | Named in interview related to medication administration and resident care. |
| Pharmacy Technician | Pharmacy Technician | Named in interview related to medication administration and pharmacy communication. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 19, 2024
Visit Reason
The Adult Care Licensure Section and the Caldwell County Department of Social Services conducted an annual survey and complaint investigation on 04/16/24-04/19/24. Two complaint investigations were initiated on 03/28/24 and a third complaint investigation was initiated on 04/02/24.
Complaint Details
Two complaint investigations were initiated on 03/28/24 and a third complaint investigation was initiated on 04/02/24 by the Caldwell County Department of Social Services.
Findings
The facility failed to provide adequate supervision to minimize falls for residents with a history of falls, failed to notify primary care providers of incidents of sexual assault and behavioral changes, and failed to protect a resident from sexual harassment resulting in trauma. Multiple falls with injuries and incidents of sexual harassment were documented with delayed or inadequate interventions.
Deficiencies (3)
Failed to provide supervision for 2 of 2 sampled residents with a history of falls, resulting in multiple falls and injuries without adequate fall prevention interventions.
Failed to ensure the primary care provider was notified for 2 of 5 sampled residents related to multiple incidents of physical and verbal sexual assault resulting in delayed care to assist with behaviors.
Failed to ensure a resident was free from sexual harassment by another resident who made sexually inappropriate comments causing emotional trauma.
Report Facts
Falls: 17
Falls: 7
Falls: 8
Falls: 6
Falls: 15
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