Gran Gran's Place

In the surveyor’s words

From the most serious findings on record at Gran Gran's Place, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Apr 23, 2026

  Based on record review and interview, the facility failed to have a trained and designated infection preventionist to oversee the infection control program. The administrator identified 32 residents resided in the facility. Findings:An undated facility INFECTION CONTROL PROGRAM policy, read in part, The goals of the Infection Control Program are to .Insure [sic] compliance with state and federal regulations relating to infection control.An undated, untitled, employee listed did not document a designated infection preventionist.On 04/22/26 at 11:21 a.m., the administrator stated the DON was responsible for infection control surveillance and antibiotic stewardship in the facility. They stated the DON did not complete training required for the infection preventionist role. […]

• No harm, potential for more than minimal, patternF656Apr 23, 2026

  Based on observation, record review, and interview, the facility failed to ensure a care plan was developed for:a. interventions for anticoagulant use for 2 (#1 and #2) of 5 sampled residents reviewed for unnecessary medication; and b. catheter care for 1 (#6) of 2 sampled residents reviewed for catheter care. The administrator identified 32 residents resided in the facility and MDS coordinator #1 identified 15 residents received anticoagulant medication. The DON identified two residents had indwelling catheters. Findings: 1. […]

• No harm, potential for more than minimal, patternF686Apr 23, 2026

  Based on record review and interview, the facility failed to ensure a resident had skin assessments performed to prevent pressure ulcers for 2 (#4 and #26) of 2 sampled residents reviewed for wounds. The administrator identified 32 residents resided in the facility. Findings: An undated policy titled Skin Integrity Check, read in part, Complete Skin integrity check (head to toe) weekly on all residents.Record the results of the assessment on the treatment documentation form. 1. A care plan for Resident #4, dated 09/12/25, showed they were a pressure ulcer risk related to urinary incontinence. The care plan showed to monitor skin during all activities of daily living. The care plan did not show to perform skin assessments. […]

• No harm, potential for more than minimal, patternF690Apr 23, 2026

  Based on observation, record review, and interview, the facility failed to obtain a physician's order for catheter care for 1 (#6) of 2 sampled residents reviewed for catheter care. The DON identified two residents who had indwelling catheters resided in the facility. Findings:On 04/19/26 at 12:56 p.m., Resident #6 was observed to have an indwelling catheter.On 04/21/26 at 1:13 p.m., LPN #1 was observed to perform catheter care for Resident #6. Resident #6 had a weak gait and held on to the television stand for support during ambulation from the bed to the recliner upon completion of care.A quarterly assessment for Resident #6, dated 02/05/26, showed the resident needed supervision or touching assistance with toileting hygiene from staff. […]

• No harm, potential for more than minimal, patternF757Apr 23, 2026

  Based on record review and interview, the facility failed to ensure anticoagulant medication was not administered without adequate monitoring for 2 (#1 and #2) of 5 sampled residents reviewed for unnecessary medication.MDS Coordinator #1 identified 15 residents received anticoagulant (blood thinner) medication resided in the facility. Findings: 1. A physician's order for Resident #1, dated 09/16/24, for Xarelto (anticoagulant medication) 15 mg one tablet by mouth one time a day related to atrial fibrillation. There was no order for monitoring side effects of the anticoagulant medication. An annual assessment Resident #1, dated 03/20/26, showed the resident had diagnoses which included coronary artery disease, atrial fibrillation, and heart failure. […]