Grand Oaks Care

In the surveyor’s words

From the most serious findings on record at Grand Oaks Care, in the surveyor’s own words.

• Actual harm, isolatedF689May 15, 2023

  Based on observation, interview, and record review, the facility failed to: 1. Ensure the plan of care was followed when the facility failed to use a Hoyer lift ([a commonly use brand] mechanical lift are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical support) for one of four sampled residents (Resident 1) during transfer from her bed to the wheelchair. This failure resulted in Resident 1 falling to the floor, sustaining a right ankle fracture (broken bone). 2. Ensure one of four sampled residents (Resident 2) was transferred to the bathroom by a qualified staff. This failure resulted in Resident 2 falling to the bathroom floor, sustaining a left shoulder fracture. Findings: 1. […]

• Actual harm, isolatedF684Jun 16, 2021

  Based on interview and record review, the facility failed to assess, report, and document changes when skin issues were first identified on 3/17/21, for one of four sampled residents (Resident 1). This failure resulted in Resident 1's delayed treatment, development of gangrene (dead tissue caused by an infection or lack of blood flow), hospitalization , and amputation of Resident 1's left hallux (great toe) and left second toe. Findings: During an interview on 3/30/21, at 2:53 PM, with Resident 1's Family Member (FM) 1, FM 1 stated Resident 1 had been at the facility for approximately one month. FM 1 stated the facility did not make FM 1 aware of any concern or issues regarding Resident 1's left foot. […]

• No harm, potential for more than minimal, widespreadF725Sep 2, 2025

  Based on interview and record review, the facility failed to ensure one of four sampled Licensed Vocational Nurses (LVN) was qualified to provide residents care when LVN 1 was working without a current license. This failure had the potential for harm, compromise quality of care, and medication errors for all residents residing in the facility.Findings:During a review of LVN 1's employee file, the file indicated LVN 1 was hired on [DATE]. Licensure verification on file indicated LVN 1's license expired on [DATE]. During a review of LVN 1's work schedule dated 6/29 through [DATE], the work schedule indicated LVN 1 worked on 6/30, 7/5, 7/14, 7/15, 7/16, 7/17, 7/18, 7/21, 7/22, 7/23, 7/24, 7/25,7/29, 7/30, 7/31, 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, and 8/9. […]

• No harm, potential for more than minimal, widespreadF867Oct 10, 2024

  Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Quality Assurance and Performance Improvement (QAPI - data-driven, proactive approach to improving the quality of care and services in the facility). This failure had the potential for the facility to not recognize, identify, address and correct resident safety, care and outcomes for 37 of 37 sampled residents. Findings: During a concurrent interview and record review on 10/10/24 at 2:35 p.m. with Administrator, the facility's QAPI dated 2024 was reviewed. The last QAPI meeting was 9/2024. During the 1/2024 QAPI meeting completing nursing staff competencies, quality of care, incomplete employee files and nursing documentation audits were identified. […]

• No harm, potential for more than minimal, widespreadF812Oct 13, 2022

  Based on observation, interview, and record review, the facility failed to properly maintain a clean and sanitary kitchen, and storage area when: 1. Kitchen appliances (microwave, toaster, stove top, and oven) were covered with grease, grime, and cooked on food debris. 2. Kitchen floors and walls were covered with dust, dirt, debris, and grime. 3. Food tray carts had food debris inside of carts with clean trays. 4. Storage shelf with cleaned pots and pans had grease and food debris. 5. Storage bins noted with grease and food stains on inside and outside of bins. 6. Dietary Cook (DC) 2 did not perform hand hygiene when preparing food. These failures had the potential to spread food borne illnesses to residents. Findings: 1. […]