Grand Oaks Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 5, 2023

  Based on observations, interviews, and record review, the facility failed to prevent, complete weekly assessments and treat pressure ulcers for 2 Residents (R55 and R64), resulting in R64 developing multiple pressure ulcers (including 2 unstageable ulcers) and the potential for R55's pressure ulcers to delay in healing and develop infection. Findings include: Review of R64's face sheet dated 3/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: cerebral palsy, abnormal posture, dementia, diabetes mellitus II, neuromuscular dysfunction of blader, need for assistance with personal care, and weakness. He was not his own responsible party. […]

• Actual harm, isolatedF693Apr 5, 2023

  Based on observations, interviews and record reviews, the facility failed to have clear tube placement orders, failed to track formula intake, failed to provide fluids in accordance with orders and failed to follow nursing standards of practice for 1 Resident (R51) sampled for tube feeding, resulting in weight loss, dehydration, and medication errors. Findings include: Review of R51's face sheet dated 3/30/23 revealed he initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnosis that included: dementia, epilepsy, gastronomy status, congestive heart failure, weakness, muscle wasting and atrophy, colostomy status, dysphagia (difficulty swallowing), cognitive communication deficit and need for assistance with personal care. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2024

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 66 residents. Findings include: On 3/19/24 at approximately 8:12 AM, observations were made of the morning meal service in the south dining room. Cook C was observed to grab a garbage can and move it into her workspace, then proceed to handle whole eggs to crack and cook. Cook C failed to wash her hands after handling the garbage can which was being used by dining room staff for refuse disposal. The FDA Food Code States: 2-301.14 When to Wash. […]

• No harm, potential for more than minimal, widespreadF725Apr 5, 2023

  Based on observation, interview and record review, the facility failed to provide adequate nurse staffing to meet R51's medical needs timely, meet care needs timely for seven (R59, R35, R55, R66, R34, R42, R2) and 6 of 10 resident in resident council, resulting in the potential for medical and care needs to go unmet and multiple residents being frustrated. Findings include: During an interview with the Nursing Home Administrator (NHA) on 3/30/23 at 11:18 AM about licensed nursing staffing for the facility she said she had 1.5 full-time clinical care coordinator (CCC) coverage. The one full time CCC has had to work the night shift to cover staffing issues, and both have had more job duties on the floor due to coverage concerns. […]

• No harm, potential for more than minimal, widespreadF812Apr 5, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure all persons in the kitchen, during food preparation and service, were wearing properly applied hair restraints. 2. Failing to properly date and label food taken from the freezer to ensure appropriate expiration dates were applied. 3. Failing to properly handle a package of sealed lunch meat after falling to the floor. 4. Failing to maintain ceiling mounted exhaust duct covering grids in a clean condition. These deficient practices have the potential to result in food borne illness among any and all 70 residents of the facility. […]