Grand the

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 24, 2022

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, observations, staff interviews, review of the facility's documentation of unvaccinated staff members, census, and testing results, review of the facility policies and procedures on contact and droplet/airborne precautions, how to apply N-95 masks, Coronavirus/COVID-19 Preparedness and Response Plan, review of the staff screening for COVID-19 documentation, medical record reviews, and review of an e-mail from the County Public Health Department, and review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker and guidance, the facility failed to… […]

• Actual harm, isolatedF689Jan 9, 2023

  Based on medical record review, observation, staff and family interview, review of electronic communication, review of the fall investigations, review of the incident log, review of the education sheet, review of the hospital records, and policy review, the facility failed to ensure fall interventions were in place to prevent falls. This resulted in Actual Harm for Resident #76 when he had a fall, was sent to the hospital and suffered an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the fourth proximal phalanx base (ring finger) as well as an age indeterminate fracture of the fifth metacarpal base (small finger) and a laceration to the head requiring a suture. […]

• Actual harm, isolatedF697Jan 9, 2023

  Based on medical record review, observation, staff, resident and family interview, review of the drug control sheet, and policy and procedure review, the facility failed to ensure pain was addressed, treated, and monitored appropriately after reports of pain for Residents #28 and #44, and failed to ensure pain medication was available and administered as ordered for Residents #18 and #25. Actual Harm occurred when Resident #28 experienced pain during incontinence care rated on a numeric pain scale as a nine out of 10 (zero being no pain and 10 being the worst pain), the State tested Nurse Assistant (STNA) continued to provide the care without addressing or reporting the pain. […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2026

  Based on observations, staff interviews, and review of facility policy review, the facility failed to ensure food was protected from potential contamination and/or spoilage. This had the potential to affect all residents in the facility, as the facility identified all residents received food from the kitchen. The facility census was 119.Findings include:Observation and interview of the kitchen with Culinary Services Manager #217 on 07/15/26 from 11:50 A.M. to 12:10 P.M. revealed cooked turkey burger patties were holding in a hot food storage container on the tray line at 111 degrees Fahrenheit during lunch tray service. Observation of the walk-in cooler revealed one tray of cooked pot roast stored partially covered with aluminum foil, leaving the pot roast open to air. […]

• No harm, potential for more than minimal, widespreadF761Mar 17, 2026

  Based on observations, staff interviews and policy review, the facility failed to ensure proper medication storage and handling practices. Five medication carts were observed out of ten total medication carts and four medication carts were observed of eight total medication rooms in the facility. This had the potential to affect all 121 residents residing in the facility who receive medications from the facility. Findings include:Observation and interview on 03/12/26 at 10:10 A.M. of the medication room on Unit C2 with Licensed Practical Nurse (LPN) #11 revealed multiple expired supplies, including a total of 47 Ultrasite needleless connectors (CMS 5000) with expiration dates of 09/30/25, 11/30/25, and 12/31/25. […]