Grande Lake Healthcare Center

In the surveyor’s words

From the most serious findings on record at Grande Lake Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 27, 2025

  Based on medical record review, review of hospital documentation, staff interview, nurse practitioner interview, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure medication orders for treatment of Influenza (Flu) Type A were timely initiated for a resident which caused a significant medication error. Actual harm occurred to Resident #13 when the resident exhibited a change in condition, tested positive for Influenza Type A, and was evaluated by a nurse practitioner who recommended the implementation of an antiviral medication which was not ordered timely or administered. This resulted in Resident #13 becoming difficult to arouse and responded only to painful stimuli. […]

• No harm, potential for more than minimal, widespreadF880Feb 27, 2025

  Based on observation, medical record review, review of infection control tracking documents, staff interview, and facility policy review, the facility failed to ensure proper infection control monitoring was timely and accurately maintained during an active influenza outbreak and failed to ensure a urinary catheter was maintained in a manner to prevent infection. This had the potential to affect all 41 residents residing in the facility. The census was 41. Findings include: 1. Review of the facility's infection control surveillance tracking revealed the document was not completed for February 2025. Interview on 02/26/25 at 124 P.M. […]

• No harm, potential for more than minimal, widespreadF679Feb 13, 2023

  Based on record review, observations, resident and staff interviews, review of the activity calendar, review of activity documentation, resident council meeting minutes, and review of policy, the facility failed to provide sufficient and quality activities to meet the needs of residents. This affected seven (#5, #15, #18, #22, #23, #29, and #30) of seven residents reviewed for activities with the potential to affect all residents the facility. The facility census was 36. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF680Feb 13, 2023

  Based on observations, review of activity calendars, review of resident council minutes, review of personnel file and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect 36 of 36 residents in the facility. Findings include: Observations on 02/06/23 to 02/09/23 over various times throughout the group survey, revealed only one activity was scheduled and offered at 1:30 P.M. No other group activities were observed being offered to meet the needs and desires of the residents. Review of the activity calendars, dated September 2022 through February 2023, revealed one activity is scheduled once per day at 1:30 P.M. […]

• No harm, potential for more than minimal, widespreadF880Jun 13, 2022

  Based on observation, staff interview, and policy review, the facility failed to wear facial masks during direct resident contact. This had the potential to affect 40 of 40 residents residing in the facility. Findings include: Observation of staff working the 200 hallway between 4:00 P.M. to 5:15 P.M., revealed Licensed Practical Nurse, (LPN) #102 was administering medication to eight residents (#22,#23, #27, #29, #26, #28,#29, and #37) on the 200 hallway. LPN #102 was observed wearing a surgical mask below her nose just covering her lower lip. Personal Care Assistant (PCA) #421 and State tested Nursing Assistant (STNA) #411 were observed going in and out of resident's room passing and gathering trays with surgical masks on not covering their nose. […]