Grande Oaks

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Sep 9, 2022

  Based on observation, medical record review, review of the facility's policy and procedure for skin management, interviews with nursing staff, family interview, and Wound Physician #123 interview, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for two residents (Residents #42 and #18). This resulted in Immediate Jeopardy that was actual harm on 08/01/22 when the facility failed to ensure Resident #18's wound care physician orders were transcribed and treatments implemented, skin assessments completed, and pressure relieving interventions were active and functional resulting in the development of pressure ulcers and the declining condition of the existing pressure ulcers to a Stage 4 pressure ulcer and an Unstageable pressure ulcer. […]

• Actual harm, isolatedF684Apr 29, 2026

  Based on record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure that a resident with a new right leg injury received timely and thorough assessment, monitoring, treatment, and physician notification following a fall related injury. This resulted in the worsening of the untreated right leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. This affected one (Resident #18) of four residents reviewed for hospitalization. […]

• Actual harm, isolatedF692Apr 29, 2026

  Based on record review, staff interviews, and policy review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health and facility failed to monitor and implement interventions to maintain proper nutritional health. This affected two (Residents #18 and #46) of four residents reviewed for nutrition. The facility census was 42.Actual harm occurred on 10/31/25 when Resident #46 was transferred to the hospital for treatment of severe dehydration related complications due to the facility's failure to adequately monitor and assess his hydration status, failure to ensure tube feeding and flush orders were written correctly and implemented as intended, and failure to respond appropriately to his documented change in condition.Findings include:1. […]

• Actual harm, isolatedF686Dec 2, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interviews, review of hospital records, review of witness statements and wound policy, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #154, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel, received left lateral ankle and foot wound treatments timely when dressings had become saturated with fecal material. […]

• Actual harm, isolatedF684Sep 9, 2022

  Based on interview, record review, observation and policy review, the facility failed to provide wound dressing changes and skin observations as ordered. This affected two of 12 residents with wounds, Residents #21 and Resident #105. This resulted in actual harm to Resident #21 when she developed [CONDITION(S)] requiring antibiotic therapy. The facility also failed to ensure neurological (neuro) checks were completed post-fall. This affected one resident (Resident #20) of three residents reviewed for falls. The facility census was 54. Findings include: 1. Resident #21 was admitted to this facility on 01/28/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]