Grande Pointe Healthcare Commu

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 17, 2024

  Based on observation, record review, self-reported incident (SRI) review, review of a police report, facility policy review and interviews, the facility failed to ensure Resident #28, who had dementia, was deemed incompetent, and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 11/26/24 at approximately 8:20 P.M. when Resident #18, who had a history of engaging in physical activity (i.e. hand holding and touching behaviors) with Resident #28 without care planned interventions, was observed by Certified Nurse Aide (CNA) #396 engaged in an activity indicative of oral sex on Resident #28. This affected one resident (#28) of three residents reviewed for abuse. […]

• Actual harm, isolatedF686Sep 30, 2024

  Based on closed medical record review, review of skin and wound notes, facility policy review and interview, the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #165 from developing in-house pressure ulcers within 30 days of admission and failed to ensure the pressure ulcer was properly treated, and interventions were initiated to promote healing and to prevent Resident #165 from developing an additional full thickness wound to the left buttock from incontinence associated dermatitis. […]

• Actual harm, isolatedF697Jun 26, 2024

  Based on record review, review of facility policy and interview the facility failed to develop and implement a comprehensive and effective pain management program for Resident #156, including a comprehensive pain assessment and effective interventions to timely treat the resident's pain. This affected one resident (#156) of three residents reviewed for pain. The facility census was 154. Actual Harm occurred on 04/21/24 when Resident #156, who was admitted to the facility with an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the sacrum, experienced moderate to severe/unbearable pain, difficulty with seated positioning, difficulty sleeping… […]

• Actual harm, isolatedF689Dec 13, 2022

  THE FOLLOWING SURVEY FINDING PERTAINS TO AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure residents were transferred in a manner to prevent injury. This affected one of three residents reviewed for falls. Facility census was 147. Actual harm occurred when Resident #152, who lacked coordination and had reduced mobility, sustained a laceration requiring transfer to an emergency room for evaluation and treatment, 14 sutures, and prophylactic antibiotics while being transferred from a wheelchair to bed. Findings include: Review of the medical record for Resident #152 revealed an admitted [DATE] and discharge date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2025

  Based on observation, interview, and review of the facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents except three residents (#68, #75, and #207) who received nothing by mouth and did not receive food from the facility's kitchen. The facility census was 147. Findings include: Observations on 03/03/25 from 10:02 A.M. to 10:23 A.M. during the tour of the kitchen with Mobile Dietary Manager (MDM) #800 revealed on a rack several white dessert plates stacked that had dried brownish, substance and crumbs on several of the plates. Observation of the oven, stove, tilt skillet, and steamer all had various food crumbs and grease on the front and the surfaces on the side of the equipment. […]