Grand Oaks Care

Inspectors wroteBased on interview and record review, the facility failed to follow the Physicians Order (PO) for one of four sampled residents (Resident 1) for a urology (surgical specialty of the urinary tract) referral. This resulted in Resident 1 not being seen by a urologist (medical doctor specializing in diagnosing and treating diseases of the urinary tract) and potential for untreated urinary tract disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective infection control practices for five of 22 sampled residents (Resident 82, Resident 36, Resident 19, Resident 62, and Resident 32) when staff did not provide hand hygiene before eating. This failure had the potential to spread infection to residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Care Plans, for two of 12 sampled residents (Resident 31 and Resident 101). This failure had the potential to not meet residents' physical, psychosocial (related to thought or behavior), and functional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of three sampled resident's (Resident 1) medical record contained accurate documentation. This failure had the potential to result in delayed treatment for the resident who was returning from hemodialysis (dialysis, life sustaining medical treatment that uses a machine to filter waste, toxins and excess fluid from the blood when kidneys are unable to function properly).2. Ensure one of one sampled resident's (Resident 10) physicians order for oxygen administration was followed as ordered. This failure had the potential to result in low oxygen saturation levels for Resident 10.3. Ensure one of two sampled residents (Resident 58) had an emergency dialysis kit at bedside. This failure had the potential for staff not to properly treat Resident 58 in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident (Resident 1) had a post (after) hemodialysis (dialysis, life sustaining medical treatment that uses a machine to filter waste, toxins and excess fluid from the blood when kidneys are unable to function properly) assessment after returning to the facility. This failure had the potential for post dialysis complications and side effects (bleeding from dialysis access site, pain, low blood pressure, nausea/vomiting) to go unnoticed and untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and chemical cleaning/disinfecting agents were stored separate in one of two medication carts. This failure had the potential to result in cross contamination of stored medications and chemical cleaning/ disinfecting agents.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure one of two cooks (Cook 2) followed its DRESS CODE policy and procedures (P&P), when [NAME] 2 did not have a beard cover. This failure had the potential for food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled Licensed Vocational Nurses (LVN) was qualified to provide residents care when LVN 1 was working without a current license. This failure had the potential for harm, compromise quality of care, and medication errors for all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure for one of two sampled residents (Resident 1) when Attending Physician (AP) was not notified of Resident 1's refusal of ordered Buspirone (used to treat symptoms of anxiety such as fear, tension, and irritability) medication. This failure resulted in a physical altercation with Resident 2 and had the potential for adverse reactions including worsening in health and increased symptoms.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (R/P) was notified when there was a change of condition for one of three sampled residents (Resident 1). This failure resulted in the R/P being unaware of Resident 1's change of condition.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of three sampled resident ' s change of condition when Resident 1 ' s blood sugar/glucose levels were above 200 (normal is 70 - 99 mg [milligrams]/dL [deciliter]) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being sent to the acute hospital and being admitted for dehydration (too little fluid in the body [can occur when the kidneys try to excrete sugar, in response to high blood sugar levels, thru urination leading to dehydration]), hyperglycemia (elevated blood sugar), and hypernatremia (elevated sodium level in the blood [can occur when there is an increase in urination related to high blood sugar and the kidneys lose more water than they retain]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) care plan was implemented when Resident 1 did not have a staff member with him at all times. This failure had the potential for Resident 1 to exhibit aggressive behaviors towards other residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on Quality Assurance and Performance Improvement (QAPI - data-driven, proactive approach to improving the quality of care and services in the facility). This failure had the potential for the facility to not recognize, identify, address and correct resident safety, care and outcomes for 37 of 37 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of 18 sampled residents (Resident 33, Resident 50, Resident 64, Resident 67, and Resident 63) call lights were within reach. This failure had the potential for residents unable to call for assistance and potential for delaying care.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (AD-health care preferences, including decisions for end-of-life care) acknowledgement form was completed for ten of 20 sampled residents (Resident 443, Resident 40, Resident 20, Resident 6, Resident 37, Resident 51, Resident 18, Resident 43, Resident 54, and Resident 87). This failure had the potential to result in the residents' wishes or health choices not being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1) A Licensed Nurse did not share her Electronic Protected health information (EPHI-resident clinical record) access code) and leave Graduate Vocational Nurse (GVN, unlicensed nursing staff) 1 unsupervised while administering narcotics (addictive pain medications) for three of three sampled residents (Resident 51, Resident 63, and Resident 18). This failure resulted in unauthorized access to residents' protected health information, falsification of residents' medical record and the potential for medication errors. 2) Physician Orders were followed when licensed nurse did not document wound care treatment for three of three residents (Resident 51, Resident 63, and Resident 18). This failure had the potential for worsening of Resident 51, Resident 63 and Resident 18's wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 47, Resident 48, and Resident 51), had Restorative Nurse Assistant (RNA - therapy for residents with limited mobility) program orders. This failure had the potential for Resident 47, Resident 48, and Resident 51 to have an avoidable reduction in range of motion.

Inspectors wroteBased on interview and record review, the facility failed to complete performance evaluations for three of eight sampled employees (Certified Nursing Assistant [CNA] 3, CNA 5 and Licensed Vocational Nurse [LVN] 1. This failure had the potential for employees not meeting performance standards providing care for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure social services assessments (SSA) were completed quarterly (every three months) for nine of 19 sampled residents (Resident 51, Resident 63, Resident 71, Resident 44, Resident 27, Resident 6, Resident 54, Resident 47, and Resident 48). This failure had the potential for the delay in providing medically related social services for the residents affecting their psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for the month of July 2024. This failure had the potential for residents' adverse health outcomes due to physician was not notified of the pharmacy recommendations.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure two opened medication bottles in the medication storage room were labeled with an opened date. This failure had the potential for contamination of medications. 2. Dispose of three bottles of medications for Resident 79 in a plastic bag in Medication Cart 2 bottom drawer. This failure had the potential for discontinued or outdated medication to be administered. 3. Ensure approximately 50 Over-The-Counter (OTC) medication bottles were safely and securely stored from unauthorized personnel. This failure had the potential for medication to be accessed by unauthorized staff and patients. 4. Ensure medications Resident 54's medications were safely and securely stored from unauthorized personnel and other residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. One of three sampled clean linen cart covers were not fully covered during transport. 2. Four of ten sampled staff (Certified Nursing Assistant-CNA 3, CNA 4, Hospice CNA, and Nursing Consultant [NC]} did not follow enhanced droplet (used to prevent spread of airborne infectious agents) and contact precautions (used to prevent the spread of infectious agents through direct or indirect contact). 3. One of one sampled Resident's (Resident 77) room was not deep cleaned prior to moving another Resident (Resident 87) into room. 4. One of ten sampled staff (Licensed Vocation Nurse [LVN] 1) did not perform appropriate hand hygiene. These failures had the potential to transmit infectious diseases to Residents, staff, and visitors.

Inspectors wroteBased on observation and interview, the facility failed to store chemical containers off the ground. This failure had the potential for the chemical containers to be knocked over and result in a toxic spill which would put staff and Resident's health and safety at risk.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 37 sampled residents' (Resident 87) room was maintained with a homelike environment. This failure resulted in Resident 87 feeling uncomfortable and not able to use his personal belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) was notified of transfer and discharge for two of three sampled residents (Resident 89 and Resident 90). This failure had the potential for unsafe resident transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent skin breakdown were implemented for one of one sampled residents (Resident 51). This failure had the potential for Resident 51 to develop skin breakdown and worsening skin injury.

Inspectors wroteBased on interview and record review, the facility failed follow their policy and procedures titled Medication Reordering and Unavailable Medications when Licensed Nurse did not reorder medications timely, notify physician of unavailable medication and obtain alternate orders for one of one sampled residents (Resident 54). This failure resulted in .Resident 54 not receiving physician ordered diabetic medications (to manage blood sugar level) and had the potential to result in adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician order for one of three sampled residents (Resident 47) for nectar thick consistency beverage. This failure had the potential for Resident 47 to have a choking incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor one of one sampled residents' (Resident 37) food preferences. This failure had the potential for Resident 37 to have unmet nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food was served at the proper temperature for two of three sampled residents (Resident 6 and Resident 7). This failure resulted in Resident 6 and Resident 7 being served food at an unappetizing temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of five sampled staff (Certified Nursing Assistant - CNA 1, CNA 3, CNA 4, and CNA 5) were wearing name tags. This failure resulted in residents and visitors being unaware of who was providing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the abuse policy was implemented for two of five sampled residents (Resident 4 and Resident 5) when an abuse allegation was not reported to the management by a staff member (Licensed Vocational Nurse - LVN 1). This failure had the potential for delayed investigation and place other residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician and Responsible Party (RP) was notified of an injury for one of three sampled residents (Resident 1). This failure resulted in the Physician and RP being unaware of the injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) call light was in working order. This failure had the potential for staff to be unaware of Resident 1 needing assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure and monitoring and wound care were completed as ordered by the physician for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to result in worsening of the residents' wounds.

Inspectors wroteBased on interview and record review, the facility failed to administer medication and check the blood sugar for one of two sampled residents (Resident 1) as per physician order. This failure had the potential to affect Resident 1's medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified for one of three sampled residents (Resident 1) when Resident 1 was not administered prescribed medications. This failure had the potential for Resident 1 to have health complications.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure when medications were not documented when administered for one of three sampled residents (Resident 1). This failure resulted in an inaccurate medication administration record (MAR).

Inspectors wroteBased on interview and record review the facility failed to develop a base line care plan for one of three sampled residents (Resident 1) partial thickness (damage to skin) wound to coccyx area (tailbone area). This failure has the potential for staff to be unaware of how to care for Resident 1's wound. During a review of Resident 1's Progress Notes (PN), dated 10/4/23, the PN indicated Resident 1 was admitted to the facility with partial thickness wound to coccyx area. During a concurrent interview and record review on 11/20/23 at 2:41 p.m. with Director of Nurses (DON), Resident 1's care plan was reviewed. DON was unable to find documented evidence a base line care plan was developed for Resident 1's partial thickness wound to coccyx. DON stated a base line care plan should have been developed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure wound care was provided according to physician order for one of three sampled residents (Resident 1) . This failure has the potential to result in worsening of Resident 1's wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Nurses Dialysis Commmunication [sic] Record (NDCR) between the facility and the dialysis center was completed for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the facility to be unaware of the needs and services the residents required.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Storage of Medication when medications were left at the bedside for one of three sampled residents (Resident 1). This failure had the potential for residents to be at risk for unsafe administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was re-evaluated for elopement risk (ER) and a care plan (CP) was developed when Resident 1 was found off facility grounds. This failure resulted in staff being unaware of Resident 1 leaving the facility unsupervised for a second time and the potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly maintain a clean and sanitary kitchen, and storage area when: 1. Kitchen appliances (microwave, toaster, stove top, and oven) were covered with grease, grime, and cooked on food debris. 2. Kitchen floors and walls were covered with dust, dirt, debris, and grime. 3. Food tray carts had food debris inside of carts with clean trays. 4. Storage shelf with cleaned pots and pans had grease and food debris. 5. Storage bins noted with grease and food stains on inside and outside of bins. 6. Dietary [NAME] (DC) 2 did not perform hand hygiene when preparing food. These failures had the potential to spread food borne illnesses to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered promptly for three of 63 sampled residents (Resident 72, Resident 56, and Resident 40 ). This failure had the potential for not meeting residents' care needs, having psychosocial distress, and potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing activity programs for five of 63 sampled residents (Resident 72, Resident 13, Resident 8, Resident 22, and Resident 11). This failure had the potential for residents not being recognized of their interests, experiencing feelings of social isolation, and sadness, affecting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) pre (before) and post (after) assessments were completed for three of five sampled dialysis residents (Resident 35, Resident 33, and Resident 36). This failure had the potential for residents who were undergoing dialysis treatment not being assessed and monitored, and potential for experiencing adverse health outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure narcotics (highly regulated, highly addictive drugs) were reconciled (inventoried) each shift for one of three medication carts (Hall 200 cart). This failure had the potential to result in an inaccurate account of the narcotic inventory and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure in serving food and drink in an appropriate temperature for 7 of 63 sampled residents (Resident 1a, Resident 1b, Resident 1c, Resident 1d, Resident 1e, Resident 1f, and Resident 58). This failure had the potential for unmet nutritional needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure all staff were trained on infection prevention and control. This failure had the potential for staff to be unaware of infection control practices and spread infectious diseases to residents and visitors. 2. Implement infection control practices when Certified Nursing Assistant (CNA) 8 did not perform hand hygiene. This failure had the potential to spread infectious diseases, including the highly contagious Covid 19 virus to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of an Advanced Directive (AD-a legal document that explains how medical decisions are made for a resident if they become too ill to make decisions), or a Physician Order for Life Sustaining Treatment (POLST) was placed in the medical record/chart for one of 63 sampled residents' (Resident 239). This failure had the potential for licensed staff to be unaware of Resident 239's desired medical treatment in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for one of 63 sampled Residents (Resident 80) with Dementia (a group of thinking and social symptoms that interferes with daily functioning). This failure had the potential for not providing the appropriate care to Resident 80 who has diagnosis of Dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to maintain hygiene for one of 63 sampled residents (Resident 58) when showers were not given as scheduled. This failure had the potential to result in skin breakdown, infection, loss of dignity, and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide restorative nursing (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) for one of 63 sampled residents (Resident 72) when Resident 72 was not assisted to get up from bed according to physician's order. This failure had the potential for Resident 72 to experience a decrease in range in motion and quality of life. 2. Provide palm guard splint (used as a barrier between fingers and palms to prevent injury to the palm from severe finger flexion contracture) for two of 63 sampled residents (Resident 72 and Resident 13) according to the physician's order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a tray card (tray diet order preference card) was followed for two of 63 sampled residents (Resident 77 and Resident 72). This failure had the potential for the resident to not receive adequate nutrition.