Grand Oaks Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that weights were obtained in accordance with physician orders for 3 residents (Resident #63, #26, and #35), out of 5 residents reviewed for the provision of nursing services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions and complete treatments for 1 resident (R16) with an unstageable pressure ulcer out of 2 residents reviewed for pressure ulcers. Findings Include:Resident #16 (R16)Review of an admission Record reflected R16 admitted to the facility with abnormal posture, weakness, muscle wasting and atrophy and dementia. Review of a Care Plan initiated 12/01/2025 reflected R16 had Altered functional mobility and ADLs (Activity of Daily Living) with interventions that included SKIN CARE INTERVENTIONS: . Heel boots at all times Date Initiated: 12/01/2025, revised on 5/4/2026. During an observation on 05/04/2026 at 10:00 AM, R16 was observed in her wheelchair in the common area and appeared to be sleeping. Heel boots were not in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled drugs were administered in accordance with physician orders and nursing professional standards of practice for 4 residents (Resident #52, #17, #26, and #68) out of 15 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure Binding Arbitration was explained in a manner understood by residents and/or resident representatives and obtain adequate informed consent prior to entering into a binding arbitration agreement for 1 resident (R62) out of 3 residents reviewed for arbitration. Findings Include:Review of an admission Record reflected R62 admitted to the facility from a hospital on 4/26/2026 for orthopedic aftercare. R62 was listed as their own responsible party. During an interview on 05/06/2026 at 1:20 PM, R62 reported that he had no idea what a binding arbitration agreement was. R62 did not recall signing the agreement and said his son handles all these matters and these things are over his head. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions for 1 resident (R16) out of 15 residents reviewed for infection control. Resident #16 (R16)Review of an admission Record reflected R16 admitted to the facility with diagnoses that included a stage 2 pressure ulcer. Review of R16's entire Care Plan initiated on 12/01/2025 did not reflect R16 was in Enhanced Barrier Precautions (EBP). Review of Interdisciplinary Documentation dated 4/28/2026 reflected Resident appears to have PI (pressure injury) to right heal (sic); 6cm x 3.5cm. It appears to have had a large blister open. Center has dark discoloration with blanchable redness surrounding. Area is tender to touch. 4x4 foam border dressing applied. Message left for CCC (Clinical Care Coordinator). [...]

Inspectors wroteThis citation pertains to intake 2677566. Based on observation, interview, and record review, the facility failed to ensure the appropriate assessing, monitoring, documenting, and care planning reflected the needs, cares, and services required for one (R2) of 4 residents reviewed for quality of care.

Inspectors wroteThis pertains to intake 2716089. Based on observation, interview, and record review, the facility failed to protect Resident#1 (R1) for the right to be free from verbal and physical abuse by Ancillary Service Provider the Podiatrist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were left within reach of 2 residents (R30 and R22) of 2 residents reviewed for availability of call lights.

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures and implement appropriate antibiotic stewardship for two (R39 and R48) of two residents reviewed for antibiotic stewardship and failed to have an affective system in place for assessing, monitoring and preventing unnecessary antibiotic usage.

Inspectors wroteThis citation pertains to intake M100150227. Based on interview and record review, the facility failed to treat a resident in a dignified manner for one (R27) of three residents reviewed for dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop or implement care plan interventions for two (R6 and R39) of 20 residents reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to formulate and implement personalized Care Plan revisions for one facility resident (R17) of two residents reviewed with documented significant weight changes.

Inspectors wroteBased on interview and record review, the facility failed to follow through the continuity of care of frequent urinary tract infections for one (R39) of one reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders, prevent pressure ulcers, accurately assess and document, and implement treatment for one (R6) of two residents reviewed for pressure injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and provide timely incontinence care, and appropriately document and treat MASD (moisture associated skin damage) for one (R6) of two residents reviewed for bowel and bladder.

Inspectors wroteBased on interview and record review, the facility failed to ensure significant changes in weight were reviewed by the medical provider for 2 residents (R30 and R17) of 5 residents reviewed for nutrition services.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate hand hygiene during peri care for two (R6 and R48) of two residents reviewed for incontinence care.

Inspectors wroteThis citation pertains to intake M100147971. Past non-compliance was accepted for this citation. Plan identified below. Based on interview and record review, the facility failed to ensure 11 residents (R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, and R14) of 16 residents reviewed, were provided medications as ordered, resulting in medication not given as ordered.

Inspectors wroteThis citation refers to MI00146957. Based on interview and record review, the facility failed to report an allegation of mental and verbal abuse in a timely manner to the state survey agency for 1 of 6 residents (R5) reviewed, resulting in allegations of abuse not being reported timely to the state survey agency, all allegations of abuse not being accurately and completely reported to the state survey agency, the potential for allegations of abuse not being investigated timely, the potential for abuse to go undetected, and the potential for residents not being protected from abusive individuals.

Inspectors wroteThis citation refers to MI00143988. Based on interview and record review, the facility failed to maintain complete, timely, and accurate medical records for 1 of 4 residents (R4), resulting in the potential for providers not having an accurate, complete, and timely picture of the resident's stay at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 66 residents.

Inspectors wroteBased on interview and record review, the facility failed to administer and document the administration of controlled substances and ensure medications were accurately reconciled for 5 residents (Resident #20, #24, #29, #32 and #54), reviewed for medication administration, resulting in medication errors.

Inspectors wroteThis citation will have two Deficient Practice Statements (DPS) A and B. DPS A Based on observation, interview and record review, the facility failed to implement best infection control practices during dining services for residents in the dining room and during incontinence care for 1 (Resident #33) reviewed during cares.