The Center at Grande

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one of seven residents (Resident #88) reviewed for misappropriation. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician when there was a need to alter treatment for 1 of 4 residents reviewed for physician notification. (Resident #1) The facility failed to immediately notify the physician on 9/24/25 when they were unable to draw the blood successfully on Resident #1 for labs. This failure could place residents at risk for delayed diagnosis or altered medical management.

Inspectors wroteBased on interview and record review the facility failed to ensure within 14 days after a facility completed a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System including a subset of items upon a resident's transfer, reentry, discharge, and death for 2 of 2 residents (Residents #16 and #115) reviewed for MDS assessments. 1. The facility failed to transmit to the CMS system Resident #16 's discharge MDS assessment, dated 01/10/25. 2. The facility failed to transmit to the CMS system Resident #115 's discharge MDS assessment, dated 11/16/24. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 4 of 10 residents reviewed for misappropriation of resident property. (Resident #'s 1, 2, 3, and 4) CNA B stole money from Resident #1, #2, and #4 during the night shifts of 2/11/25 to 2/12/25 and 2/13/25 to 2/14/25. CNA B stole money and credit card information from Resident #3 during the night shifts of 2/11/25 to 2/12/25 and 2/13/25 to 2/14/25. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for Resident#197 that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one of one resident (Resident #197) reviewed for baseline care plan. The facility failed to ensure Resident #197's baseline care plan included information related to Resident #197's respiratory needs. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plan for one of one residents (Resident #197) reviewed for care plans. The facility failed to ensure Resident #197's care plan included information related to Resident #197's respiratory needs was developed within 7 days of the comprehensive assessment and included that the resident was receiving Albuterol for (chronic obstructive pulmonary disease) COPD and shortness of breath. This failure could place residents at risk of not receiving medication as ordered to meet their current Respiratory needs.

Inspectors wroteBased on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for (Resident #197) reviewed for Nebulizer therapy. Resident #197's Nebulizer therapy ordered by the physician dated 1/17/2024 Albuterol Sulfate inhalation Nebulization solution, 0.083%, to Inhale orally four times a day for COPD for 30 days administer for 15 minutes. Order date 1/17/2024, there was no order for self-administration. This failure could place residents who receive Nebulization therapy at risk for respiratory distress.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #197) reviewed for pharmacy services. LVN A failed to ensure Resident # 197's medications were secure and left physician ordered medications at the bedside. LVN A failed to ensure Resident #197 inhaled her medications. These failures placed Resident #197 at risk of not receiving full dosage and treatment of medication as ordered.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for (Resident #197) resident reviewed for resident records. The facility failed to ensure Resident #197's Medication Administration Record (MAR) reflected documentation of Cleanse Nebulizer mask with soap and water after every use. Allow to dry to air, placed on a paper towel, and taken apart. Once dry and place back together and on hook of nebulizer machine in her Electronic Health Record (EHR). This failure could place all residents who receive nebulizer treatment at risk of having errors in care and treatment.