Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grande Lake Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of chronic illnesses tested positive for Influenza Type A and was recommended to start Tamiflu by a CNP. However, the order was not placed timely, leading to a significant medication error. The resident's condition worsened, resulting in hospitalization with diagnoses of renal insufficiency, hypoxia, and pneumonia. Staff interviews revealed communication lapses and failure to follow up on the CNP's plan, contributing to the delay in treatment.
The facility failed to maintain proper infection control during an influenza outbreak, with incomplete tracking for February 2025. An IP and DON acknowledged the lapse. Additionally, a resident's urinary catheter bag was improperly placed on the floor, contrary to facility policy, as confirmed by a CNA.
The facility failed to assess two residents for their ability to self-administer medications, as required by policy. One resident self-administered insulin and other medications without an assessment or physician order, while another applied Lidocaine patches and kept Flonase at the bedside without proper documentation or orders. The DON confirmed the lack of assessments and orders for both residents.
A facility failed to ensure privacy for a resident during a mechanical lift transfer. The resident, who was cognitively impaired and required a Hoyer lift for transfers, was exposed to the hallway as CNAs left the door open during the process. This violated the facility's policy on resident rights, which requires privacy to be maintained during care.
A facility failed to provide a resident with a Kennedy cup as care planned, despite the resident's cognitive impairment and need for assistance with ADLs. Observations showed the resident was given regular cups instead, and staff interviews confirmed the absence of the Kennedy cup. The facility's policy requires assistive devices to promote independence, which was not followed.
A facility failed to ensure arbitration agreements were explained to a resident with severe cognitive impairment. The resident, with diagnoses including dementia and legal blindness, signed an agreement without understanding its implications. The Admissions Director assessed cognition through previous records and basic questions but lacked documentation of conversations with the resident's out-of-state DPOA.
A facility failed to maintain a resident's dignity by not covering the urinary catheter collection bag. The resident, who was cognitively intact and admitted with an indwelling urinary catheter, was observed without a cover on the collection bag. This was confirmed by a CNA during a complaint investigation.
The facility did not conduct timely care conferences for two residents, failing to adhere to its policy of completing a baseline care plan within 48 hours of admission and conducting quarterly reviews. This non-compliance was confirmed through staff interviews and policy reviews.
Delayed Antiviral Treatment for Influenza Type A
Penalty
Summary
The facility failed to ensure timely initiation of medication orders for the treatment of Influenza Type A for Resident #13, resulting in a significant medication error. Resident #13, who had a medical history including chronic obstructive pulmonary disease, bipolar disorder, chronic kidney disease stage three, heart failure, and atherosclerotic heart disease, tested positive for Influenza Type A. A Certified Nurse Practitioner (CNP) assessed the resident and recommended starting the antiviral medication Tamiflu. However, the order for Tamiflu was not placed in a timely manner, leading to a delay in treatment. As a result of the delay, Resident #13 experienced a change in condition, becoming difficult to arouse and responding only to painful stimuli, which necessitated hospitalization. The resident was diagnosed with acute on chronic renal insufficiency, hypoxia, pneumonia, and Influenza Type A. Interviews with facility staff revealed communication lapses and a failure to follow up on the CNP's verbal plan to start Tamiflu, contributing to the oversight. The Centers for Disease Control and Prevention (CDC) guidelines emphasize the importance of starting antiviral treatment promptly to reduce flu complications, which was not adhered to in this case.
Infection Control and Catheter Care Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control monitoring during an active influenza outbreak. The infection control surveillance tracking document was not completed for February 2025, despite the outbreak beginning with an employee testing positive on February 11, 2025, followed by a resident on February 13, 2025. The Infection Preventionist (IP) acknowledged the lack of updated tracking information during an interview on February 26, 2025, and the Director of Nursing (DON) confirmed the incomplete tracking record on February 27, 2025. The facility's policy required the IP to collect and analyze infection surveillance data to support antibiotic stewardship activities, which was not adhered to during this period. Additionally, the facility failed to maintain a urinary catheter in a manner that prevents infection for a resident admitted with an indwelling urinary catheter. On February 24, 2025, the resident's urinary catheter collection bag was observed lying on the floor without a barrier, and a Certified Nurse Aide (CNA) rolled a bedside table over it. The CNA confirmed the improper placement of the catheter bag, which was against the facility's undated catheter care policy that specified the catheter bag should not be on the floor.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine if residents were clinically appropriate to self-administer their medications, affecting two residents. Resident #7, who was cognitively intact and required assistance for activities of daily living, was observed self-administering multiple medications, including insulin and inhaled medication, without a self-administration assessment or physician order. The Director of Nursing confirmed that no assessment or order was in place for Resident #7 to self-administer medications. Similarly, Resident #10, who was also cognitively intact, was observed applying Lidocaine patches and keeping Flonase at the bedside for self-administration without a self-administration assessment or physician order. The Director of Nursing verified that Resident #10 did not have a completed self-administration assessment and was not documenting the administration of Flonase, as the nurses were doing that. The facility's policy requires an interdisciplinary team assessment and a physician order for residents to self-administer medications, which was not followed in these cases.
Failure to Ensure Privacy During Resident Transfer
Penalty
Summary
The facility failed to ensure privacy for Resident #27 during a mechanical lift transfer, as observed on February 24, 2025. Resident #27, who was admitted with diagnoses including myocardial infarction, dysphagia, Alzheimer's disease, and depression, was cognitively impaired and wheelchair-bound, requiring a mechanical lift for transfers. During the transfer, Certified Nurse Aides (CNAs) #604 and #704 left the door to the resident's room open, exposing the resident's body to the hallway. The resident's dress was moved above her incontinence brief, and her full breast was exposed while the CNAs prepared and executed the transfer using the Hoyer lift. The CNAs confirmed in an interview that they did not close the door while providing care, which was a violation of the facility's policy on resident rights. The policy mandates that residents' privacy should be respected during treatment, medication, or care, including closing the door or drawing the privacy curtain. This oversight affected the privacy and dignity of Resident #27, as the door remained open throughout the process, allowing potential exposure to anyone passing by in the hallway.
Failure to Provide Assistive Drinking Devices as Care Planned
Penalty
Summary
The facility failed to provide assistive drinking devices as care planned for a resident with specific needs. The resident, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage, contractures, diabetes mellitus type II, and neuromuscular dysfunction of the bladder, was identified as cognitively impaired and requiring assistance with activities of daily living. The care plan for this resident included the use of a Kennedy cup, a lightweight, spill-proof drinking cup, to be available at the bedside and with all meals to address the potential for altered nutrition. Observations revealed that the resident did not have the Kennedy cup during meal times, both in their room and in the dining room. Instead, the resident was provided with regular cups and an open can of soda, which did not align with the care plan. Interviews with a CNA confirmed the absence of the Kennedy cup during these observations. Additionally, the Dietary Manager confirmed that Kennedy cups were available at all times, yet no staff requested one for the resident. The facility's policy mandates the provision of assistive eating devices to promote independence in drinking and eating, which was not adhered to in this case.
Failure to Ensure Proper Explanation of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were properly explained and presented to residents with the cognitive ability to understand the document's content. This deficiency was identified during a review of Resident #145's medical records, arbitration agreements, and interviews with staff and the resident. Resident #145, who had been admitted with diagnoses including moderate dementia with agitation, atrial fibrillation, COPD, hypertension, legal blindness, bilateral unspecified hearing loss, heart failure, and cognitive communication deficit, was assessed with severe cognitive impairment. Despite this, the resident signed an arbitration agreement, indicating a lack of understanding of the document's implications. Interviews revealed that the Admissions Director (AD) attempted to assess the resident's cognitive function by reviewing previous documentation and asking basic questions. However, the AD acknowledged that Resident #145's Durable Power of Attorney (DPOA) lived out of state and was contacted without documentation of the conversation. The AD also noted that the resident's condition had deteriorated since admission, and if the resident had been in their current state, they would not have been asked to sign the paperwork. The resident, who was alert and oriented only to self, could not recall the details of the arbitration agreement and was unaware of its significance.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering the urinary catheter collection bag. This deficiency was identified during an observation of a resident who was admitted with an indwelling urinary catheter. The resident, who was cognitively intact, was observed without a cover on the urinary catheter collection bag, which was confirmed by a Certified Nurse Aide. This oversight affected the resident's right to a dignified existence and was part of a complaint investigation.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences for two residents, as required by their policies. Resident #15, who was admitted with multiple diagnoses including metabolic encephalopathy and pressure ulcer, did not have a care conference completed in January upon admission. The resident's care conferences were only documented on later dates, indicating a lapse in the required timeline for care planning. Similarly, Resident #48, admitted with conditions such as cerebral infarction sequelae and chronic kidney disease, did not have a care conference completed in May when admitted, and subsequent care conferences were not conducted quarterly as mandated. The facility's policy requires a baseline care plan within 48 hours of admission and quarterly reviews, which were not adhered to in these cases. This deficiency was confirmed through staff interviews and policy reviews, highlighting non-compliance with established care planning protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vancrest Of St Mary's | 1.5 mi | ★★★★★ | 5 | 0 |
| Transitional Care Unit | 1.7 mi | ★★★★★ | 4 | 0 |
| Otterbein St Marys Retirement Community | 2.8 mi | ★★★★★ | 0 | 0 |
| Gardens At Celina | 7.9 mi | ★★★★★ | 3 | 0 |
| Celina Manor | 8.2 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.