Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Gran Gran's Place during CMS and state inspections, most recent first.
A facility failed to have a trained and designated infection preventionist overseeing the infection control program. The administrator stated the DON was handling infection control surveillance and antibiotic stewardship, but the DON had not completed the required IP training. The facility had not had a trained and designated IP since the previous DON left, and no attempts had been made to obtain one.
Incomplete care plans for anticoagulant therapy and catheter care: two residents receiving anticoagulants had care plans that did not include anticoagulant monitoring or side-effect interventions, despite physician orders and quarterly assessments showing anticoagulant use. Another resident with an indwelling catheter had a care plan that addressed I&O but did not include catheter care interventions, even though staff described routine catheter care practices and the resident had a physician order for catheter placement.
Failure to provide and document skin assessments was identified for two residents at risk for pressure ulcers. One resident had urinary incontinence, was dependent for mobility, and had a stage IV pressure ulcer not present on admission, while another resident was admitted with an unstageable wound present on admission and was also dependent for mobility. The care plans and physician orders did not include skin assessments, and the record contained no documentation of full body skin assessments; the DON and an LPN stated assessments were done with wound care but were not documented, and were not completed outside of wound care.
A facility failed to obtain a physician's order for catheter care for a resident with an indwelling catheter. The resident had intact cognition, needed assistance with toileting hygiene, and staff observed catheter care being performed even though an LPN stated there was no order. An RN said catheter care included peri-care, cleaning the catheter tubing, and routine catheter changes, and the DON stated there was no documentation that catheter care had been completed since insertion.
A facility failed to ensure anticoagulant meds were adequately monitored for two residents. One resident received Xarelto for atrial fibrillation and another received Eliquis, but neither resident’s care plan or MAR/TAR showed documented monitoring for bleeding or other side effects. Staff gave inconsistent accounts of where anticoagulant monitoring should be documented, and an RN, LPN, DON, and pharmacist described different expectations for monitoring and documentation.
Gloves Not Changed During Wound Care: An LPN did not change gloves appropriately while providing wound care for two residents with wounds, including one with an unhealed pressure ulcer and another with diagnoses of PVD and CAD. The LPN used the same gloves after removing old dressings, cleaning wounds, and applying new dressings, and also did not change gloves between multiple wounds on the same resident, contrary to the facility's infection control policy and the DON's stated process.
The facility failed to provide adequate nutrition by not offering meal replacements when residents consumed less than 50% of meals and not providing scheduled snacks. A resident with malnutrition did not receive documented meal replacements, and another with dementia was not offered snacks when asleep. A third resident on a mechanically altered diet had significant missed meal replacements, with no physician notification of meal refusals.
The facility did not complete annual competency reviews for two CNAs, as confirmed by the DON. Personnel files lacked documentation of these reviews, leading to a deficiency finding.
The facility failed to ensure the dietary manager, in position since July 2021, completed their certification for dietary management. During a survey, the dietary manager confirmed the absence of certification, and the Administrator could not explain why the training was not attended. This deficiency was noted in a facility with 35 residents.
The facility failed to ensure dietary staff followed proper food handling protocols. The dietary manager and a dietary aide were observed handling food with bare hands during meal service, contrary to the facility's policy requiring the use of utensils to avoid manual contact. The dietary manager acknowledged that gloves should be worn for items that could cause contamination but did not adhere to this policy.
The facility did not provide annual education on the influenza vaccine and its potential side effects to residents. Three residents received the vaccine without updated education, with consents signed years prior. The DON confirmed that annual education would begin this year.
A resident with hypertension, dementia, and gastroesophageal reflux disease experienced a significant decline in meal intake and weight loss. Despite being on a mechanically altered diet and refusing or consuming less than 50% of meals over several days, the physician was not notified. The MDS coordinator confirmed the lack of documentation, and the DON was unaware of the issue.
A resident with early onset Alzheimer's and dementia experienced changes in their care needs, requiring more assistance with eating and toileting. Despite these changes, the facility did not complete a significant change assessment. The MDS coordinator acknowledged that an assessment should have been conducted due to the permanent changes in the resident's condition.
A facility failed to document a physician's response regarding a dose reduction of Sertraline for a resident with depression and Alzheimer's. Despite a Consultant Pharmacist's request for a physician's input on the necessity of a dose reduction or contraindication, no response was recorded. The DON could not find any documentation of the physician's response to the GDR request.
A resident with Alzheimer's and early-onset dementia did not have timely lab results due to a delay in receiving a CMP ordered for April. The lab was initially drawn in early April, but the CBC clotted, requiring a recollection. The CMP results were only obtained in July after the MDS coordinator contacted the lab.
Lack of Trained and Designated Infection Preventionist
Penalty
Summary
The facility failed to have a trained and designated infection preventionist responsible for the infection prevention and control program. Record review showed an undated infection control program policy stating the goals of the program were to ensure compliance with state and federal infection control regulations, but an undated employee list did not identify any designated infection preventionist. During interview, the administrator stated the DON was handling infection control surveillance and antibiotic stewardship, but the DON had not completed the training required for the infection preventionist role. The administrator also stated the facility had not had a trained and designated infection preventionist since the previous DON left in December 2025 and had not made any attempts to acquire one. The DON stated they did not have formal training for the infection preventionist role.
Incomplete care plans for anticoagulant therapy and catheter care
Penalty
Summary
The facility failed to develop complete care plans with measurable interventions for anticoagulant use for two residents and for catheter care for one resident. Resident #1 had a physician’s order for Xarelto 15 mg daily related to atrial fibrillation, and a quarterly assessment showed diagnoses including coronary artery disease, atrial fibrillation, and heart failure, with the resident receiving an anticoagulant; however, the care plan dated 04/01/26 did not include interventions for anticoagulant use. Resident #2 had a physician’s order for Eliquis 2.5 mg every 12 hours for anticoagulant therapy, and a quarterly assessment showed the resident received an anticoagulant medication, but the care plan dated 09/12/25 did not include anticoagulant interventions. Resident #6 was observed with an indwelling catheter, and a physician’s order dated 03/12/26 directed placement of an 18 French catheter to gravity drainage. The revised care plan dated 03/12/26 included indwelling catheter re-inserted with intake and output every shift, but it did not contain catheter care interventions. The resident’s quarterly assessment dated 02/05/26 showed intact cognition with a BIMS of 15, and the resident stated the catheter was placed because they could not empty their bladder. Staff interviews identified catheter care as cleaning the tubing, providing peri-care each shift, using enhanced barrier precautions, and changing the catheter routinely, while the MDS coordinator stated the care plan lacked catheter care interventions because there was no physician’s order for catheter care.
Failure to Document Skin Assessments for Residents at Risk for Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for two residents reviewed for wounds. Resident #4 was identified as pressure ulcer risk related to urinary incontinence, dependent on mobility, and had a stage four pressure ulcer that was not present on admission. The resident’s care plan directed staff to monitor skin during activities of daily living, but it did not include skin assessments, and monthly physician orders did not show skin assessments. A quarterly assessment also documented the resident’s pressure ulcer risk and wound status. Resident #26 was admitted with an unstageable wound present on admission and was at risk for pressure ulcers, with dependence for mobility documented on the admission assessment. Admission orders did not include skin assessments, and the interim care plan listed skin treatment orders but did not include skin assessment or monitoring. The resident’s record contained no documentation of full body skin assessments. The DON stated skin assessments were done with wound treatment or on admission/readmission, but there was no implemented skin assessment sheet, and LPN #2 stated skin assessments were done with wound care but were not documented anywhere and were not completed outside of wound care.
Missing Physician Order for Catheter Care
Penalty
Summary
The facility failed to obtain a physician's order for catheter care for Resident #6, one of two sampled residents reviewed for catheter care. Resident #6 had an indwelling catheter, a weak gait, and required supervision or touching assistance with toileting hygiene per a quarterly assessment dated 02/05/26. The resident's cognition was intact with a BIMS score of 15. A physician's order dated 03/12/26 authorized placement of an 18 French indwelling catheter to gravity, and the care plan revised the same day noted the catheter had been re-inserted with intake and output every shift, but there was no physician's order for catheter care. During observation, Resident #6 was seen with an indwelling catheter, and an LPN later performed catheter care. The LPN stated the day shift did not have orders for catheter care, described catheter care as cleaning the tubing and providing peri-care each shift, and stated there should be an order. An RN stated catheter care included enhanced barrier precautions, cleaning the catheter tubing during peri-care, and routine catheter change, and said there should be a physician's order to ensure documentation of completed care. The DON stated there was no documentation that catheter care had been completed for the resident since insertion.
Anticoagulant Monitoring Not Documented
Penalty
Summary
The facility failed to ensure anticoagulant medications were not administered without adequate monitoring for 2 of 5 sampled residents reviewed for unnecessary medication. One resident had a physician order for Xarelto 15 mg daily related to atrial fibrillation, and the record showed diagnoses including coronary artery disease, atrial fibrillation, and heart failure. The resident’s annual assessment indicated anticoagulant use, but the care plan did not include interventions for anticoagulant therapy, and the medication and treatment administration records from 04/01/26 through 04/22/26 did not show anticoagulant monitoring while the medication was administered as ordered. An LPN stated they had monitored for side effects but did not document that monitoring was completed. A second resident had a physician order for Eliquis 2.5 mg every 12 hours, and the quarterly assessment showed anticoagulant use. The care plan did not show anticoagulant therapy or monitoring, and the medication and treatment administration records reviewed from 02/2026 through 04/2026 showed the medication was administered without documentation of anticoagulant monitoring. Staff statements reflected inconsistent understanding of what monitoring was required and where it should be documented; one LPN said monitoring was only documented in nurse’s notes or incident reports if bleeding took a while to stop or labs were ordered, while the DON stated anticoagulant monitoring was checked off twice a day for signs such as nose bleeds, dark stools, blood in the urine, bruising, and gums bleeding. An RN stated monitoring documentation was only done when a resident received two or more blood thinners, and the pharmacist stated documentation of signs and symptoms of bleeding would probably be expected.
Gloves Not Changed During Wound Care
Penalty
Summary
The facility failed to ensure gloves were used appropriately during wound care for 2 of 4 sampled residents reviewed for wounds. On 04/21/26 at 10:39 a.m., an LPN donned a gown and gloves to perform wound care for Resident #4, who had an unhealed pressure ulcer on the coccyx and a physician order to cleanse the wound, apply calcium alginate, and cover with a silicone dressing daily and as needed. At 10:42 a.m., the LPN removed the old coccyx dressing, cleansed the wound, and applied a new dressing without changing gloves after removing the old dressing, cleaning the wound, and applying the new dressing. On 04/21/26 at 11:34 a.m., the same LPN donned a gown and gloves to clean Resident #11's left pinky toe and apply a new dressing. The LPN then used the same gloves to clean the resident's left heel, pat it dry, apply betadine, and leave it open to air, and then cleaned the resident's right leg and applied a clean dressing without changing gloves between wounds or between cleaning and dressing application. Resident #11 had diagnoses including peripheral vascular disease and coronary artery disease and had an unhealed pressure ulcer. The facility's infection control policy stated caregivers should wash hands before contact with clean dressing supplies and that once gloves are soiled with wound secretions, they should not contact remaining clean dressings and supplies until gloves are removed and hands washed. The DON stated gloves should be changed after removing old dressings, after hand hygiene, before finishing wound care, and between multiple wounds on the same resident.
Failure to Provide Adequate Nutrition and Meal Replacements
Penalty
Summary
The facility failed to provide adequate nutrition to residents by not offering meal replacements when less than 50% of a meal was consumed and not providing scheduled snacks. Resident #19, diagnosed with pressure ulcer and protein-calorie malnutrition, had a care plan requiring supplements if meals were less than 50% consumed. However, the dietary flow records for June 2024 showed missed opportunities for meal replacements during breakfast, lunch, and dinner. The Director of Nursing (DON) confirmed that health shakes should be given if residents did not eat much, but the documentation did not reflect this practice. Resident #13, with Alzheimer's and dementia, was supposed to receive a health shake if consuming less than 50% of meals and snacks twice daily. Observations showed that snacks were not offered when the resident was asleep, and the dietary flow records indicated numerous missed meal replacements. Similarly, Resident #24, with hypertension, dementia, and gastroesophageal reflux disease, was on a mechanically altered diet but had significant missed meal replacements documented in June and July 2024. The dietary supervisor and DON were unaware of the residents' meal refusals, and there was no documentation of physician notification regarding the decline in meal intake.
Failure to Conduct Annual Competency Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual competency reviews were completed for two certified nurse aides (CNAs) whose records were reviewed. During a review of personnel files, it was found that there was no documentation of annual competency checks for these CNAs. The Director of Nursing (DON) confirmed that the competency checks were not conducted annually, which led to the deficiency being identified.
Dietary Manager Certification Deficiency
Penalty
Summary
The facility failed to ensure that the designated dietary manager had completed their certification for dietary management. The dietary manager had been in the position since July 2021, and as of the survey conducted on July 10, 2024, they had not obtained the necessary certification. During an interview, the dietary manager confirmed that they did not have the certificate for dietary management. Additionally, the facility's Administrator was unable to provide a clear explanation for the lack of certification, stating that the dietary manager had not attended the required training. This deficiency was identified in a facility with 35 residents.
Improper Food Handling by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff adhered to proper food handling protocols during meal service, as observed by surveyors. The dietary manager was seen handling a piece of bread with bare hands, placing it in a toaster, and then serving it to a resident without using gloves or utensils. Similarly, a dietary aide was observed splitting a biscuit and handling sausage with bare hands before serving it to a resident. The facility's policy on food handling, which requires the use of clean utensils to avoid manual contact with prepared foods, was not followed. When questioned, the dietary manager indicated that gloves should be worn for items that could potentially cause contamination, such as meat products or eggs, but did not adhere to this policy during the observed incidents.
Failure to Provide Annual Vaccine Education
Penalty
Summary
The facility failed to provide annual education and information on potential side effects of the influenza vaccine to residents, as required. This deficiency was identified during a review of records and interviews, where it was found that three out of five residents reviewed for vaccinations did not receive the necessary education. Specifically, Resident #5's informed consent for the influenza vaccine was signed in 2019, but the vaccine was administered in 2023 without updated education. Similarly, Resident #6's consent was signed in 2022, and Resident #13's consent was signed in 2018, both without annual updates on education and side effects. During an interview, the Director of Nursing (DON) acknowledged that starting this year, the facility would begin providing the required annual education.
Failure to Notify Physician of Resident's Meal Intake Decline
Penalty
Summary
The facility failed to notify the physician of a significant decline in meal intake and weight loss for a resident diagnosed with hypertension, dementia, and gastroesophageal reflux disease. The resident was on a mechanically altered diet, and records showed they refused or consumed less than 50% of their meals for a significant number of days in June and July 2024. Despite this decline, there was no documentation that the physician had been informed. The MDS coordinator confirmed the lack of notification, and the DON stated that any nurse could notify the physician but was unaware of the resident's eating issues.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who was reviewed for assessments. The resident had diagnoses of early onset Alzheimer's and dementia. A quarterly assessment in January documented that the resident needed supervision or touching assistance with eating and substantial or maximal assistance with toileting. By April, the resident's condition had changed, requiring partial to moderate assistance with eating and being dependent on staff for toileting. Despite these changes, a significant change assessment was not completed. The MDS coordinator confirmed that a significant change assessment should have been conducted, as the resident experienced changes in two or more areas that were considered permanent.
Failure to Document Physician Response for Dose Reduction
Penalty
Summary
The facility failed to ensure a physician's response was documented for a dose reduction of Sertraline for one of the residents reviewed for unnecessary medications. The resident in question had diagnoses including depression and Alzheimer's and was prescribed Sertraline at a dose of 125 mg daily. A Consultant Pharmacist's Medication Regimen Review requested a physician's input on whether a dose reduction was warranted or if there was a clinical contraindication for such a reduction. However, the form did not contain a response from the physician. The Director of Nursing (DON) was unable to locate any documentation indicating that the physician had responded to the request for a gradual dose reduction (GDR) of Sertraline.
Delayed Lab Results for Resident with Alzheimer's
Penalty
Summary
The facility failed to ensure timely receipt of laboratory results for a resident diagnosed with Alzheimer's and early-onset dementia. A physician's order required a comprehensive metabolic panel (CMP) and complete blood count (CBC) to be conducted every six months in April and October. However, the clinical health record lacked the CMP results for April 2024. The MDS coordinator confirmed that the lab was ordered and drawn on April 2, 2024, but the CBC sample clotted, necessitating a recollection on April 10, 2024. The CMP results were not received until July 9, 2024, after the MDS coordinator had to contact the lab to obtain them.
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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 Yukon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spanish Cove Housing Authority | 0.5 mi | ★★★★★ | 0 | 0 |
| Ranchwood Nursing Center | 1 mi | ★★★★★ | 21 | 3 |
| Heritage Park | 6.1 mi | ★★★★★ | 0 | 0 |
| The Grand At Bethany Skilled Nursing And Therapy | 6.2 mi | ★★★★★ | 9 | 0 |
| The Health Center At Concordia | 7.1 mi | ★★★★★ | 0 | 0 |
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