Grand Oaks Care

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on March 31, 2026.

  CMS has cited this home for F0658 6 times since 2023.

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CMS lists this as a standard inspection.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0880 3 times since 2022.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0656 3 times since 2022.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on February 23, 2026.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0698 3 times since 2022.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0761 2 times since 2024.

• Citation F0812. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0812 2 times since 2022.

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CMS lists this as a standard inspection.

• Citation K0711. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide a written emergency evacuation plan.

  CMS lists it as corrected on February 27, 2026.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on February 27, 2026.

• Citation K0293. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on February 23, 2026.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on February 27, 2026.

  CMS has cited this home for K0741 2 times since 2022.

• Citation E0032. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on February 23, 2026.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on September 3, 2025.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS has cited this home for F0580 5 times since 2024.

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CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on July 7, 2025.

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CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on May 9, 2025.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on February 13, 2025.

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• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on October 24, 2024.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on October 24, 2024.

• Citation F0578. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on October 24, 2024.

  CMS has cited this home for F0578 2 times since 2022.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 24, 2024.

• Citation F0688. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on October 24, 2024.

  CMS has cited this home for F0688 2 times since 2022.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on October 24, 2024.

• Citation F0745. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide medically-related social services to help each resident achieve the highest possible quality of life.

  CMS lists it as corrected on October 24, 2024.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on October 24, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on October 24, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 24, 2024.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on October 24, 2024.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on October 24, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on October 24, 2024.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on October 24, 2024.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on October 24, 2024.

  CMS has cited this home for F0755 4 times since 2022.

• Citation F0805. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on October 24, 2024.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on October 24, 2024.

  CMS has cited this home for F0806 2 times since 2022.

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CMS lists this as a standard inspection.

• Citation K0712. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on October 31, 2024.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on October 31, 2024.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on October 31, 2024.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on October 31, 2024.

  CMS has cited this home for K0353 2 times since 2022.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on October 31, 2024.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on October 31, 2024.

• Citation E0039. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on October 31, 2024.

• Citation K0918. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on October 31, 2024.

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• Fine

  CMS changed the fine from May 15, 2023 from $53,064 to $34,492.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on June 21, 2024.

  CMS has cited this home for F0804 2 times since 2022.

• Citation F0837. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

  CMS lists it as corrected on June 21, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on June 21, 2024.

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• Name

  CMS lists a new name for this home. It was TWIN OAKS REHABILITATION & NURSING CENTER.

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on May 8, 2024.

• Citation F0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on May 8, 2024.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on April 25, 2024.

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CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on February 29, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on February 29, 2024.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on February 29, 2024.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on January 22, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on January 22, 2024.

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• Fine

  CMS changed the fine from June 9, 2021 from $8,520 to $8,883.

CMS lists this as a complaint inspection.

• Citation F0698. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on December 28, 2023.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 28, 2023.

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CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 30, 2023.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on November 17, 2022.

• Citation F0676. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on November 17, 2022.

• Citation F0679. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on November 17, 2022.

• Citation F0698. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on November 17, 2022.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on November 17, 2022.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on November 17, 2022.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 17, 2022.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on November 17, 2022.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on November 17, 2022.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on November 17, 2022.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on November 17, 2022.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on November 17, 2022.

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CMS lists this as a standard inspection.

• Citation K0347. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly provide smoke detection systems in areas open to corridors.

  CMS lists it as corrected on November 17, 2022.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on November 17, 2022.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on November 17, 2022.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on November 17, 2022.

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