Grenada Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, resident, resident representative, and staff interviews, and record reviews, the facility failed to ensure a resident's right to be treated with dignity and respect as evidenced by failure to respond in a timely manner to the resident's requests for assistance causing the resident embarrassment and humiliation for one (1) of four (4) residents reviewed, Resident #2.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide timely incontinence care for a resident, causing the resident embarrassment and humiliation. This also put the resident at risk for skin impairment and discomfort for one (1) of four (4) residents reviewed. Resident #2. Findings Include: Review of the facility policy Activities of Daily Living (ADL), Supporting with revision date of March 2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .An observation and interview with Resident #2 on 04/06/26 at 11:00 AM revealed him lying in bed and there were multiple large smears of a yellowish substance on his bed pad, fitted sheet and on his flat sheet. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse by a Certified Nurse Assistant (CNA) for one (1) of three (3) residents reviewed for abuse (Resident #7). This deficient practice resulted in the resident being forcefully pushed down onto the bed by a staff member, creating potential for physical injury and psychological harm.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs. This deficient practice resulted in prolonged call-light response times and delays in assistance with care needs and had the potential to affect all 101 residents residing in the facility.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to provide written transfer notice to a resident's representative for one (1) of nine (9) residents records reviewed. Resident #1 Findings Include Review of the facility policy, titled “Transfer or Discharge Notice”, revealed, “Policy Interpretation and Implementation…5. The resident and representatives are notified in writing of the following information: a. The specific reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged …” Review of the online complaint received revealed that Resident #1’s resident representative was not notified by the facility of his transfer to the emergency room on 6/25/25. [...]

Inspectors wroteBased on staff interview and record review the facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Second quarter 2024.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure staff completed competency skills check-off and completed Enhanced Barrier Precautions training prior to caring for residents with a tracheostomy for one (1) of four (4) respiratory staff personnel files reviewed.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection, as evidenced by failing to ensure Enhanced Barrier Precautions (EBP) and proper hand hygiene during resident care treatment for one (1) of four (4) resident care treatments observed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete an Annual Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) no later than 14 days of the Assessment Reference Date (ARD) for one (1) of 19 assessments reviewed.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review the facility did not report an allegation of abuse to the State Agency within two (2) hours after the incident reportedly occurred for one (1) of four (4) investigations.

Inspectors wroteBased on observations, staff interviews and facility policy review, the facility failed to properly label and store food items in a cooler in the kitchen according to professional standards for food service safety, failed to properly label food items stored in the resident nourishment refrigerators, failed to maintain a temperature log for the resident nourishment refrigerators, and failed to maintain a cleaning schedule for the resident nourishment refrigerators located on A-Hall and C-Hall nursing units of the nursing facility for one (1) of two (2) tours.

Inspectors wroteBased on resident interviews, staff interviews, record review, and facility policy review the facility failed to provide activities on the weekends, as evidenced by, independent activities only listed on the activity calendar for Saturday's and no scheduled activities on Sunday's for three (3) of 29 sampled residents. Resident #26, Resident #67, Resident #178.

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to respect the right of a resident as evidenced by the facility applying a lap tray to a cognitively intact resident against her wishes for one (1) of 29 residents sampled. Resident # 45. Findings Include Record review of the facility policy titled, Resident's Rights with no revision date revealed under #3. Is assured of adequate and appropriate medical care is fully informed by a physician, of his medical condition unless medically contraindicated (as documentation by a physician, in his medical record) is afforded the opportunity to participate in the planning of his medical treatment to refuse to participate in experiment research and to refuse medication and treatment after being fully informed of and understanding the consequences of such actions. [...]

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to review and gain consent on a cognitively intact residents Advanced Directives (Resident # 52) and failed to obtain a physician's order and formulate a Do Not Resuscitate (DNR) status in the medical record (Resident #181) for two (2) of 29 resident's advance directives reviewed. Resident # 52 and #181 Findings Include: An interview on [DATE] at 3:15 PM, with the Administrator revealed the facility did not have a policy related to the process for ensuring the appropriate code status for DNR for residents. Resident # 52 An interview on [DATE] at 4:10 PM, with Resident #52 revealed no one from the facility had talked to him about his wishes regarding wanting CPR (cardio pulmonary resuscitation) or not. [...]

Inspectors wroteBased on observation, staff, resident interview and resident representative interview, record review and facility policy review the facility failed to ensure a resident was assessed for the need of physical restraint as evidenced by no restraint assessment completed prior to applying a lap tray for one (1) of 18 residents reviewed. Resident #45 Findings Include Record review of the facility policy titled, Physical Restraints and Involuntary Seclusion with a revision date of 10/08/20 revealed under Policy .#1. Restraints will not be used unless the facility's Interdisciplinary Team has completed an assessment and evaluation to identify causative medical or environmental factors and considered less restrictive alternatives (except in an emergency). #3 The patient/resident will have the right to refuse or accept the use of restraints. [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review the facility failed to complete a baseline care plan, within 48 hours, for new admits to the nursing facility as evidenced by observation of incomplete baseline care plans for one (1) of eight (8) resident investigations.

Inspectors wroteBased on staff interview, record review and policy review the facility failed to develop a care plan for the application of an Aspen collar, splint, and a Wrist-Hand-Finger Orthosis (WHFO) for Resident # 17 and implement a care plan for monitoring of side effects and behaviors for psychotropic medication (Resident # 229) for two (2) of 20 residents care plans reviewed.

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to include a resident in the development of their plan of care for one (1) of 18 resident care plans reviewed. Resident # 52. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive Person Centered with a revision date of January 2023 revealed Policy Interpretation and Implementation .#1. The Interdisciplinary Team (IDT) , in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. An interview on 5/1/23 at 4:10 PM, with Resident #52 revealed no one from the facility had asked him to attend a care plan meeting. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to assure that services being provided meet professional standards of quality as evidenced by staff failed to sign off medications as administered for one (1) of four (4) residents reviewed( Resident #60) and failed to check the 5 rights of medication prior to the administration for one (1) of four (4) residents reviewed. (Resident #181)

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide professional standards of practice to a resident related to application and documentation for an Aspen Collar, for a right-hand Wrist-Hand-Finger Orthosis (WHFO) splint, and for a left knee extension splint, for one (1) of four (4) residents reviewed for Position and Mobility.

Inspectors wroteBased on staff interview, record and policy review the facility failed to ensure residents were free from unnecessary medications as evidenced by no monitoring for side effects of psychotropic medications or the presence of behaviors for one (1) of six (6) residents reviewed for unnecessary medications. Resident # 229.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to ensure that the medication error rate was no greater than 5% during a medication administration observation, for Resident #282. The medication error rate was calculated at 6.9%.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to ensure Drugs and biological's used in the facility were stored in accordance with currently accepted professional principles as evidenced by a medication storage room left open and left unattended for one (1) of four (4) medication rooms reviewed.

Inspectors wroteBased on observation, staff interviews, record review and facility policy review the facility failed to prevent the possible spread of infection as evidenced by staff failed to remove gloves and perform hand hygiene after administering eye drops and prior to administering oral medication, and failed to sanitize an eye drop box before placing it in the medication cart that was sitting on a residents bedside table without a barrier for one (1) of four (4) residents reviewed during medication and treatment administration. Resident #62.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary environment and store food in a manner to prevent the likelihood of foodborne illnesses for one (1) of one (1) kitchen tour.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, homelike environment for three (3) of four (4) halls observed.

Inspectors wroteBased on record review, staff interview, and facility statement, the facility failed to accurately code a Minimum Data Set (MDS) related to discharge status, for one (1) of 22 MDS assessments reviewed, Resident #90.

Inspectors wroteBased on facility policy review, record review and staff interview the facility failed to implement the care plan related to a diet order for one (1) of 22 residents care plans reviewed, Resident #89.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to properly label opened medications and discard expired medications within the manufacturer's recommended time frame for two (2) of three (3) medication carts, and one (1) of four (4) medication storage rooms.