Grenada Living Center

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a call light was accessible for one (1) of 17 residents reviewed for call lights. Resident #45. Findings Include: Review of the facility policy titled Call Light/Bell with a revision date of 1/24 revealed under, Purpose: To provide the resident with a means of communication with staff members .To provide staff members with a means of summoning assistance when they are with the resident . An observation and interview with Resident #45 on 4/07/25 at 10:50 AM revealed he was sitting in his wheelchair inside his room watching television. The right side of the bed was turned against the wall with the call light cord wrapped around the bed rail multiple times, and the end of the call light was hanging down behind the bed, unreachable. The resident verbalized that he used the call light to request help but could not do that with it tied to the bed rail where he could not access it. He revealed that if he needed help, he would roll his wheelchair to the door and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to honor a resident's choice related to food preferences for one (1) of two (2) residents reviewed for choices. Resident #61. Findings Include: Record review of the facility policy Dignity and Respect with revision date of 07/22 revealed A facility must .care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. The facility shall protect and promote the rights of the residents .3. All residents should have autonomy of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care .4 .Resident's individual preferences regarding such things as menus .will be elicited and respected by the facility, and efforts will be made to accommodate these wishes . An observation and interview on 4/07/25 at 12:10 PM with Resident #61 revealed she was sitting in her room eating her lunch meal. She stated that she did not like rice or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to accurately submit a resident's information for Preadmission Screening and Resident Review (PASRR) for a Level II evaluation for one (1) of three (3) residents reviewed for PASRR. (Resident #43) Findings include: Review of the facility policy titled, Pre-admission Screening PAS/PASRR (MS Only) last reviewed 8/24, revealed, To enter a Long-Term Care program an eligible beneficiary must have a Pre-admission Screening (PAS) application completed to determine clinical eligibility for individuals seeking admission to a Division of Medicaid certified nursing facility on all residents regardless of payor source . Process . Review the medical records and other relevant medical documentation to verify major medical conditions and services . Record review of the admission Record revealed Resident #43 was admitted on [DATE], with diagnoses of Unspecified Psychosis, Major Depressive Disorder, and Psychotic Disorder with Delusions.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan related to fluid restriction for one (1) of 17 resident care plans reviewed. (Resident #20). Findings include: Review of a facility policy titled, Care Plan Process, last revised 12/24, revealed, The comprehensive care plan is an interdisciplinary communication tool .The care plan must include measurable objectives and timeframes and must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of a care plan for Resident # 20 revealed, Focus The resident is at risk for nutritional problems r/t (related to) ESRD (End Stage Renal Disease) with fluid restriction on Hemodialysis . last revised 9/05/24 Interventions: 1000 ml (milliliters) fluid restriction. Document fluid intake. Day shift not to exceed 450 ml. Evening shift not to exceed 450 ml. Night shift not to exceed 100 ml . Record review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to ensure accurate monitoring and documentation of fluid intake for a resident on fluid restriction for one (1) of (4) four residents reviewed for fluid restrictions (Resident #20). Findings include: Review of the facility policy titled, Fluid Restriction, last reviewed February 2022, revealed the policy statement: Fluids will be restricted for residents as directed by the physician orders . Procedure: 3. Nursing service will document intake . Record review of the Order Summary Report for Resident #20 revealed an order dated 8/26/24 for a 1000 milliliter (ml) fluid restriction. The order directed that fluid intake must be documented and specified the following shift limits: day shift not to exceed 450 ml, evening shift not to exceed 450 ml, and night shift not to exceed 100 ml. Record review of the Intake and Output (I&O) forms for Resident #20 from 3/30/25 through 4/7/25 revealed incomplete documentation. Daily 24-hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to follow a physician 's order for a referral to a pain management clinic for Resident #23, this was for one (1) of three (3) residents reviewed for pain. Findings Include: Review of the facility policy titled Pain Screen and Management with a revision date of 12/23 revealed, All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until an acceptable level of relief of pain is achieved. All residents have the right to treatment for pain. On 4/07/25 at 11:15 AM, an observation and interview with Resident #23 revealed he was lying in bed and verbalized he was hurting in his lower abdomen (kidney area) and his lower ribs (lung area). The resident revealed he was unsure if he had taken something for the pain. An observation and interview of Resident #23 on 4/08/25 at 9:40 AM revealed he was lying in bed and the resident stated that he was hurting all over. The resident revealed that he had had a log truck accident in the past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide privacy during one (1) of seven (7) treatment observations during the survey. Resident #6 Findings include: A review of the facility policy titled, Residents Rights, with a revision date of 11/17 revealed, All residents in a long-term care facility have rights guaranteed to them under Federal and State law. Residents residing at this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights include: # 5 Privacy and confidentiality . #26 The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications. personal care, visits, and meeting of family and resident groups, but this does not require the facility to provide a private room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review the facility failed to identify triggers to avoid potential re-traumatization and failed to develop the care plan to include individualized trauma- informed approaches for one (1) of four (4) residents reviewed for trauma- informed care. Resident #15. Findings include: A record review of the facility policy, titled Documentation-Social History, with a revision date of 10/23, revealed, Purpose, to record observations, outcomes, and responses in relation to social services as well as interventions, including trauma informed care, as identified in the comprehensive care plan, and the delivery of direct social services . A record review of Resident #15's Face Sheet revealed she was admitted to the facility on [DATE] with a diagnosis of Post-traumatic Stress Disorder (PTSD). A record review of Resident #15's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/11/23 revealed a diagnosis of PTSD. The Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by not performing hand hygiene during wound care and medication administration (Residents #6, #36, and #39), failure to use a clean barrier during medication pass (Resident #78) and failure to properly sanitize a glucometer after use (Resident #36) for two (2) of four (4) days of survey. Findings Include: Review of the facility policy titled, General Infection Prevention and Control Nursing Policies with an origination date of 06/14 and a review date of 08/21 revealed It is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff, and visitors. Some of the specific guidelines include: All items used for resident care will be cleaned and disinfected between uses or will be designated for that resident's use only .other common-use items will be cleansed and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations staff interviews, and record review, the facility failed to discard expired bread as evidenced by the observation of 28 packs of buns and rolls, with expired use by dates, in the dietary department, for one (1) of three (3) dietary tours. Review of facility policy titled, RECEIVING AND INSPECTION OF FOOD, with a review date 0f 9/12, revealed, Policy: The facility shall ensure that food is delivered to the facility in a safe condition . c. Reject if packaging has the following problems: vii. Expired code or use by date. Findings include: The initial kitchen tour observation, on 05/02/22 at 10:15 AM, revealed 20 packs of hamburger buns, six (6 )packs of hoagie buns, and two (2) packs of dinner rolls, in the dry goods storage room with an expiration date of 4/24/22. The observation also revealed a sign, that was posted, on the fourth brown bread tray, that contained six (6) packs of expired hamburger buns, that read, Use First. The observation revealed that the expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review the facility failed to accurately code a Minimum Data Set (MDS) for one (1) of 19 MDS's reviewed. Resident #32 Findings include: Review of the facility policy titled, Resident Assessment, with the latest revision date of 09/19, revealed an assessment will be completed on each resident utilizing the MDS. The completed assessment guides the staff in identifying key information about the resident and serves as a basis for identifying specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental and psychosocial well-being. The assessment will describe the resident's physical and mental deficits, strenghths, and the requirements of assistance to meet their needs. The assessment will also identify risk factors associated with the possible functional decline and describe the resident's objectives for maintaining or improving their functional abilities. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.