Inspection Reports for
Grenada Living Center
1950 Grandview Drive, Grenada, MS, 38901
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Inspection Report — Apr 10, 2025
Routine CMS
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including call light accessibility, resident food preferences, PASARR screening, care plan implementation, fluid restriction monitoring, and pain management.
Findings
The facility was found deficient in ensuring call light accessibility for a resident, honoring resident food preferences, accurately completing PASARR screening, implementing care plans for fluid restriction, documenting fluid intake accurately, and following physician orders for pain management referrals.
Deficiencies (6)
F 0558: The facility failed to ensure a call light was accessible for one of 17 residents reviewed. Resident #45's call light was wrapped around the bed rail and unreachable.
F 0561: The facility failed to honor a resident's food preferences for one of two residents reviewed. Resident #61 was served rice and mustard greens despite these being listed as dislikes.
F 0645: The facility failed to accurately submit a resident's PASARR information for Level II evaluation for one of three residents reviewed. Resident #43's psychiatric diagnoses and psychotropic medications were omitted.
F 0656: The facility failed to implement a care plan related to fluid restriction for one of 17 residents reviewed. Resident #20's fluid intake documentation was incomplete and inconsistent with prescribed restrictions.
F 0692: The facility failed to ensure accurate monitoring and documentation of fluid intake for a resident on fluid restriction for one of four residents reviewed. Resident #20's fluid intake was not properly reported or documented.
F 0697: The facility failed to follow a physician's order for a referral to a pain management clinic for one of three residents reviewed. Resident #23's referral was never made or scheduled.
Report Facts
Residents reviewed for call lights: 17
Residents reviewed for food preferences: 2
Residents reviewed for PASARR: 3
Resident care plans reviewed: 17
Residents reviewed for fluid restrictions: 4
Residents reviewed for pain management: 3
Fluid restriction order: 1000
Fluid restriction shift limits: 450
Fluid restriction shift limit: 100
Medication doses: 300
Medication doses: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed call light accessibility issue for Resident #45 and medication administration for Resident #23 |
| CNA #4 | Certified Nurse Aide | Confirmed call light inaccessibility for Resident #45 |
| RN #1 | Registered Nurse | Confirmed meal ticket process and resident food preferences for Resident #61 |
| Dietary Manager | Dietary Manager | Confirmed food preferences not honored for Resident #61 |
| Administrator | Administrator | Acknowledged food preference deficiencies for Resident #61 |
| Accounts Manager | Accounts Manager | Completed PASARR screening incorrectly for Resident #43 |
| Director of Nursing | Director of Nursing | Confirmed PASARR screening error for Resident #43, care plan and fluid restriction deficiencies for Resident #20, and pain management referral issue for Resident #23 |
| Social Worker | Social Worker | Confirmed PASARR screening error for Resident #43 |
| CNA #2 | Certified Nurse Assistant | Acknowledged failure to report fluid intake for Resident #20 |
| LPN #4 | Licensed Practical Nurse | Confirmed fluid restriction awareness but incomplete fluid intake documentation for Resident #20 |
| Nurse Practitioner | Nurse Practitioner | Discussed pain management and medication allergies for Resident #23 |
| Medical Doctor | Medical Doctor | Discussed Resident #23's complex pain management needs and referral |
| Medical Records Nurse | Medical Records Nurse | Reported Social Services did not schedule pain management appointment for Resident #23 |
| Social Services | Social Services | Unaware of pain management referral order for Resident #23 |
Inspection Report — Oct 5, 2023
Routine CMS
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations regarding resident privacy, trauma-informed care, infection prevention and control, and medication administration practices.
Findings
The facility was found deficient in maintaining resident privacy during treatment, failing to develop individualized trauma-informed care plans for residents with PTSD, and not adhering to infection control protocols including hand hygiene, use of barriers during medication pass, and proper sanitization of equipment.
Deficiencies (3)
F 0583: The facility failed to provide privacy during treatment for Resident #6 as the nurse did not close the door, pull the privacy curtain, or close blinds while care was provided.
F 0699: The facility failed to identify trauma triggers and develop individualized trauma-informed care plans for Resident #15 diagnosed with PTSD.
F 0880: The facility failed to prevent infection spread by not performing hand hygiene during wound care and medication administration, not using a clean barrier during medication pass, and not properly sanitizing a glucometer after use.
Report Facts
Residents reviewed for trauma-informed care: 4
Treatment observations: 7
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Named in privacy deficiency for Resident #6 | |
| Director of Nursing (DON) | Confirmed expectations for privacy, trauma-informed care, and infection control | |
| Licensed Practical Nurse (LPN) #1 | LPN | Unaware of PTSD diagnosis and lack of care plan for Resident #15 |
| Social Worker (SW) #1 | Social Worker | Completed social assessment and acknowledged lack of trauma-informed care plan for Resident #15 |
| Licensed Practical Nurse (LPN) #3 | LPN | Failed to perform hand hygiene and properly sanitize glucometer during glucose check and insulin administration for Resident #36 |
| LPN #2 | LPN | Failed to use barrier during medication pass for Resident #78 |
| LPN/Infection Control Nurse | Infection Control Nurse | Confirmed infection control expectations and deficiencies |
Inspection Report — May 5, 2022
Routine CMS
Date: May 5, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and food safety practices in the nursing home.
Findings
The facility failed to accurately code a Minimum Data Set (MDS) for one resident regarding dialysis treatment and failed to discard expired bread in the dietary department, posing a potential risk of food-borne illness to residents.
Deficiencies (2)
F 0636: The facility failed to accurately code the Minimum Data Set (MDS) for Resident #32 by not marking dialysis treatment, which could affect resident care and financial reimbursement.
F 0812: The facility failed to discard expired bread, with 28 packs of buns and rolls past their use-by date found in the dietary department, risking food-borne illness to residents.
Report Facts
Expired bread packs: 28
MDS reviewed: 19
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS nurse | Confirmed dialysis should be marked on MDS for Resident #32 | |
| Administrator | Confirmed dialysis should be marked on MDS and dietary staff should check bread dates | |
| Dietary Staff Member #1 (Dietary Manager) | Acknowledged failure to check expiration dates on bread and confirmed expired bread presence | |
| Dietary Staff Member #2 | Confirmed process of separating expired bread and presence of expired bread stacked with fresh bread |
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