Inspection Reports for
Grenada Rehabilitation and Healthcare Center
1966 Hill Drive, Grenada, MS, 38901
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Inspection Report — Oct 29, 2025
Complaint Investigation CMS
Date: Oct 29, 2025
Visit Reason
The inspection was conducted following complaints regarding physical abuse by a Certified Nurse Assistant and concerns about insufficient nursing staff leading to delayed care and response times.
Complaint Details
The complaint investigation substantiated physical abuse by CNA #4 against Resident #7. Numerous complaints from residents and families about staffing shortages and delayed care were confirmed by interviews and record reviews.
Findings
The facility substantiated physical abuse by a CNA who pushed a resident onto a bed causing potential harm. Additionally, the facility failed to maintain sufficient nursing staff to meet residents' needs, resulting in prolonged call-light response times and delays in care affecting all 94 residents.
Deficiencies (2)
F 0600: The facility failed to protect a resident from physical abuse by a CNA who forcefully pushed the resident onto the bed, confirmed by interviews and investigation.
F 0725: The facility failed to provide enough nursing staff daily to meet residents' needs, causing delays in call-light responses and care for all 101 residents.
Report Facts
Residents affected by abuse: 1
Residents affected by staffing issues: 101
Residents per CNA ratio: 15
Staffing shifts and resident counts: 95
Staffing shifts and resident counts: 91
Staffing shifts and resident counts: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Assistant | Named in physical abuse finding and terminated after investigation. |
| CNA #1 | Certified Nurse Assistant | Witnessed abuse and reported it to administration. |
| Administrator | Administrator (ADM) | Conducted investigation and confirmed abuse and staffing issues. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse and staffing concerns. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Handled scheduling and confirmed staffing problems. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed about staffing shortages and care delays. |
| Respiratory Therapist | Respiratory Therapist | Reported staffing shortages affecting care for residents with tracheostomies. |
Inspection Report — Aug 13, 2025
Complaint Investigation CMS
Date: Aug 13, 2025
Visit Reason
The inspection was conducted in response to an online complaint alleging that the facility failed to provide written transfer notification to a resident's representative.
Complaint Details
The complaint alleged that the resident's representative was not notified of the resident's transfer to the emergency room on 6/25/25. This was substantiated by record review and staff interview.
Findings
The facility failed to provide written transfer notice to the representative of one resident who was transferred to the emergency room. The Administrator stated no notification was sent because the resident returned within a few hours.
Deficiencies (1)
F 0628: The facility failed to provide required documentation or notification related to a resident's transfer or discharge. Specifically, the resident's representative was not notified in writing of the transfer to the emergency room on 6/25/25.
Report Facts
Residents records reviewed: 9
Residents affected: 1
Inspection Report — Jul 18, 2024
Complaint Investigation CMS
Date: Jul 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident #58.
Complaint Details
The complaint investigation found that the facility did not report an allegation of abuse within the required timeframe. The allegation involved Resident #58 and was substantiated by staff interviews and policy review.
Findings
The facility did not report an allegation of abuse to the State Agency within two hours after the incident occurred. Interviews and record reviews confirmed that Nursing Assistant #1 delayed reporting the incident until the next day, contrary to facility policy.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse to the State Agency within two hours after the incident involving Resident #58. Nursing Assistant #1 did not report the incident immediately as required by policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Named in failure to report abuse allegation involving Resident #58. | |
| Certified Nursing Assistant #1 | Witnessed the abuse incident involving Resident #58. | |
| Registered Nurse #1 | Interviewed regarding the delayed reporting of the abuse incident. | |
| Director of Nursing | Director of Nursing | Interviewed about the facility's awareness of the abuse incident and disciplinary action. |
Inspection Report — Jul 18, 2024
Annual Inspection CMS
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including timely completion of resident assessments, staff competency, infection control, and accurate staffing data submission.
Findings
The facility failed to complete timely Minimum Data Set (MDS) assessments for residents, did not ensure competency training and proper infection control practices for respiratory staff, and submitted inaccurate staffing data to the Payroll-Based Journal (PBJ) system.
Deficiencies (5)
F0636: The facility failed to complete an Annual Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #24.
F0638: The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #49.
F0726: The facility failed to ensure one respiratory therapist completed competency skills check-off and Enhanced Barrier Precautions training prior to providing care for residents with tracheostomies.
F0851: The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for the second quarter of 2024.
F0880: The facility failed to prevent infection spread by not ensuring Enhanced Barrier Precautions and proper hand hygiene during tracheostomy care for Resident #53.
Report Facts
Number of assessments reviewed: 19
Number of respiratory staff personnel files reviewed: 4
Number of resident care treatments observed: 4
Number of quarters reviewed: 4
Quarter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT #1 | Respiratory Therapist | Named in findings for lack of competency training and improper infection control during tracheostomy care |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding staffing data submission and infection control standards |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Confirmed lack of in-service training for respiratory therapist |
| Respiratory Therapist Director | Respiratory Therapist Director | Interviewed regarding training and infection control standards |
| Human Resources/Payroll Coordinator | Human Resources/Payroll Coordinator | Interviewed regarding Payroll-Based Journal data submission |
| Corporate Consultant | Corporate Consultant | Confirmed errors in Payroll-Based Journal data entry |
| MDS Coordinator | MDS Coordinator | Confirmed late completion of Minimum Data Set assessments |
| MDS Consultant | MDS Consultant | Confirmed ongoing issues with timely MDS completion and submission |
Inspection Report — May 15, 2023
Routine CMS
Date: May 15, 2023
Visit Reason
Routine inspection of Grenada Rehabilitation and Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to respect resident rights, incomplete or missing care plans, medication administration errors, improper storage and labeling of food, inadequate infection control practices, and failure to maintain proper documentation and assessments related to restraints and advance directives.
Deficiencies (13)
F 0550: The facility failed to respect the right of a cognitively intact resident by applying a lap tray against her wishes without proper consent.
F 0578: The facility failed to review and gain consent on cognitively intact residents' advance directives and failed to obtain a physician's order for Do Not Resuscitate status for two residents.
F 0604: The facility failed to ensure a resident was assessed for the need of physical restraint prior to applying a lap tray and did not obtain timely consent.
F 0655: The facility failed to complete a baseline care plan within 48 hours for a new admit resident.
F 0656: The facility failed to develop and implement comprehensive care plans for a resident's orthopedic devices and psychotropic medication monitoring.
F 0657: The facility failed to include a resident in the development of their plan of care.
F 0658: The facility failed to meet professional standards of quality in medication administration, including failure to sign off medications and failure to check the five rights of medication.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences related to orthopedic devices for a resident.
F 0758: The facility failed to monitor for side effects and behaviors related to psychotropic medications for a resident.
F 0759: The facility's medication error rate was 6.9%, exceeding the acceptable threshold of 5%, due to errors in medication administration for a resident.
F 0761: The facility failed to ensure drugs and biologicals were stored securely, as a medication storage room was left open and unattended with medications accessible.
F 0812: The facility failed to properly label and store food items, maintain temperature logs, and clean resident nourishment refrigerators, risking foodborne illness.
F 0880: The facility failed to prevent possible spread of infection by not removing gloves and performing hand hygiene after administering eye drops and before oral medications, and not sanitizing an eye drop box.
Report Facts
Medication error rate: 6.9
Residents reviewed for restraint assessment: 18
Residents sampled: 29
Residents care plans reviewed: 20
Residents reviewed for unnecessary medications: 6
Medication error opportunities observed: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to remove gloves and perform hand hygiene after eye drops and before oral meds; failed to sanitize eye drop box |
| LPN #3 | Licensed Practical Nurse | Medication administration errors including wrong medication form and missed medication |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including consent, medication administration, and storage issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Administered IV medication without checking five rights |
| Infection Control Nurse | Infection Control Nurse | Provided education on medication administration and infection control practices |
| Dietary Manager | Dietary Manager | Confirmed expired food items and lack of proper labeling and cleaning schedules |
| Occupational Therapist | Occupational Therapist | Failed to document splint application for Resident #17 |
| Physical Therapist | Physical Therapist | Confirmed lack of documentation for splint application |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed Resident #17 not wearing ordered orthopedic devices |
| LPN #4 | Licensed Practical Nurse | Confirmed failure to follow psychotropic medication care plan |
Inspection Report — Mar 3, 2023
Complaint Investigation CMS
Date: Mar 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and develop a care plan for a resident at risk of wandering and elopement.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent elopement of Resident #1, who was cognitively intact but exhibited wandering and exit seeking behaviors. The resident left the facility unnoticed and was found injured in the community. The facility was notified by the local hospital emergency room. Immediate Jeopardy was identified and removed after corrective actions.
Findings
The facility failed to develop and implement a comprehensive care plan and provide supervision to prevent elopement of Resident #1, who exhibited exit seeking behaviors and left the facility unnoticed and unsupervised. This failure placed the resident and others at risk of serious harm. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan with measurable actions for Resident #1 exhibiting exit seeking behaviors and wandering risk. Supervision was inadequate, allowing the resident to elope unnoticed and sustain injuries.
F 0689: The facility failed to provide adequate supervision and accident hazard prevention to stop Resident #1 from eloping through a window, resulting in injury and risk of serious harm.
Report Facts
Resident wandering risk score: 28
Resident last seen time: 21
Resident found time: 21.53
Distance from facility: 236.22
Number of residents audited: 88
Number of residents at high risk for wandering: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | On duty charge nurse who responded to Resident #1's elopement and assessed injuries. |
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #1's exit seeking behavior and last saw resident before elopement. |
| CNA #1 | Certified Nursing Assistant | Assigned to Resident #1, monitored wandering behavior and provided observations. |
| CNA #2 | Certified Nursing Assistant | Assisted in monitoring Resident #1 and responded to elopement event. |
| Administrator | Nursing Home Administrator | Notified of Immediate Jeopardy and participated in corrective action plan. |
| ADON | Assistant Director of Nursing | Conducted resident audits, investigations, and staff in-services related to elopement. |
| DON | Director of Nursing | Conducted audits and interviews regarding wandering residents and care plans. |
| RDCS | Regional Director of Clinical Services | Conducted audits and staff in-services on care plans and wandering interventions. |
| SDC | Staff Development Nurse | Conducted nursing staff in-service on care plans for wandering and elopement risk. |
| Maintenance Supervisor | Maintenance Supervisor | Inspected elopement site and window, described physical environment of elopement. |
Inspection Report — Feb 18, 2020
Routine CMS
Date: Feb 18, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to facility environment, resident assessments, care planning, medication management, and food safety.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to housekeeping and maintenance issues. There were inaccuracies in resident assessments, failure to implement care plans, improper medication labeling and storage, and unsanitary food storage and kitchen conditions.
Deficiencies (5)
F 0584: The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, homelike environment for three of four halls observed, including dirt accumulation, broken trim, cracked tiles, leaking faucets, and missing end caps exposing sharp edges.
F 0641: The facility failed to accurately code a Minimum Data Set (MDS) related to discharge status for one of 22 MDS assessments reviewed, resulting in incorrect discharge coding for Resident #90.
F 0656: The facility failed to implement the care plan related to a diet order for one of 22 residents reviewed, Resident #89, who did not receive meal trays as ordered due to swallowing issues.
F 0761: The facility failed to properly label opened medications and discard expired medications within the manufacturer's recommended time frame for two of three medication carts and one of four medication storage rooms, including expired creams and insulin past discard dates.
F 0812: The facility failed to maintain a clean and sanitary kitchen environment and store food properly, with observations of undated opened food items, carbon buildup on oven, food debris on ice machine, and unsanitary conditions in food preparation and storage areas.
Report Facts
MDS assessments reviewed: 22
Residents affected: 1
Residents affected: 1
Medication carts observed: 3
Medication storage rooms observed: 4
Expired tubes of barrier cream: 4
Expired tubes of skin repair cream: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding inaccurate coding of Resident #90's MDS assessment |
| LPN #2 | Licensed Practical Nurse / Wound Nurse | Interviewed about responsibility for removing expired wound or skin supplies |
| LPN #1 | Licensed Practical Nurse | Interviewed about insulin labeling and expiration practices |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding insulin vial labeling and discard dates |
| Director of Nursing | Director of Nursing | Provided statements on medication policies and responsibilities |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about care plan implementation for Resident #89 |
| Dietary Services Manager | Dietary Services Manager | Interviewed about kitchen cleaning schedules and food storage practices |
| Administrator | Facility Administrator | Interviewed regarding environmental concerns and kitchen sanitation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #89 not receiving meal trays |
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