Grand Boulevard Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Grand Boulevard Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584May 28, 2026

  Based on observations, staff interviews, and a review of the facility's work order logs, the facility failed to maintain a clean, comfortable, and homelike environment for residents.The findings include: 1. During a tour of the facility conducted on 05/27/2026 at approximately 11:00 AM, it was noted in room [ROOM NUMBER] that five ceiling tiles were bowing from the ceiling and the paint above the wall mounted air conditioning unit appeared warped and peeling. (Photographic evidence obtained) On 05/27/2026 at approximately 11:30 AM, the air conditioner (AC) vents were observed actively dripping condensation from the ceiling onto the floors in the hallways near Rooms 210, 204, 503, 501, 408, 404, 402, and 206 while maintenance staff replaced ceiling tiles. […]

• No harm, potential for more than minimal, isolatedF657May 28, 2026

  Based upon observations, interviews, and record reviews, the facility failed to review and revise care plans after the comprehensive and quarterly assessments were completed for 2 out of 2 residents reviewed (Resident #9 and #4) The findings include:1. A record review was conducted on for Resident #9. Documentation revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis of a Stroke with right side paralysis and contracture. During review of Resident #9's plan of care, it was noted that an alteration in metabolic balance related to diabetes was initiated on 12/13/2021 with interventions dated for revision on 07/26/2025. […]

• No harm, potential for more than minimal, isolatedF880May 28, 2026

  Based on observations, interviews, and record review, the facility failed to ensure appropriate infection control practices were followed for 3 of 3 residents reviewed for infection control. (Residents #99, #38 and #48)The findings include: 1. An observation of Percutaneous Endoscopic Gastrostomy (PEG) tube care was conducted for Resident #99 on 05/27/2026 at approximately 11:44 AM. (A PEG tube is used to provide long term nutrition for individuals who are unable to eat orally) Staff A, a Licensed Practical Nurse (LPN), was observed performing hand hygiene and donning gloves before the procedure; however, no gown or mask was worn. Hand hygiene was performed again after Staff A completed the care. […]

• No harm, potential for more than minimal, isolatedF554Feb 20, 2025

  Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 19 sampled residents to self-administer medications. (Resident #67) The findings include: An observation of Resident #67 was conducted on 02/17/25 at 10:35 AM. A medicine cup with 4 pills was observed sitting on the over bed table. When asked about this, the resident stated, If a nurse is in a hurry, then they leave the medication at the bedside, but they never watch me take my medications. A telephone interview was conducted with Employee C (a Licensed Practical Nurse) on 02/19/25 at 2:01 pm. […]

• No harm, potential for more than minimal, isolatedF641Feb 20, 2025

  Based on record review, staff interviews, and policy review, the facility failed to ensure the minimum data set (MDS) accurately reflected the resident's status for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #57) and 1 of 1 sampled residents reviewed for hospitalization . (Resident #83) The findings include: Resident #57 A review of Resident #57's electronic record revealed the Medicare 5-day MDS with an assessment reference date (ARD) of 2/3/25 indicated in section M that the resident had two stage 2 pressure ulcers present upon admission or re-entry. A review of the weekly wound documentation dated 1/31/25 revealed the right heel and sacral area had stage 2 pressure wounds that were facility acquired. […]