Grand River Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Grand River Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF697May 12, 2025

  Based on observation, medical record review, hospital record review, facility policy review, staff, and resident interviews, the facility failed to develop and implement a comprehensive, individualized, and effective pain management program for Resident #220 who was admitted with acute pain from unspecified fracture of upper and lower end of left tibia, and nondisplaced cervical fracture caused by a motor vehicle accident. Actual Harm occurred beginning on 04/25/25 when Resident #220 did not receive the ordered medication pain reliever Oxycodone five milligram immediate release tablet every four hours as needed. The medication was not administered until 04/26/25 at 2:26 P.M. […]

• Actual harm, isolatedF686Nov 7, 2023

  Based on observation, closed record review, facility policy review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #76. Actual Harm occurred on 08/26/23 when Resident #76, who was a paraplegic and required extensive assistance to total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his sacrum (area at the base of the spinal cord) and a deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney… […]

• Actual harm, isolatedF686May 13, 2021

  Based on observation, record review, interview and facility policy review, the facility failed to appropriately assess and treat a pressure ulcer for Resident #52. Actual Harm occurred on 04/07/21 when Resident #52, who had impaired cognition, required extensive two staff assistance for bed mobility, was always incontinent of bowel, and had no unhealed pressure ulcer/injury present upon admission, developed a sacral wound on 04/05/21, and the wound was not assessed or treated until 04/07/21, when it was identified as an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). This affected one Resident (#52) of three residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF692May 13, 2021

  Based on observation, interview and record review, the facility failed to identify, treat an infection for Resident #43. Actual harm occurred on 03/11/21 when Resident #43, who required extensive two staff assistance with bed mobility, transfers, and toileting, was occasionally incontinent of urine and frequently incontinent of bowel, had diarrhea and a significant weight loss of 10.8 percent in 17 days. This affected one Resident (#43) of three residents reviewed for significant weight loss. The facility census was 59. Findings include: Review of the medical record for Resident #43 revealed an initial admitted [DATE] and a re-entry date of 02/20/21. […]

• Actual harm, isolatedF686Mar 22, 2021

  Based on closed record review, interview and policy review, the facility failed to ensure adequate interventions were implemented timely to appropriately treat a pressure ulcer for Resident #71. Actual Harm occurred on 02/18/21 when Resident #71, who had impaired cognition, required extensive two staff assistance for bed mobility, and was incontinent of urine and bowel, was admitted with a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis), that deteriorated to an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). This affected one resident (Resident #71) of three residents reviewed for pressure ulcers. […]