Grayson Health and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF730Dec 14, 2023

  Based on staff interview and facility document review, the facility staff failed to complete reviews of nurse aides at least every 12 months and failed to provide in-service education based on the outcome of these reviews. The findings were: The facility administration failed to complete performance reviews for nurse aides at least every 12 months and therefore failed to provide in-service education which was based on the outcome of the performance reviews. After completing the sufficient and competent nurse staff task, the surveyor asked the human resource manager about nurse aide performance reviews. The nurse aides had received in-service education during their employment however, the education was not based on the outcome of these reviews. […]

• No harm, potential for more than minimal, isolatedF580Nov 20, 2025

  Based on staff interview, clinical record review and facility document review, the facility staff failed to immediately notify the resident representative of a significant change in resident condition for one of four residents in the survey sample, resident #1.The findings included:Resident #1's diagnoses included but were not limited to chronic atrial fibrillation, chronic obstructive pulmonary disease, pleural effusion, muscle weakness, hypertension, Alzheimer's disease, osteoarthritis, repeated falls, anxiety disorder and acute on chronic congestive heart failure.The annual/5-day minimum data set (MDS) with an assessment reference date of 5/15/25 assigned the resident a brief interview for mental status (BIMS) score of 8 out of 15 indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF684Aug 1, 2024

  Based on staff interview and clinical record review, the facility staff failed to follow medical provider orders for 2 of 4 sampled residents (Resident #1 and Resident #4). The findings included: 1. For Resident #1, the facility staff failed to notify the medical provider of blood sugar readings less than 60 or greater than 450 on four (4) separate occasions during the month of April 2024. This was a closed record review. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. […]

• No harm, potential for more than minimal, isolatedF760Aug 1, 2024

  Based on staff interview and facility document review, the facility staff failed to ensure 2 of 4 sampled residents were free of significant medication errors (Resident #1 and Resident #4). The findings included: 1. For Resident #1, the facility staff failed to follow the medical provider orders for the administration of Novolog, a fast-acting insulin used to lower blood sugar levels, on 28 separate occasions. This was a closed record review. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. […]

• No harm, potential for more than minimal, isolatedF684Dec 14, 2023

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow the providers order for 1 of 24 current residents, Residents #267. The findings included: For Resident #267, the facility nursing staff failed to administer the medications Gabapentin and Risperdal per the providers orders. Resident #267's diagnoses included, but were not limited to, diabetes, bipolar disorder, peripheral vascular disease, and orthopedic aftercare. There was no completed minimum data set assessment for Resident #267. This resident was alert and orientated to self and place. Resident #267's care plan included the intervention give all medications as ordered. […]