Grenada Living Center

In the surveyor’s words

From the most serious findings on record at Grenada Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Dec 9, 2022

  Based on record review, staff interviews and facility policy review the facility failed develop a comprehensive care plan for one (1) of nine (9) residents reviewed. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. The area was assessed by the Nurse Practitioner (NP) on 10/7/22 and identified as a stage 2 pressure ulcer. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 10/16/22 when Resident #1's wound began to deteriorate. The facility failed to develop an updated plan of care when Resident #1 developed actual skin breakdown. […]

• Immediate jeopardy, isolatedF686Dec 9, 2022

  Based on interviews with staff and Resident Representative interviews, record review and facility policy review, the facility failed to identify a pressure ulcer and prevent its deterioration for one (1) of nine (9) residents reviewed for pressure ulcers, Resident #1. On 10/7/22, Licensed Practical Nurse (LPN) #2 identified an excoriation area to Resident # 1's buttocks. Nurse Practitioner (NP) #1 visited the facility on 10/7/22 and assessed Resident #1's area to the buttocks. NP #1 ordered wound care treatment for Resident #1. Resident # 1 received daily wound care treatments with air mattress function checks every shift. On 10/12/22 Resident #1's wound was assessed again by NP #1 who documented the area as an unstageable pressure ulcer and changed the treatment order for Resident #1. […]

• Immediate jeopardy, isolatedF726Dec 9, 2022

  Based on record review and interviews, the facility failed to provide a competent treatment nurse for one (1) of nine (9) residents to prevent a pressure ulcer from worsening as evidenced by Resident #1 was found on 10/7/22 with an excoriation on the sacral area and was admitted to the hospital on 10/20/22 with an unstageable sacral pressure ulcer with eschar, foul drainage, and sepsis. During the week of treatments beginning 10/8/22 through 10/12/22, there were four (4) different nurses providing treatments and observations of Resident #1's sacral excoriation. […]

• Immediate jeopardy, isolatedF865Dec 9, 2022

  Based on facility policy/procedure review, provider's plan of correction review, record review and interviews, the facility failed to contact the Primary Medical Doctor (MD) and failed to update the interventions for Resident #1 in the High-Risk Management Committee Meeting on 10/19/22 for one (1) of nine (9) residents sampled regarding a worsening unstageable sacral ulcer. Resident #1. A routine body audit was completed for Resident #1 on October 04, 2022, by Licensed Practical Nurse (LPN) #1. On 10/7/22, LPN #2 identified an excoriation area to Resident #1's buttocks. On 10/16/22, the wound status was identified as deteriorating. On 10/20/22, Resident #1 was admitted to Hospital #1 for diagnosis of wound sepsis. […]

• Immediate jeopardy, isolatedF580Oct 18, 2021

  Based on record review, policy/procedure review and interviews the facility failed to notify the Primary Physician and Resident Representative of a significant change in the resident's physical status related to an acute surgical incision and the need to alter treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/14/21 when the facility neglected to contact the Primary Physician to update him on the progress of an acute surgical incision so that treatment orders could be changed. The facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]