Grenada Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Mar 3, 2023

  Based on staff interview, record review, and facility policy review, the facility failed to develop and implement care plan interventions for a resident who displayed exit seeking behaviors and eloped from the facility for one (1) of three (3) residents reviewed. Resident #1. The facility failed to provide supervision to prevent elopement for Resident # 1, who was a wandering risk. Resident #1 began exhibiting exit seeking behaviors on 1/21/23. The facility failed to develop a care plan for these behaviors until 2/8/23. On 2/23/23, the resident left the facility through a window unnoticed and unsupervised until the resident was in a community approximately 236.22 feet away from the facility. The Resident was last seen in the facility at 9:00 PM on 2/23/23. […]

• Immediate jeopardy, isolatedF689Mar 3, 2023

  Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent a resident from leaving the facility unsupervised for one (1) of three (3) residents reviewed. Resident #1. The facility failed to provide supervision to prevent elopement for Resident # 1, who was a wandering risk. The resident left the facility through a window unnoticed and unsupervised until the resident was in a community approximately 236.22 feet away from the facility. The Resident was last seen in the facility at 9:00 PM on 2/23/2023. He was not discovered to be missing until 9:53 PM on 2/23/2023 when the facility was notified by the local hospital emergency room (ER) that Resident #1 was in the ER. […]

• Actual harm, isolatedF550Apr 6, 2026

  Based on observation, resident, resident representative, and staff interviews, and record reviews, the facility failed to ensure a resident's right to be treated with dignity and respect as evidenced by failure to respond in a timely manner to the resident's requests for assistance causing the resident embarrassment and humiliation for one (1) of four (4) residents reviewed, Resident #2. Findings include:On 04/06/26 at 11:00 AM an observation and interview with Resident #2 revealed him lying in bed and there were multiple large smears of a yellowish substance on his bed pad, fitted sheet and on his flat sheet. Resident #2 attempted to cover up the yellowish substance with the clean part of the top flat sheet. […]

• Actual harm, isolatedF677Apr 6, 2026

  Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide timely incontinence care for a resident, causing the resident embarrassment and humiliation. This also put the resident at risk for skin impairment and discomfort for one (1) of four (4) residents reviewed. Resident #2.Findings Include: Review of the facility policy Activities of Daily Living (ADL), Supporting with revision date of March 2018, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .An observation and interview with Resident #2 on 04/06/26 at 11:00 AM revealed him lying in bed and there were multiple large smears… […]

• Actual harm, isolatedF600Oct 29, 2025

  Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse by a Certified Nurse Assistant (CNA) for one (1) of three (3) residents reviewed for abuse (Resident #7). This deficient practice resulted in the resident being forcefully pushed down onto the bed by a staff member, creating potential for physical injury and psychological harm. Findings include: Review of the facility policy titled Abuse Prohibition Policy, last reviewed 5/17/25, revealed the following: Intent: Each resident has the right to be free from abuse .Definitions: Physical Abuse includes hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment . […]