Grey Stone Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 30, 2025

  Based on interview and record review, the facility failed to ensure residents were adequately assessed and provider orders were followed after a change in condition post-surgery for 1 of 4 residents reviewed. The facility failed to ensure the resident was assessed and a doppler study completed timely as ordered when Resident B's leg showed a change in condition. This deficient practice resulted in hospitalization and death. (Resident B). The Immediate Jeopardy began on 3/20/25 when the facility failed to assess Resident B's change of condition. The Assistant Director of Nursing (ADON) and Minimum Data Assessment (MDS) Nurse were notified of the Immediate Jeopardy on April 29, 2025 at 3:51 P.M. […]

• Actual harm, isolatedF684Oct 24, 2025

  Based on observation, record review, and interview, the facility failed to ensure residents were adequately assessed and provider lab orders followed up on timely after a resident change in condition. The deficit practice resulted in a resident's need for hospitalization for gastrointestinal bleed and blood transfusion for 1 of 3 residents reviewed (Resident L).Findings include:A report, dated 10/16/25, alleged Resident L had a change in condition for several weeks. His condition was not assessed and charted on daily, and he was not followed closely. He had been given several IV's (intravenous fluids) and eventually was sent to the hospital for evaluation. On 10/22/25 at 12:09 P.M., Resident L's record was reviewed. […]

• Actual harm, isolatedF686Oct 24, 2025

  Based on observation, interview and record review, the facility failed to ensure a dependent resident at risk for pressure ulcers, was provided timely care and services to prevent development and worsening of a newly identified pressure ulcer for 1 of 3 residents reviewed. The resident was not provided care over an entire shift resulting in a deep tissue injury which progressed to an unstageable pressure ulcer to the left heel (Resident J).Findings include:A report, dated 10/20/25, indicated Resident J's family had been concerned, the resident's clothing had not been changed from one day to the next. […]

• Actual harm, isolatedF686Sep 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure services were effectively provided to identify, monitor, and treat an area of facility-acquired skin impairment and failed to ensure interventions were implemented to provide effective pressure relief to the wound for a resident admitted without skin impairment for 1 of 4 residents reviewed for pressure injuries. (Resident 243) This deficient practice resulted in the facility-acquired skin impairment deteriorating to a stage three pressure injury with infection that required antibiotic therapy. Findings include: Resident 243's record was reviewed on 9/17/24 at 10:46 AM. […]

• Actual harm, isolatedF684Jan 25, 2024

  Based on observation, interview and record review, the facility failed to prevent a non-pressure related wound from resting directly on the floor for 1 of 2 residents reviewed (Resident E). This resulted in Resident E's wound becoming infected requiring antibiotics. Findings include: On 1/24/24 at 11:01 A.M., Resident E was observed seated in a wheelchair next to her bed. Her bare feet was in direct contact with the floor with no barrier. The right foot was wrapped with a gauze dressing from the midfoot to above her ankle. Her right pant leg was pulled up and her calf was visible. The exposed calf was red in color with thick white scales of skin. The exposed forefoot skin was swollen, reddened with thick scales. There were old non-skid strips beneath her feet. […]