Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grenada Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A cognitively intact, fully dependent resident with a right BKA and multiple rib fractures remained in a soiled brief and heavily soiled bed linens for an extended period after a bowel movement, despite pressing the call light and being briefly checked by staff who did not return. The resident expressed embarrassment, humiliation, and a desire to leave, and his representative reported finding him "in a mess," notifying staff at the nursing desk, and observing a nurse enter and then leave the room without care being provided. Later, the ADM and DON observed the resident still lying in feces-soiled linens and acknowledged that he relied on staff for all ADLs and that his condition was unacceptable and a dignity issue.
A resident who was cognitively intact but fully dependent on staff for ADLs, including incontinence care, was observed lying in bed with fecal matter smeared on the bed pad and sheets after a bowel movement. The resident reported having been in a soiled brief for over an hour and expressed embarrassment and distress. After the resident activated the call light, a staff member entered only to deactivate it and leave without providing care. The resident’s representative later found the resident still soiled, notified staff at the nursing desk, and observed a nurse enter and then leave after texting a CNA. The CNA acknowledged being notified by an LPN that the resident needed changing but prioritized passing lunch trays and feeding another resident instead of providing incontinence care or seeking assistance. The resident remained in the soiled brief until the CNA finally entered with supplies nearly two hours after the initial observation.
A resident, who was cognitively intact and had a history of cerebral infarction, was physically abused by a CNA who forcefully pushed the resident onto the bed during care. The incident was witnessed by another CNA, and peer interviews indicated the CNA had previously spoken roughly to residents. The resident confirmed the abuse at the time, and the CNA denied the allegation, but the event was substantiated through investigation.
The facility did not maintain adequate nursing staff, leading to prolonged call-light response times and delays in care for multiple residents, including those with high-acuity needs such as incontinence and tracheostomy care. Staff and family interviews confirmed frequent staff shortages, excessive call-ins, and high resident-to-CNA ratios, resulting in unmet care needs and repeated complaints.
A resident with a history of cerebral infarction was transferred to the emergency room, but the facility did not provide the required written transfer notice to the resident's representative. The Administrator confirmed that no written notification was sent, as the resident returned within a few hours and staff did not think it was necessary.
The facility failed to submit accurate PBJ data for Q2 2024, resulting in a deficiency due to excessively low reported weekend staffing. Errors occurred because administrative nurses did not consistently submit forms for weekend shifts, and the DON's hours were not accurately captured. Despite adequate staffing, reporting inconsistencies led to the issue.
A facility failed to report an abuse allegation involving a resident and a CNA within the required timeframe. The incident, witnessed by an NA, involved inappropriate contact by the resident and a retaliatory action by the CNA. The NA delayed reporting the incident until the next day, leading to a deficiency finding.
A respiratory therapist at the facility failed to complete competency skills check-off and Enhanced Barrier Precautions training before caring for a resident with a tracheostomy. The therapist performed care without proper PPE, unaware of the resident's precaution status. Interviews revealed a lack of oversight and training, with the DON and ADON confirming the therapist was not included in previous training sessions. The facility also lacked a policy for competency skills check-offs.
A respiratory therapist failed to follow Enhanced Barrier Precautions during tracheostomy care for a resident, neglecting to wear a protective gown and perform proper hand hygiene. Despite an EBP sign on the door, the RT was unaware of the requirements, leading to potential infection risks. The facility's Director of Nurses confirmed the breach in infection control standards.
A facility failed to complete an Annual MDS for a resident within the required timeframe, exceeding the 14-day limit set by CMS. The resident's assessment reference date was June 6, 2024, but the completion date was July 1, 2024. Interviews with the MDS Coordinator and Consultant revealed ongoing issues with timely MDS completion, despite an action plan being in place. The resident had been admitted with a diagnosis of Transient Cerebral Ischemic Attack.
A facility failed to complete a Quarterly MDS for a resident with Cerebral Palsy within the required timeframe, exceeding the 14-day limit after the ARD. The MDS Coordinator and Consultant acknowledged ongoing issues with timely MDS completion, despite an action plan in place, citing time management as a contributing factor.
Failure to Timely Respond to Call Light and Provide Incontinence Care, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to respond in a timely manner to a resident’s request for assistance with incontinence care, resulting in the resident remaining in a soiled brief and bed for an extended period. On 04/06/26 at 11:00 AM, a cognitively intact resident with a right below-knee amputation, multiple left rib fractures, and dependence on staff for all ADLs, transfers, turning, and repositioning was observed lying in bed with multiple large smears of yellowish fecal matter on his bed pad, fitted sheet, and flat sheet. The resident attempted to cover the soiled areas with the clean part of the top sheet and reported he had a bowel movement and had been lying in a dirty diaper for over an hour while waiting for someone to come and change him. At 11:08 AM, he pressed his call light for assistance. At 12:23 PM, the same resident was again observed in the same position, still in a soiled brief with yellow fecal matter smeared on the bed pad and sheets. He stated that the situation made him feel bad, that no one else would want to lie like that, and that he felt embarrassed, upset, and wanted to leave as soon as he could. He confirmed that someone had come in earlier, saw what he needed, left to get help, and did not return. The resident’s representative, present from 12:00 PM, reported finding him “in a mess” with a large bowel movement all over him and his bed, and stated that when he saw her, he was embarrassed and tried to cover it with his sheet. She reported notifying staff at the nursing desk and observing a nurse enter the room and then leave and text someone, yet no one came to provide care. At 12:46 PM, the Administrator and DON observed the resident still lying in a soiled brief with fecal matter on the bed pad and sheets and acknowledged that he could not care for himself, depended on staff to meet his needs, and that this situation was not acceptable and was a dignity issue.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for a resident who was dependent on staff for all ADLs, transfers, turning, and repositioning. The resident had a right below-the-knee amputation, multiple left rib fractures, and a history of traumatic subarachnoid hemorrhage, and was cognitively intact with a BIMS score of 13. Facility policy on ADL support stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming, personal, and oral hygiene. On the survey date at 11:00 AM, the resident was observed lying in bed with multiple large smears of yellowish fecal matter on the bed pad, fitted sheet, and flat sheet. The resident attempted to cover the soiled area with a clean part of the top sheet and reported having had a bowel movement and lying in a dirty brief for over an hour while waiting for someone to come and change him. At 11:08 AM, the resident pressed the call light, and at 11:11 AM an unidentified staff member entered the room, deactivated the call light, and exited without providing incontinence care. At 12:23 PM, the resident was again observed in the same position, still in a soiled brief with fecal matter smeared on the bed linens, stating that the situation made him feel bad, embarrassed, and upset, and that he wanted to leave as soon as he could. The resident’s representative reported arriving around noon, finding the resident in a large bowel movement “all over him and his bed,” and observing that he tried to cover it up when she entered due to embarrassment. She stated she notified staff at the nursing desk that he needed help, but no one came, and that she saw a nurse enter the room and then leave to text someone. CNA #1 stated that LPN #1 had notified her earlier that the resident needed to be changed and that she intended to care for him next but instead passed lunch trays and fed another resident, acknowledging she was very busy and should have changed him sooner or asked for help. LPN #1 confirmed that the resident’s sister had requested assistance, that she told the resident she would get help and texted CNA #1, but did not follow up to ensure care was provided. At 12:46 PM, the Administrator and DON observed the resident still lying in a soiled brief with fecal matter on the bed pad and sheets and confirmed this was not acceptable, and at 12:50 PM CNA #1 finally entered with supplies to provide care, approximately one hour and fifty minutes after the initial observation.
Resident Physically Abused by CNA During Care
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) physically abused a resident by forcefully pushing the resident down onto the bed. The incident was witnessed by another CNA, who reported that the resident was standing beside his bed and refusing assistance when the CNA entered the room and pushed him hard enough to cause him to fall backward onto the bed. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had a history of cerebral infarction, confirmed at the time of the incident that the CNA had pushed him. During a subsequent interview, the resident became withdrawn and did not wish to discuss the event further. The facility's Abuse Prohibition Policy defines physical abuse to include actions such as shoving and requires immediate reporting and removal of accused staff from resident care duties pending investigation. Peer interviews revealed that some staff had previously heard the CNA speak roughly to residents. The CNA involved denied the allegation during a phone interview, stating she only assisted the resident, but documentation and witness statements substantiated the occurrence of physical abuse. The CNA had received abuse-prevention training prior to the incident.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of its residents, as evidenced by prolonged call-light response times and delays in assistance with care needs. Interviews with residents, family members, and staff revealed that residents often waited up to an hour or more for help, particularly with toileting and incontinence care. One resident with an overactive bladder reported frequent episodes of incontinence due to long wait times, while another resident, who required extensive assistance due to a tracheostomy and anoxic brain damage, had to rely on a privately hired sitter because staff were not available to provide timely care. Staff interviews confirmed that excessive call-ins and staff shortages were common, resulting in high resident-to-CNA ratios, especially on weekends and night shifts. Certified Nurse Assistants and LPNs reported caring for as many as 15 to 16 residents each, with many residents requiring two-person assistance due to high acuity and total-care needs. The Director of Nursing, Assistant Director of Nursing, and Administrator all acknowledged ongoing staffing concerns, frequent complaints from residents and families, and the inability to consistently cover shifts when staff called in. Review of staffing records showed that on several occasions, only three or four CNAs were available per shift to care for nearly 90 to 95 residents across multiple wings, including a specialized tracheostomy unit. The facility's own policy required sufficient and competent nursing staff to meet resident needs, but interviews and documentation demonstrated that this standard was not met, resulting in delays in care and unmet resident needs.
Failure to Provide Written Transfer Notice to Resident Representative
Penalty
Summary
The facility failed to provide a written transfer notice to a resident's representative when the resident was transferred to the emergency room. According to the facility's own policy, both the resident and their representative must be notified in writing of the specific reason for transfer, the effective date, and the location of transfer or discharge. Record review showed that the resident, who had a diagnosis of cerebral infarction, was transferred to the emergency room, but no written notification was sent to the representative. During an interview, the Administrator confirmed that no written notification was provided because the resident returned within a few hours, and staff did not believe it was necessary in this situation.
Inaccurate PBJ Data Submission Leads to Staffing Deficiency
Penalty
Summary
The facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for the second quarter of 2024, resulting in a deficiency. The PBJ Staffing Data Report for Fiscal Year Quarter 2, 2024, indicated excessively low weekend staffing, which was triggered by incorrect data submission. Interviews revealed that the Human Resources/Payroll Coordinator relied on administrative nurses to submit forms for weekend shifts, which were not consistently provided. The Director of Nurses (DON) admitted to working many weekend shifts but was unsure if she submitted the necessary forms. The Corporate Consultant confirmed that the hours worked by the DON and a treatment nurse were not accurately captured in the PBJ report due to errors in data entry. Despite being adequately staffed, inconsistencies in reporting led to the deficiency.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe. This deficiency involved Resident #58 and was based on interviews, record reviews, and facility policy examination. The facility's Abuse Prohibition Policy mandates that any employee aware of an abuse allegation must report it immediately to the Abuse Coordinator. However, Nursing Assistant (NA) #1 did not report an incident involving Certified Nursing Assistant (CNA) #1 and Resident #58 until the following day. During the incident, Resident #58 reportedly touched CNA #1 inappropriately, and CNA #1 responded by hitting the resident with his own hand. NA #1 witnessed the event but delayed reporting it due to CNA #1's presence. Further investigation revealed that Registered Nurse (RN) #1 was not informed of the incident by NA #1 on the day it occurred, despite being in the room shortly after the event. The Director of Nursing (DON) confirmed that the facility was unaware of the incident until the day after it happened. As a result, NA #1 was suspended pending investigation for failing to report the abuse allegation immediately, as required by the facility's policy. The disciplinary action record was signed by NA #1, acknowledging the delay in reporting.
Failure to Ensure Competency and Training for Respiratory Therapist
Penalty
Summary
The facility failed to ensure that staff completed competency skills check-off and Enhanced Barrier Precautions training before caring for residents with a tracheostomy. This deficiency was identified in the case of a respiratory therapist (RT) who was observed performing tracheostomy care for a resident without wearing the appropriate personal protective equipment, specifically a gown, despite the presence of an Enhanced Barrier Precaution sign on the resident's door. The RT admitted to not being aware of the resident's precaution status and confirmed that she had not received training on enhanced barrier precautions. Interviews with the Director of Nurses (DON), Assistant Director of Nurses (ADON), and the Respiratory Therapist Director revealed a lack of awareness and oversight regarding the RT's training status. The DON and ADON confirmed that all nursing staff were supposed to be trained on enhanced barrier precautions, but the RT had not been included in the training sessions conducted in September 2023. Additionally, the RT did not have a competency skill check-off for tracheostomy care, despite being employed part-time since 2022. The facility lacked a policy for competency skills check-offs, contributing to the oversight.
Infection Control Breach During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program during the care of a resident with a tracheostomy. The respiratory therapist (RT) did not follow Enhanced Barrier Precautions (EBP) as required by the facility's policy. Despite the presence of an EBP sign on the resident's door, the RT entered the room without wearing a protective gown and performed tracheostomy care without proper hand hygiene. The RT applied sterile gloves over soiled gloves and failed to wash her hands between the dirty and clean processes, which is against the facility's standards of practice for tracheostomy care. The RT admitted to not being aware of the need for a gown and proper hand hygiene, revealing a lack of training in EBP. The Director of Nurses and the Respiratory Director confirmed that the RT's actions were not in line with the facility's infection control standards, acknowledging the potential risk of infection to the resident. The resident involved had been admitted with diagnoses including pneumonitis due to inhalation of food and vomit, cerebral infarction, and required attention to a tracheostomy.
Late Completion of MDS Assessment
Penalty
Summary
The facility failed to complete an Annual Minimum Data Set (MDS) for a resident within the required timeframe, as mandated by the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident was completed more than 14 days after the Assessment Reference Date (ARD), which is a violation of the facility's policy and CMS guidelines. The resident's assessment reference date was documented as June 6, 2024, but the assessment completion date was recorded as July 1, 2024, exceeding the permissible 14-day period. Interviews with the MDS Coordinator and MDS Consultant revealed awareness of ongoing issues with timely MDS completion and submission. Despite an action plan being in place for about a year to address these problems, the issues persist, with time management cited as a contributing factor. The MDS Consultant acknowledged the need to alter the existing plan to prevent late assessments, emphasizing the importance of timely MDS completion for accurate billing and resident care planning. The resident involved had been admitted with a diagnosis of Transient Cerebral Ischemic Attack.
Failure to Timely Complete MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly Minimum Data Set (MDS) for a resident within the required timeframe, as mandated by the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident was completed more than 14 days after the Assessment Reference Date (ARD), which is a violation of the facility's policy and CMS guidelines. The resident in question was admitted with a diagnosis of Cerebral Palsy, and the assessment was crucial for ensuring accurate billing and the development of an appropriate plan of care. The MDS Coordinator confirmed that the assessment was completed late and acknowledged that the facility has had ongoing issues with timely MDS completion. Despite being on an action plan for about a year to address these problems, the issues persist, partly due to time management challenges. The MDS Consultant also confirmed awareness of the facility's issues with MDS completion and submission, indicating that the existing plan of action needed adjustments to prevent future late assessments.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grenada
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grenada Living Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Middleton Oaks Health And Rehabilitation | 19.5 mi | ★★★★★ | 4 | 0 |
| Tallahatchie General Hosp Ecf | 21.8 mi | ★★★★★ | 3 | 0 |
| Golden Age Nursing Home | 25.6 mi | ★★★★★ | 3 | 0 |
| Crystal Rehabilitation And Healthcare Center | 26.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.