Above 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 Granada Post Acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and hearing difficulties consistently refused to wear hearing aids, yet the care plan was not updated to reflect this refusal or to document alternative interventions. Staff acknowledged the ongoing refusal and communicated by speaking directly into the resident's ear, but the facility did not revise the care plan as required by policy.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care in these areas.
A resident with osteopenia, fractures, and contractures who was fully dependent on staff did not have a comprehensive, person-centered care plan. The care plan lacked specific details about the location of the osteopenia and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not sufficiently individualized to guide care.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect data transmission to CMS. One resident's MDS did not reflect dental issues, another's did not indicate the absence of natural teeth, and a third's was inaccurately coded regarding oral status. The MDS Nurse acknowledged these inaccuracies, which could result in unmet care needs.
A facility failed to submit an accurate Level I PASRR for a resident with psychosis, depression, and anxiety disorder. The initial PASRR, completed by the hospital, did not reflect these SMIs, leading to a determination that the resident did not require a Level II PASRR Mental Health Evaluation. The Social Services Director acknowledged the oversight and the need for a new assessment, as per facility policy.
The facility failed to implement care plans for two residents, one with epilepsy and another requiring oxygen therapy. Resident 288's care plan required padded siderails to prevent injury during seizures, but observations showed no padding was applied. Resident 191, dependent on supplemental oxygen, lacked a care plan for oxygen administration, and no oxygen sign was posted outside the room. Interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for comprehensive care planning.
A LTC facility failed to implement proper interventions for pressure ulcer prevention for four residents. Incorrect settings on low-air-loss mattresses (LALM) were observed for three residents, with one resident not receiving a LALM as ordered. The facility's policy for air mattresses was not followed, leading to potential risks for pressure ulcer development or worsening.
A resident with epilepsy was observed multiple times in bed without the required padding on siderails, as specified in their care plan. Despite the facility's policy and the resident's high risk for injury, the necessary safety measures were not implemented, placing the resident at risk.
A facility failed to post an oxygen signage for a resident receiving oxygen therapy, as observed during a survey. The resident, with a history of acute respiratory failure and other health issues, was receiving supplemental oxygen via nasal cannula. A nurse and the DON acknowledged the absence of the sign, which was required by the facility's policy for safety.
A resident with Parkinson's, diabetes, and seizure disorders received medications late and incorrectly, resulting in an 18.75% medication error rate. An LVN administered six medications over an hour late and applied Lidocaine cream to the wrong knee. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed.
A resident on a pureed diet was not provided with a menu or offered alternative meal options, despite expressing dissatisfaction with the meals and consuming less than 50% of them. The resident, who communicated through a digital device, reported the meals were inedible and lacked variety. Staff failed to offer alternatives, citing the pureed diet as a reason, and there was confusion over which department was responsible for providing menus. Facility policies requiring substitute food items and menu postings were not followed, impacting the resident's nutritional status and quality of life.
A facility failed to ensure staff were knowledgeable about handling unlabeled resident clothes and did not complete a belonging list upon a resident's readmission. Interviews revealed discrepancies in staff understanding of the process for managing unlabeled clothes, with some staff placing them in a donation box and others keeping them in the laundry room. Additionally, an inventory list was not created upon the resident's readmission, contrary to facility policy, potentially violating the resident's right to a safe and homelike environment.
A resident with polyneuropathy and joint replacement surgery experienced a fall, but the facility failed to conduct an IDT meeting or update the care plan with safety interventions. Despite the resident's cognitive intactness and partial assistance needs, the care plan lacked measures to prevent future falls, such as providing a reacher, which was only added nine days later. The DON confirmed the absence of documentation for an IDT meeting and the delay in care plan revision.
The facility failed to implement infection control measures by improperly cohorting residents and not posting necessary signage for contact isolation and Enhanced Barrier Precautions (EBP). A resident with MRSA was placed in a room with two others without contact precautions, and staff did not wear PPE when entering the room. Additionally, signage for EBP was missing for two residents, leading to potential risks of infection transmission.
A resident's transfer to a GACH Rehab was delayed due to the facility's failure to send complete documentation, including essential PT notes. The resident, with conditions like hemiplegia and muscle weakness, required further therapy, but the incomplete referral led to the case being closed by the rehab center. Interviews revealed that the facility's Social Services could not confirm the transmission of the missing documents, resulting in the resident not being accepted for transfer.
Failure to Update Care Plan for Resident's Refusal of Hearing Aids
Penalty
Summary
The facility failed to timely develop a comprehensive care plan addressing a resident's ongoing refusal to wear hearing aids. The resident, who had diagnoses including congestive heart failure and moderate cognitive impairment, was documented as having difficulty hearing and required substantial assistance with activities of daily living. Despite the care plan indicating the use of hearing aids to help the resident hear effectively, multiple staff interviews and observations confirmed that the resident consistently refused to wear the hearing aids. Staff, including a CNA, Social Services Director, and LVN, acknowledged the resident's refusal and reported communicating by speaking directly into the resident's ear, but the care plan was not updated to reflect this ongoing issue. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, including documentation of services not provided due to resident refusal. However, the care plan did not address the resident's persistent refusal to use hearing aids, nor did it outline alternative interventions or document the resident's exercise of their right to refuse. This omission was confirmed by staff interviews and record reviews, indicating a failure to meet the facility's own policy and regulatory requirements for care planning.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as needed.
Failure to Develop Comprehensive, Person-Centered Care Plan for Resident with Osteopenia
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with osteopenia, as well as other conditions including fracture, contracture, and disorders of bone density and structure in the right shoulder. The resident was totally dependent on staff for all activities of daily living and did not have the capacity to make decisions, according to the History and Physical. However, the Minimum Data Set indicated the resident was able to understand and be understood by others. The care plan in place for osteopenia included general interventions such as handling the resident gently and observing for joint pain and stiffness, but it did not specify the location of the osteopenia or provide detailed, measurable objectives and timetables tailored to the resident's specific needs. During an interview, the DON acknowledged that the care plan lacked specificity regarding the location of the osteopenia and stated that care plans are intended to guide resident care and should be more individualized. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's physical, psychosocial, and functional needs, but this was not implemented for the resident in question.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion and documentation of the Minimum Data Set (MDS) assessments for three residents, leading to the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Resident 23's MDS, dated March 6, 2025, did not reflect the resident's dental concerns, despite observations of poor dentition and broken teeth. The MDS Nurse (MDSN) acknowledged the inaccuracy, noting that the MDS should have indicated the resident's dental issues to ensure appropriate care planning. Resident 24's MDS was also inaccurately coded, failing to reflect the resident's lack of natural teeth. During an observation, Resident 24 was seen without upper and lower teeth and consuming soft or pureed foods. The MDSN confirmed the incorrect coding of the oral/dental assessment, which could potentially result in unmet care needs and services for the resident. Similarly, Resident 19's MDS did not accurately represent the resident's oral/dental status, as the resident had no natural teeth and was on a pureed diet. The MDSN was aware of this discrepancy and acknowledged the incorrect coding. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, and the information should reflect the resident's status, which was not adhered to in these cases.
Inaccurate PASRR Assessment for Resident with SMI
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was submitted for a resident, which is a tool used to identify possible serious mental illness (SMI) and determine if specialized services are required. The resident in question was admitted with diagnoses of psychosis, depression, and anxiety disorder, yet the Level I PASRR assessment did not reflect these SMI diagnoses. Consequently, the PASRR determination letter indicated that the resident did not require a Level II PASRR Mental Health Evaluation, as the Level I assessment inaccurately showed no SMIs. The Social Services Director (SSD) acknowledged that the Level I PASRR was initially completed by the hospital before the resident's admission to the facility. Upon review, the SSD noted that the Level I PASRR did not accurately reflect the resident's SMIs and admitted that a new and accurate Level I PASRR should have been completed and submitted. The facility's policy requires that all residents have a Level I PASRR completed to ensure they receive necessary services for their SMI in the appropriate setting, which was not adhered to in this case.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to implement a care plan for Resident 288, who was admitted with a diagnosis of epilepsy and severe cognitive impairment. The care plan, dated 3/6/2025, required padding on the siderails of the resident's bed to prevent injury during seizures. However, observations on multiple occasions revealed that the siderails were not padded, placing the resident at risk for physical harm. Interviews with the Registered Nurse Supervisor confirmed the absence of padding and acknowledged the risk of injury if a seizure occurred. For Resident 191, the facility did not develop or implement a care plan for oxygen administration, despite the resident's dependence on supplemental oxygen due to conditions such as acute respiratory failure and congestive heart failure. Observations showed that there was no oxygen sign posted outside the resident's room, and the care plan lacked specific interventions for oxygen therapy. Interviews with the Licensed Vocational Nurse and the MDS Nurse revealed that the oxygen care plan was not initiated upon readmission, leaving the resident's oxygen therapy unmonitored and without clear guidelines for staff. The facility's policies and procedures require comprehensive, person-centered care plans and additional safety measures for residents at higher risk of injury. However, the lack of adherence to these policies resulted in deficiencies in care planning and implementation for both residents, potentially compromising their safety and well-being.
Improper Use of Low-Air-Loss Mattresses in LTC Facility
Penalty
Summary
The facility failed to ensure proper interventions for preventing the development or worsening of pressure ulcers for four residents. For Residents 288, 74, and 191, the settings on their low-air-loss mattresses (LALM) were incorrect. Resident 288's mattress was set at 350 lbs, despite a physician order for a 150-lb setting, and the resident's weight was 154 lbs. Similarly, Resident 74's mattress was set at 280 lbs and later at 250 lbs, while the resident's weight was 140 lbs, and the physician order required a 150-lb setting. Resident 191's LALM was labeled with another resident's name and incorrect weight settings, leading to potential confusion and improper therapeutic support. Resident 23 did not receive a LALM as ordered by the physician, despite being at risk for developing pressure ulcers. Observations over multiple days confirmed that Resident 23 was lying in bed without the prescribed LALM. The Treatment Nurse acknowledged the absence of the LALM but could not provide a reason for this oversight. The facility's policy and procedure for air mattresses were not followed, as the mattresses were not set according to the residents' weights, and the labeling was incorrect. The Treatment Nurse and Quality Assurance Nurse confirmed these discrepancies, acknowledging that the incorrect settings and labeling could lead to the development or worsening of pressure ulcers. The Director of Nursing also stated that the LALM should be set according to the resident's weight to prevent skin breakdown.
Failure to Pad Siderails for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure the safety of Resident 288 by not padding the siderails of the resident's bed, as required by the care plan. Resident 288, who was admitted with a diagnosis of epilepsy, was observed on multiple occasions lying in bed with metal siderails that lacked the necessary padding. The resident's care plan, dated 3/6/2025, specifically indicated that padding should be applied to the siderails to prevent injury in the event of a seizure. Despite this, observations on 3/24/2025 and 3/25/2025 confirmed the absence of padding on the siderails. Interviews with RN 1 corroborated the oversight, as the nurse acknowledged the requirement for padding due to the resident's seizure disorder. During a concurrent observation and interview on 3/26/2025, RN 1 confirmed that Resident 288 was at risk for injury without the padding, especially if a seizure occurred. The facility's policy on Bed Safety and Bed Rails, revised in 8/2022, also indicated that additional safety measures should be implemented for residents with a higher risk of injury, which was not adhered to in this case.
Failure to Post Oxygen Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to place an oxygen signage at the room door entrance for a resident receiving oxygen therapy, which was observed during a survey. The resident was receiving supplemental oxygen via nasal cannula at three liters per minute, but there was no sign indicating oxygen was in use outside the room. The resident had a history of acute respiratory failure with hypoxia, dependence on supplemental oxygen, pneumonia, congestive heart failure, and diabetes mellitus. The resident's cognitive abilities were severely impaired, and they were dependent on assistance for daily activities. During an interview, a Licensed Vocational Nurse acknowledged the absence of the oxygen sign and stated that it should have been posted for safety reasons. The Director of Nursing also confirmed that oxygen signage should have been placed on the doorway. The facility's policy and procedure for oxygen administration required an 'Oxygen in Use' sign to be placed on the outside of the room entrance door, which was not followed in this instance.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 18.75%. This was due to the actions of an LVN who did not administer medications to a resident in a timely manner as per the physician's orders. The resident, who had a history of Parkinson's Disease, type 2 diabetes mellitus, and convulsions, received six medications more than one hour after the scheduled administration time. Additionally, the LVN applied Lidocaine cream to the resident's right knee instead of the left knee as prescribed. The resident's medical records indicated that the medications were crucial for managing conditions such as Parkinson's disease, diabetes, and seizure disorders. The medications included benztropine, carbidopa-levodopa, docusate sodium, empagliflozin, Lidocaine cream, and primidone. The LVN acknowledged that the medications were administered late and that the Lidocaine cream was applied incorrectly, which could lead to adverse effects and symptoms that the medications were intended to treat. Interviews with the LVN and the Director of Nursing confirmed that the medications should have been administered within a specific time frame, which was not adhered to in this instance. The facility's policy required medications to be administered within one hour of their prescribed time, a guideline that was not followed, leading to the identified deficiency.
Failure to Provide Menu and Alternative Meal Options
Penalty
Summary
The facility failed to provide a daily menu and offer alternative menu options for a resident, identified as Resident 3, who was on a pureed diet. Resident 3, who was admitted with diagnoses including muscle wasting, dysphagia, and severe protein-calorie malnutrition, was cognitively intact and communicated through a digital device. Despite being on a pureed diet, Resident 3 reported that the meals were inedible and lacked variety, leading to dissatisfaction and reduced food intake. The resident had not received a menu since admission and was not offered alternative meal options despite expressing dissatisfaction and consuming less than 50% of the meals. Observations and interviews revealed that Resident 3's meals were not varied, and the resident was not provided with a menu to choose alternative options. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) involved did not offer alternative meals, citing the resident's pureed diet as a reason. The LVN acknowledged that without a menu, Resident 3 could not see what was available and was unable to request preferred meals. The Dietary Services Supervisor and Director of Nursing (DON) had conflicting views on which department was responsible for providing menus, leading to a lack of clarity and failure to meet the resident's dietary needs. The facility's policies indicated that residents should be offered substitute food items for dislikes and that menus should be posted in accessible areas. However, these policies were not followed, resulting in Resident 3 not receiving a menu or alternative meal options. The failure to adhere to these policies and provide appropriate dietary care had the potential to impact Resident 3's nutritional status and quality of life, as the resident was consuming less than the recommended amount of food.
Failure to Protect Resident's Property and Ensure Staff Knowledge
Penalty
Summary
The facility failed to ensure staff were knowledgeable about the process for handling unlabeled resident clothes found in the laundry area and did not complete a resident belonging list upon readmission for one of the residents. This deficiency was identified during interviews and record reviews. A Licensed Vocational Nurse stated that dirty clothes during room transfers should be given to the laundry and returned to the resident once clean. However, a Laundry Services staff member indicated that unlabeled clothes were placed in the facility's donation box, while another staff member stated they should be kept in the laundry room. The Director of Nursing confirmed that unlabeled clothes should be kept in a designated area and compared to residents' belongings lists if clothes are reported missing. The report also highlighted that upon readmission, an inventory list of the resident's belongings was not created, as confirmed by the Medical Records review. The facility's policy and procedure on theft and loss, as well as the role of the nursing assistant during admission, require an inventory of all resident property, including clothing and valuables. The failure to adhere to these procedures had the potential to violate the resident's right to a safe and homelike environment, as it did not adequately protect the resident's property from loss or theft.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement its policies and procedures regarding comprehensive care planning and fall prevention for a resident who experienced a fall. After the resident's fall, the facility did not conduct an Interdisciplinary Team (IDT) meeting with the resident and their family representative to discuss and revise the care plan. The care plan was not updated to include safety interventions or measures to prevent future falls, despite the resident's fall being unwitnessed and resulting in a hospital transfer. The resident, who was cognitively intact and required partial assistance with activities of daily living, had a history of polyneuropathy and joint replacement surgery. The facility's policies required that care plans be reviewed and revised periodically and after changes in a resident's condition. However, the care plan did not include interventions such as providing a reacher to help the resident reach items, which was only added nine days after the fall. The Director of Nursing acknowledged the lack of documentation for an IDT meeting and the delay in updating the care plan.
Infection Control Deficiencies in Cohorting and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control measures for five out of seven residents by not ensuring proper cohorting and signage for contact isolation and Enhanced Barrier Precautions (EBP). Residents 1 and 3 were cohorted with Resident 2, who had orders for contact isolation due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. Despite Resident 2's need for contact precautions, Residents 1 and 3, who did not have such orders, were placed in the same room, contrary to the facility's policy. Additionally, the facility did not post clear signage to inform staff and visitors about the EBP required for Residents 6 and 7. Observations revealed that PPE supply drawers were present outside Resident 6's room without appropriate signage, and a PPE cart was observed across Resident 7's bed without EBP signage. Licensed Vocational Nurses (LVNs) and a Certified Nurse Assistant (CNA) acknowledged the absence of necessary signage, which is crucial for communicating the type of precautions and PPE required. Furthermore, staff failed to wear personal protective equipment (PPE) when entering a contact isolation room. A Physical Therapy Assistant (PTA) entered the room shared by Residents 1, 2, and 3 without donning PPE, despite a Contact Precaution sign on the door. The Infection Prevention Nurse (IPN) and Director of Nursing (DON) confirmed that staff should always wear PPE in such rooms, as the entire room is considered infected. The facility's policy indicated that residents with active infections should be placed in a private room or cohorted with residents with the same microorganism, which was not followed in this case.
Incomplete Documentation Delays Resident Transfer to Rehab
Penalty
Summary
The facility failed to ensure that all necessary documents were sent to the General Acute Care Hospital (GACH) Rehabilitation Center for a resident's evaluation and transfer. The resident, who was admitted with conditions such as hemiplegia, hemiparesis, muscle weakness, and gait disorders, required a transfer to the GACH Rehab for further physical therapy. However, the referral sent by the facility's Social Services (SS) was incomplete, lacking essential Physical Therapy (PT) notes. Despite attempts to send the missing documents, the SS could not provide confirmation of their transmission, leading to the GACH Rehab closing the resident's case due to incomplete documentation. Interviews with the SS and the Admissions Director (AD) at GACH Rehab revealed that the facility's failure to provide complete documentation resulted in the resident not being accepted for transfer. The AD confirmed that the missing PT notes were crucial for determining the resident's eligibility for admission. The facility's policy on discharge planning emphasized the importance of incorporating all relevant resident information to avoid delays, which was not adhered to in this case. This oversight delayed the resident's transfer and access to necessary therapies, impacting their potential for maintaining optimal physical, mental, and psychosocial well-being.
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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 Lynwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Post-acute Care | 0 mi | ★★★★★ | 65 | 0 |
| Lynwood Post Acute Care Center | 0 mi | ★★★★★ | 34 | 0 |
| Downey Post Acute | 1.4 mi | ★★★★★ | 20 | 0 |
| Briarcrest Nursing Center | 2.2 mi | ★★★★★ | 17 | 0 |
| Paramount Convalescent Hosp. | 2.5 mi | ★★★★★ | 24 | 0 |
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