Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Granger Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide appropriate ROM services and implement ordered interventions for two residents with post-stroke hemiplegia and hand contractures. One resident had a tightly contracted hand with fingernails pressing into the palm, no splint or padding in place, no therapy for the contracture, and no specific orders or care plan interventions addressing the hand, leading the resident to place tissues in the palm independently. Another resident had contracted fingers with no padding, reported no restorative exercises and no splint, despite a physician’s order for a left hand splint. The ARNP and OT cited insurance coverage issues and had not completed evaluations or treatments, and the DON was unable to identify what actions had been taken to follow the splint order, contrary to facility policy requiring therapy referral and provision of appropriate ROM interventions and equipment.
Surveyors found that medications in one of the medication carts were not stored and labeled according to professional standards. A resident’s Latanoprost eye drops, labeled as requiring refrigeration and expiring 42 days after opening, were kept in the cart instead of a refrigerator and lacked a written expiration date. Additionally, four bottles of prescribed eye drops and nine prescribed inhalers in the same cart were not labeled with open dates. An RN acknowledged not knowing how long these medications were good after opening, and the DON stated there was no facility policy on post-opening expiration, despite pharmacy guidance and a storage policy requiring refrigeration for certain drugs.
Surveyors found that staff failed to follow the facility’s infection control and EBP requirements during wound care for a resident with PVD and a venous leg ulcer. A RN placed wound care supplies directly on the bed, did not wear a gown, did not change gloves between dirty and clean steps, and then returned used supplies to a shared treatment cart. Interviews with a CMA and the DON confirmed that facility policy required gown and gloves for high-contact care such as wound care, glove changes with hand hygiene when moving from dirty to clean tasks, and use of a barrier for supplies.
A resident with insomnia and other conditions had an order for Ambien 5 mg at bedtime, with doses documented on the MAR over two months. The individual narcotic record for this controlled medication showed an initial quantity altered from 30 to 31 tablets, while the pharmacy manifest confirmed only 30 were dispensed. Administration and waste entries reduced the count over time, but a shift-change narcotic count revealed that one Ambien tablet was unaccounted for, and recounts documented a sudden change from 14 to 12 tablets remaining. Staff interviews showed conflicting explanations about a dropped pill, an RN’s initial refusal to sign the narcotic count due to a discrepancy, and acknowledgment that the received quantity entry appeared overwritten. The DON and ADON confirmed a missing tablet and lack of supporting documentation such as a bubble-pack photocopy, and the facility’s controlled substances policy requiring accurate receipt counts, end-of-shift counts, discrepancy documentation, and a written investigation was not fully followed, resulting in a failure to maintain accurate control and accountability of this controlled drug.
The facility lacked a clinically qualified nutrition professional, as the Dietary Manager was not certified and the Registered Dietician was only present one day a week. The Dietary Manager had not completed certification courses and lacked food safety certifications, while the Registered Dietician's limited presence was confirmed by both the dietician and the Administrator.
The facility failed to maintain a safe environment, with surveyors observing damaged baseboard heaters with bent or missing safety grates. Residents expressed dissatisfaction, and staff interviews revealed the issue had been ongoing. Maintenance logs showed delayed repairs, despite the facility's policy requiring safe and operable systems.
The facility was found deficient in food service safety standards due to improper handling of food by staff. Observations revealed that the Dietary Manager and other staff members, including CNAs and CMAs, made direct contact with food and serving surfaces with ungloved hands and failed to perform hand hygiene. Interviews confirmed that these actions were against the facility's policies, which prohibit bare hand contact with food and require frequent hand washing.
The facility failed to uphold residents' rights to dignity and respect, as evidenced by reports from three residents with intact cognition. They described a CNA's rude behavior, excessive wait times for assistance, and dismissive attitudes, particularly during the night shift. Despite grievances filed, residents felt no action was taken. Interviews and facility documentation corroborated these issues, highlighting a failure to adhere to policies on dignity and respect.
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents receiving skilled care under Medicare A. Instead, the facility provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and lacked documentation for the NOMNC. The Social Services Director was not trained on the NOMNC form, leading to this deficiency.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with mental health issues and a foot lesion, was non-compliant with wearing prescribed boots, which was not documented in the care plan. Another resident, with memory impairments and a history of pressure ulcers, used a body pillow for positioning, but this was not reflected in the care plan. Staff acknowledged these issues, but the care plans were not revised accordingly.
A facility was found to have a medication error rate of 16% during a medication pass, exceeding the acceptable rate of less than 5%. Errors included a CMA crushing an extended-release tablet for a resident and administering incorrect dosages and formulations to another. Additionally, the ADON did not follow proper insulin pen procedures, potentially affecting insulin delivery. These issues highlight a failure to adhere to medication administration protocols.
Failure to Provide ROM Interventions and Implement Hand Splint Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide services and treatment to maintain or improve range of motion (ROM) and prevent further decline for residents with contractures. Resident #40 had a history of stroke with left-sided hemiplegia and documented functional limitations in ROM of the left upper and lower extremities. Her care plan problem for history of CVA with left-sided weakness included goals to prevent complications such as contractures, but listed only general interventions such as administering medications, allowing time to communicate, and therapy as ordered, without specific interventions for her left hand contracture. Observations showed her left hand was tightly closed with fingers curled into the palm, no padding or device in place, and visible indentations in the palm from fingernails. Resident #40 reported she could not open her left hand due to contracture, did not receive therapy for the contracture, and that the facility did not provide anything to keep her hand open or prevent her fingernails from digging into her skin. She stated she sometimes placed Kleenex in her palm herself for relief. A review of her EHR revealed no orders or interventions addressing the left hand contracture. The ARNP confirmed the resident had a left hand contracture, stated she had recommended a splint but believed insurance would not pay, and acknowledged there was no order for a washcloth or foam block despite having discussed these options with the resident. The OT reported he was only working with the resident on power wheelchair safety and had not evaluated or treated her hand contracture or assessed her for a splint. Resident #44 also had a history of stroke with hemiplegia and documented ROM impairment on one side. Observation showed the four fingers of her left hand curled into the palm with the thumb extended and no padding between the fingers and palm. She reported having contractures from strokes, being unable to open her fingers independently, sometimes using gauze under her fingers, not receiving restorative exercises for her hand, and not having a splint, stating she was not able to receive therapy due to insurance. Her orders included a physician’s order for her to be fitted for and receive a left hand splint for contracted fingers, but the ARNP and OT stated that insurance would not cover a splint or evaluation, and the OT had not completed an evaluation or provided treatment. The DON was unsure what had been done since the splint order was received or what else had been done to prevent further contracture, despite a facility policy stating that residents with ROM limitations would be referred to therapy for focused assessment and that the facility would provide appropriate interventions, exercises, therapy, and equipment such as braces or splints.
Improper Storage and Labeling of Eye Drops and Inhalers
Penalty
Summary
Surveyors identified a failure to properly store and label medications in one of two medication carts reviewed on the 100/200 hall. During observation with an RN, a bottle of Latanoprost eye drops prescribed for dry eye syndrome for Resident #35 was found in the medication cart with a label indicating it needed refrigeration, an open date, and a statement that it expired 42 days after opening, but no actual expiration date was written. The Latanoprost was a bedtime medication that should have been refrigerated rather than kept in the cart. The Medication Administration Record showed the resident had been receiving the Latanoprost nightly during the review period. In the same medication cart, surveyors also found four bottles of prescribed eye drops and nine prescribed inhalers that were not labeled with an open date. The RN present acknowledged that the Latanoprost should be refrigerated and stated she did not know how long eye drops and inhalers were good for after opening. The DON reported the facility did not have a policy for expiration dates on medications after opening and stated they would follow pharmacy recommendations. A faxed document from the pharmacist indicated that Latanoprost expires 42 days after opening, and the facility’s Medication Storage Policy instructed that all medications requiring refrigeration are to be stored in refrigerators in each medication room.
Failure to Follow Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and wound care practices for one resident. The resident’s MDS dated 2/6/26 documented diagnoses of peripheral vascular disease and a venous ulcer, and the care plan initiated on 8/8/25 required EBP due to a PVD wound on the left lower leg, with EBP to be instituted during high-contact activities. Facility policy dated 3/25/24 stated that gloves and gown must be applied before performing high-contact resident care activities, including wound care. During an observation, a RN entered the resident’s room and placed wound treatment supplies directly on the resident’s bed, applied gloves without donning a gown, removed the resident’s sock and leg dressing, and cleansed scattered open wounds on the left lower leg. The RN then continued the procedure with the same gloves on while wrapping the leg with medicated dressing, gauze, and Coban, and only after completing the treatment removed gloves and performed hand hygiene. The RN then placed the wound cleanser and medicated dressing box back into the treatment cart with other residents’ supplies. A CMA interview confirmed that the EBP sign on the door meant staff should wear gown and gloves with all hands-on care, and the DON stated the expectation was to change gloves and perform hand hygiene when going from dirty to clean during wound treatment, to wear gown and gloves for the treatment, and to place supplies on a barrier.
Failure to Maintain Accurate Control and Accountability of Ambien for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate control and accountability of a Schedule IV controlled hypnotic medication (Ambien) for one resident. The resident had diagnoses including diabetes, depression, and primary insomnia, with an MDS indicating no cognitive impairment and use of a hypnotic. Physician orders on the MAR for Ambien 5 mg at bedtime were documented for December and January, with administration entries showing doses given on multiple days and held on days when the resident was hospitalized. The resident’s Individual Patient’s Narcotic Record for Ambien showed an order dispensed on 12/12/25 with a quantity documented as 30, later altered to appear as 31 by writing a “1” over the “0,” and the first dose recorded as given on 12/20/25 with 30 pills remaining. The controlled drug record entries documented one tablet administered daily from 12/20/25 through 12/29/25, and then from 1/2/26 through 1/6/26, with the running balance decreasing by one each time. On 1/7/26, the record showed one tablet dropped and wasted with two staff initials, leaving 15 remaining, and another tablet given the same day, leaving 14. On 1/8/26, two separate recount entries were made, both signed by two staff, documenting 12 tablets remaining. Staff interviews revealed that during the 1/8/26 morning shift change narcotic count, an RN and an LPN identified that the Ambien count was off by one or two tablets, with the RN stating the count was incorrect and refusing initially to sign off on the narcotic count. The RN reported that the LPN, who had the cart keys on night shift, suggested pills may have popped out of the card due to a full drawer, but the RN did not find any loose pills in the drawer. Further interviews clarified that the facility’s Controlled Drugs-Count Record for that date nonetheless contained signatures from the RN and the LPN, with a comment of the total number of controlled cards and bottles, and an instruction on the form that signing acknowledges agreement with the quantities on hand. The DON stated he was notified of a discrepancy on the cart and that no one was willing to sign for the cart being accurate, and he verbally interviewed staff but did not document those interviews or obtain written statements. The ADON reported that upon recount she determined that one Ambien tablet was unaccounted for, based on the count sheet showing a jump from 14 remaining to 12 remaining, and she confirmed there was no photocopy of the bubble pack to verify the original quantity or any pills that may have popped out. The pharmacist and pharmacy shipping manifest confirmed that only 30 Ambien tablets were dispensed and delivered, while the narcotic record had been altered to appear as 31 received. The nurse who signed as receiving the medication stated she documented 30, denied changing the number, and explained she would have properly lined out and initialed any correction rather than writing over the number. The CMA who first administered the medication also denied altering the received quantity and stated she believed there were 30 tablets remaining after the first dose, consistent with her documentation. The facility’s Controlled Substances policy required accurate counting upon delivery, proper documentation of quantity received, end-of-shift counts by oncoming and outgoing nurses, documentation and reporting of discrepancies to the DON, and investigation of any narcotic reconciliation discrepancies, which was not fully supported by the documentation and events surrounding the missing Ambien tablet and altered quantity on the narcotic record. An additional staff interview indicated that on the evening before the count discrepancy, the night-shift nurse reported dropping an Ambien tablet, which another nurse observed and then observed being disposed of in the dissolvable medication waste container. The next morning, during the narcotic count with the RN and the night-shift nurse, the count was short by one pill, and the night-shift nurse reported that one pill was missing. The Director of Clinical Services confirmed that following the documented administration pattern, the record would show a discrepancy of two pills short on 1/8/26 and noted that the received quantity on the narcotic record appeared to have been changed from 30 to 31 by writing a “1” over the “0.” These combined documentation irregularities, the unaccounted-for Ambien tablet(s), and the lack of clear, contemporaneous investigative documentation demonstrate that the facility did not ensure accurate control and accountability of this controlled medication for the resident, in contrast to its written controlled substances policy. The facility’s own policy on controlled substances, revised December 2012, required that controlled substances be counted upon delivery by both the receiving nurse and the delivery person, with both signing the designated record, and that an individual resident controlled substance record include the quantity received and number on hand. It also required nursing staff to count controlled medications at the end of each shift, with both oncoming and outgoing nurses making the count together and documenting and reporting any discrepancies to the DON, and required the DON to investigate any discrepancies and provide the administrator with a written report of findings. In this case, the altered quantity on the narcotic record, the missing Ambien tablet(s), the inconsistent count documentation, and the absence of a written investigative report or staff statements show that these policy requirements were not fully met for this resident’s controlled medication. Overall, the events leading to the deficiency include the pharmacy’s documented dispensing of 30 Ambien tablets, the facility’s narcotic record being altered to appear as 31 tablets received, the administration and waste documentation that did not reconcile with the remaining count, the discovery of a missing tablet during shift-change counts, and the lack of complete, accurate documentation and investigation consistent with facility policy. These factors resulted in the facility’s failure to ensure accurate control and accountability of the resident’s controlled hypnotic medication.
Deficiency in Nutrition Professional Qualifications
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full-time Registered Dietician. The Dietary Manager admitted to not having certification as a dietary manager, although she had completed courses to obtain it, with the classes scheduled to finish on 1/15/2025. Additionally, the Registered Dietician was only physically present in the facility one day a week, as confirmed by both the dietician and the Administrator. Facility records further indicated that the Dietary Manager did not hold any certifications in food safety, had not taken the test to become a Certified Dietary Manager, and had not been in the role for two years or more.
Facility Fails to Maintain Safe Environment Due to Damaged Heaters
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by multiple observations of damaged baseboard heaters throughout the facility. On several occasions, surveyors noted that the safety grates on the baseboard heaters were bent, broken, or completely removed, allowing easy access to the interior of the heating units. Residents expressed dissatisfaction with the state of their rooms, specifically pointing out the damaged heaters. One resident mentioned that the heater had been in disrepair since their admission, and another described the appearance as 'trashy.' Interviews with staff, including a Certified Medication Aide, a Registered Nurse, the Assistant Director of Nursing, and the Director of Maintenance, revealed that the issue with the baseboard heaters had been ongoing for a significant period. The Director of Maintenance acknowledged the chronic nature of the problem and the challenges in receiving timely reports from staff about broken grates. Maintenance logs indicated that requests for repairs had been made months prior, with some repairs only recently completed. The facility's maintenance policy, last revised in 2009, mandates that the maintenance department is responsible for ensuring the safety and operability of the building's systems, including heating systems.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during multiple instances of improper food handling by staff. On one occasion, the Dietary Manager was seen opening a package of crackers with ungloved hands and making direct contact with the crackers before serving them to a resident. Additionally, the Dietary Manager served a plate of food to a resident while touching the top of the plate and the food with ungloved hands, without performing hand hygiene after assisting a previous resident. Similar lapses were observed with other staff members, including a Certified Nurse Aide (CNA) and Certified Medication Aides (CMAs), who were seen touching the interior of plates and the serving ends of utensils with bare hands, and failing to perform hand sanitation during food service. Interviews with staff, including the Dietary Cook and the Dietary Manager, revealed that the facility's expectations were not being met, as staff should avoid contact with the tops of plates, interior surfaces of cups and bowls, and the serving surfaces of utensils. The facility's policy documents, such as 'Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices' and 'Dish & Utensil Handling', clearly state that contact between food and bare hands is prohibited and that hand hygiene should be performed frequently. Despite these guidelines, the observations indicated a failure to comply with these standards, leading to the deficiency in food service safety.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the treatment of three residents, all of whom had intact cognition as indicated by their BIMS scores. Resident #12 reported that a CNA, identified as Staff A, exhibited rude behavior, making her feel like a burden and causing her to wait excessively for assistance, resulting in incontinence. Despite filing grievances, Resident #12 felt that no action was taken to address her concerns. Resident #13 also reported similar issues with Staff A, noting that he was rude and dismissive, particularly during the night shift. She recounted an incident where she waited nearly an hour for assistance, and when her call light was finally answered, Staff A instructed her to perform tasks she required assistance with, such as removing her socks, under the guise of it being good exercise. Resident #14 echoed these sentiments, describing Staff A's behavior as making her feel like "a piece of garbage" due to the long wait times and dismissive attitude. Interviews with other residents and staff corroborated these accounts, with additional grievances filed regarding rude staff and delayed response times to call lights. The Director of Social Services acknowledged receiving multiple grievances about staff behavior but was uncertain about any actions taken. Facility documentation revealed that Staff A had previously received a written warning for neglectful behavior, yet issues persisted. The facility's policy on dignity and respect emphasized the importance of treating residents with respect and providing prompt care, which was not adhered to in these instances.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents who were receiving skilled care under Medicare A. Resident #7 began receiving skilled care on August 5, 2024, and Medicare covered the stay until August 23, 2024. However, the facility could not provide documentation that Resident #7 received the NOMNC form. Instead, they provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The SNF Beneficiary Protection Notification Review form indicated that the resident did not receive a NOMNC because the resident informed therapy staff that she was done and refused further therapy. Similarly, Resident #142 began receiving skilled care on September 13, 2024, with Medicare coverage extending until October 18, 2024. The facility also failed to provide documentation of a NOMNC form for this resident, instead providing a SNF ABN form. The SNF Beneficiary Protection Notification Review form noted that the resident did not receive a NOMNC due to receiving the SNF ABN. The Social Services Director, who had been employed for eight months, stated she was only trained to provide the SNF ABN form and was not trained regarding the NOMNC form.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, leading to deficiencies in their care. Resident #24, who had a history of mental health issues and an open foot lesion, was observed outside in cold weather without the prescribed walking boot or CAM boot, wearing only gripper socks. Despite being non-compliant with wearing the boots, the care plan did not document this non-compliance or any education provided to the resident regarding foot care. The Director of Nursing acknowledged the resident's non-compliance and stated that education had been given, but this was not reflected in the care plan. Resident #32, who had memory impairments and a history of a Stage III pressure ulcer, was observed with a body pillow used for positioning to prevent falls and assist in healing. However, the care plan did not document the use of the body pillow for positioning, despite staff acknowledging its purpose. The Assistant Director of Nursing and other staff members confirmed the use of the pillow for repositioning and fall prevention, but the care plan failed to reflect these interventions. The facility's policy requires care plans to be updated with changes in the resident's condition, but this was not adhered to in these cases.
Medication Administration Errors Observed in Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16% during a medication pass. Staff B, a Certified Medication Aide, was observed preparing and administering medications for Resident #22, including crushing an extended-release tablet of Oxybutynin, which should not be crushed. Additionally, Staff B administered an incorrect dosage of Fenofibrate and the wrong formulation of Senna to Resident #21. The errors were attributed to incorrect medication preparation and failure to verify medication orders accurately. Furthermore, the Assistant Director of Nursing (ADON) was observed administering insulin to Resident #28 without following the manufacturer's instructions for the insulin pen. The ADON failed to prime the pen correctly and did not hold the pen in place for the recommended duration after administration, potentially compromising the delivery of the full insulin dose. These observations indicate a lack of adherence to proper medication administration protocols, as outlined in the facility's policy, which requires triple-checking medication labels against the Medication Administration Record (MAR) and following specific procedures for insulin administration.
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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 Granger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kennybrook Village | 5.2 mi | ★★★★★ | 5 | 0 |
| On With Life Long Term Care | 5.5 mi | ★★★★★ | 2 | 0 |
| Brio Of Johnston, Llc | 6.8 mi | ★★★★★ | 12 | 0 |
| Madrid Home For The Aged | 8 mi | ★★★★★ | 7 | 0 |
| Spurgeon Manor | 8.7 mi | ★★★★★ | 4 | 0 |
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