Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Griswold Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility inaccurately submitted the PBJ Staffing Data Report, failing to reflect 24-hour licensed nursing coverage on several dates, despite evidence from Facility Daily Assignment Sheets showing such coverage was present. The Administrator acknowledged the inaccuracy, which affected the reported staffing for a census of 31 residents.
A resident with severe cognitive impairment experienced issues with their trust account, including missed insurance payments and restricted access to funds. The facility failed to send quarterly statements and did not provide access to funds during nights and weekends, contrary to policy.
A facility failed to provide quarterly financial statements to residents and their POAs, as required by federal regulations. This was highlighted by a case where a resident's POA reported discrepancies in the trust account balance. The Business Office Manager admitted to not sending any statements since starting the position, and the Administrator confirmed the lack of compliance with the facility's policy.
A resident with severe cognitive impairment had a trust account balance exceeding the Medicaid limit, but neither the resident nor their POA was notified. The Business Office Manager failed to send statements or provide accurate account information, and the Administrator acknowledged the oversight in communication regarding the need for a spend down.
The facility did not adhere to its policy of completing background checks before employment, as evidenced by Staff K, a CMA, working shifts before their background check was finalized. The Administrator and Business Office Manager acknowledged this oversight, which contravened the facility's policy requiring all employees to have completed checks before working with residents.
The facility failed to provide restorative care to maintain or improve the range of motion for two residents. One resident with cerebral palsy and quadriplegia did not receive passive range of motion exercises as indicated in their care plan. Another resident, who had completed physical therapy without improvement, was not provided with a restorative program despite recommendations. Staff interviews confirmed the absence of a restorative program, and the facility lacked a formal policy, which was under development.
A resident with incontinence issues reported delays in receiving care due to insufficient staffing at the facility. Staff interviews confirmed that staffing levels were often inadequate, with only one CNA available at times, leading to delays in care. The ADON acknowledged the facility was operating below minimum staffing levels, and there was no clear policy on staffing or answering call lights.
A resident with severe cognitive impairment and a history of Guillain Barre was given a flu vaccine despite instructions from emergency contacts not to administer it. The facility's records incorrectly listed the POA, and there was no documentation of consent or declination. The facility lacked a policy for determining and documenting POA, leading to the administration of the vaccine against the resident's and emergency contacts' wishes.
The facility failed to accurately assess the need for anticoagulant therapy for two residents. One resident's MDS did not document the use of Apixaban, an anticoagulant, despite a physician's order, while another resident's MDS incorrectly documented Plavix as an anticoagulant. The ADON acknowledged the miscoding, and the facility lacked a policy on MDS assessment accuracy.
A facility failed to include anticoagulant therapy in a resident's care plan, despite a physician's order for Apixaban. The resident, with no cognitive impairment, had no care plan focus, goals, or interventions for this therapy. The DON and Administrator acknowledged the oversight, noting the absence of a policy for care plan development.
A resident with moderately impaired cognition did not consistently receive prescribed tubi grips for edema, as documented in the TAR. Despite the resident's preference for wearing them, staff interviews revealed that the grips were often not applied, and there was no documentation of refusal. The Assistant DON noted that treatments were incorrectly marked as completed, indicating a failure to follow physician orders.
A resident with dementia, diabetes, and stroke experienced a decline in ADL abilities due to the facility's failure to provide a restorative nursing program. Initially requiring minimal assistance, the resident's condition worsened, necessitating substantial assistance with toileting and no ambulation attempts. Staff interviews revealed the absence of therapy and restorative program evaluations, contributing to the decline.
A facility failed to provide a well-balanced diet for a resident on a pureed diet. Staff H served incorrect portion sizes by using a regular diet menu instead of the appropriate pureed diet chart. The Dietary Manager confirmed that staff lacked knowledge of correct scoop sizes for pureed diets, leading to the deficiency.
A facility failed to serve food at appropriate temperatures and in an appealing manner for a resident. The Dietary Manager did not document food temperatures before serving a pureed diet, reheating the food multiple times in a microwave, which resulted in an unappealing presentation. This action was against the facility's policy requiring temperature documentation for all meals.
A facility failed to follow proper infection prevention practices during the care of a resident with an indwelling catheter. Two staff members did not perform hand hygiene between glove changes, despite handling feces and transitioning from dirty to clean tasks. The ADON acknowledged the missed hand hygiene opportunities, which are crucial for preventing infection transmission.
A resident with severe cognitive impairment and a history of Guillain Barre syndrome received a flu vaccine despite their POA's declination. The facility failed to follow its procedures for obtaining consent, as the ADON could not find any documentation of consent or declination. The facility's manual required documentation of declination, which was not adhered to, resulting in the vaccine being administered without proper consent.
The facility failed to document consent for COVID-19 immunizations for two residents, one with severe cognitive impairment and another rarely understood. The ADON confirmed the absence of consent documentation and could not provide a policy with vaccination guidelines. The facility's policy stated residents should be counseled on the vaccine's importance.
The facility failed to maintain accurate medication administration documentation and obtain medications as ordered for three residents. A resident with severe cognitive impairment did not receive Olanzapine IM due to its absence in the Emergency Kit, and there was no documentation explaining the lack of administration. Another resident had missing documentation for daily vitals and several medications, with the facility running out of medication on specific dates. A third resident had medications coded as unavailable without supporting documentation, highlighting issues in the facility's medication ordering and documentation processes.
Inaccurate PBJ Staffing Report Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report covering the period from April 1 to June 30. The report indicated a failure to maintain licensed nursing coverage 24 hours a day on specific dates, including 5/28, 6/14, 6/15, 6/16, 6/19, 6/20, and 6/28. However, a review of the Facility Daily Assignment Sheets for these dates showed that 24-hour nursing coverage was indeed present. The Administrator acknowledged that the PBJ was submitted inaccurately, despite the facility's expectation for accurate staffing descriptions. The facility reported a census of 31 residents during this period, and the discrepancy was identified through a review of staffing reports and staff interviews.
Failure to Manage Resident's Financial Affairs
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs, specifically regarding access to personal funds and management of a trust account. Resident #24, who has severe cognitive impairment, was affected by this deficiency. The resident's power of attorney (POA) and daughter reported issues with the resident's trust account, including missed payments for secondary health insurance and restricted access to funds. The facility did not provide access to the resident's funds during nights and weekends, and there were discrepancies in the trust account management, such as missing money and double payments for insurance. Staff interviews revealed that the facility did not send quarterly statements to residents or their representatives, and there was confusion about the billing account. Staff B, the Business Office Manager, acknowledged missed insurance payments and a lack of understanding of the billing account. Staff J, the Private Pay Manager, noted a change in personnel and issues with receiving insurance payments. The facility's administrator confirmed the lack of quarterly statements and acknowledged the absence of available funds outside business hours, contrary to the facility's policy.
Failure to Provide Resident Financial Statements
Penalty
Summary
The facility failed to provide individual financial records to residents and their power of attorney (POA) in the form of quarterly statements and upon request, as required by federal regulations. This deficiency was identified through a review of clinical and financial records, interviews with family and staff, and policy review. Specifically, the facility did not send out quarterly statements for resident trust accounts, which was confirmed by the Business Office Manager, Staff B, who acknowledged not sending any statements since starting her position in May. The Administrator also confirmed that no quarterly statements had been sent to residents or their POAs. The issue was highlighted by the case of a resident with severe cognitive impairment, whose POA/daughter reported discrepancies in the resident's trust account balance. The daughter had requested an accurate statement from Staff B, who inaccurately reported the trust account balance as approximately $1500, while the actual balance was documented as $3,877.19. The facility's policy stated that trust account statements should be available upon request, but this was not adhered to, leading to confusion and concern over the management of the resident's personal funds.
Failure to Notify Resident of Excess Trust Account Balance
Penalty
Summary
The facility failed to notify a resident receiving Medicaid benefits when their account balance reached $200 less than the SSI resource limit for one person. Resident #24, who had a severe cognitive impairment as indicated by a BIMS score of 5, had a trust account balance that exceeded $2000 since June 3, 2024. Despite this, the resident's power of attorney (POA) was not informed of the excess funds, and no quarterly statements were provided. The POA was misinformed by the Business Office Manager, Staff B, about the trust account balance, being told it was approximately $1500 when it was actually $3,877.19 as of August 31, 2024. Staff B, who started in May, admitted to not sending out any statements during her tenure and acknowledged the oversight in notifying the resident or their representative about the excess funds. The Administrator also recognized the failure to notify the POA and the resident about the need to complete a spend down to maintain Medicaid eligibility. The facility's policy required notification and discussion with the resident or responsible party when the trust account neared the state-specified maximum balance, which was not adhered to in this case.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing background checks prior to staff employment. Specifically, Staff K, a Certified Medication Assistant (CMA), was hired on 5/26/22, but their background check was not completed until 6/7/22. Despite this, Staff K worked 1 hour on 5/26/22 and 7.75 hours on 6/1/22, before the background check was finalized. The Business Office Manager and the Administrator both acknowledged that the facility's expectation was to complete background checks before staff began working with residents, which did not occur in this instance. The facility's policy, revised in January, mandates that all employees undergo criminal background checks, state and federal required checks, employment reference checks, and license confirmation prior to employment.
Failure to Provide Restorative Care for Range of Motion
Penalty
Summary
The facility failed to provide restorative care to maintain or improve the range of motion for two residents, leading to a deficiency in care. Resident #2, diagnosed with cerebral palsy, quadriplegia, and seizure disorder, had documented limitations in both upper and lower extremities. Despite the care plan indicating a need for passive range of motion (PROM) exercises, the Minimum Data Set (MDS) assessment showed no restorative nursing program (RNP) was provided during the 7-day look-back period. Staff interviews confirmed that Resident #2 did not participate in therapy services due to his diagnoses, but it was acknowledged that he would benefit from PROM exercises. Similarly, Resident #8, who had recently completed physical therapy without improvement, was recommended for a restorative program. However, the care plan was not updated following the end of physical therapy, and no restorative program was implemented. Interviews with staff revealed that the facility did not currently offer a restorative program, and the Assistant Director of Nursing (ADON) was in the process of developing one. The facility lacked a formal RNP policy, which was noted to be under development by the ADON.
Inadequate Staffing Leads to Delayed Care for Resident
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of a resident, as evidenced by the experiences of Resident #11. The resident, who had no cognitive impairment and was frequently incontinent of urine, reported that there was not enough staff to attend to her needs. She stated that after requesting assistance to change her brief, staff would return only after several hours, leaving her in a soiled brief for extended periods. This was corroborated by staff interviews, which revealed that staffing levels were often inadequate, with only one CNA available at times, leading to delays in care. Staff members, including CNAs and agency staff, confirmed the insufficient staffing levels, which affected their ability to provide timely care. One CNA mentioned that incontinence care was only provided when the resident activated her call light, and another staff member reported being the only CNA on the floor at times, which delayed response times to call lights. The ADON acknowledged that the facility was operating below the minimum staffing levels on specific dates, and there was no clear policy on staffing or answering call lights. The facility's administration, including the ADON and the Administrator, admitted to the staffing challenges and the lack of a formal policy on call light response. The Administrator believed that staffing was adequate once additional non-certified staff arrived, although these staff members could not perform hands-on care. The report highlights the facility's failure to maintain adequate staffing levels, which directly impacted the quality of care provided to residents, particularly those with incontinence needs.
Failure to Honor Resident's Self-Determination in Vaccine Administration
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding the consent or declination of vaccines and the designation of a Power of Attorney (POA). Resident #28, who had a severe cognitive impairment and a history of Guillain Barre, was administered a flu vaccine despite explicit instructions from both emergency contacts that the resident should not receive it due to medical history. The facility's records incorrectly listed emergency contact #2 as the POA, although neither emergency contact had signed any paperwork to become the POA. The facility's process for obtaining consent for vaccines was not followed, as there was no documentation of consent or declination from the POA. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the errors in the facility's documentation and procedures. The ADON clarified that emergency contact #1 had financial POA, but no one had medical POA for Resident #28. The facility lacked a policy for determining and documenting POA, which contributed to the confusion and subsequent administration of the flu vaccine against the resident's and emergency contacts' wishes. The facility's Infection Prevention and Control Manual required documentation of education and refusal if a vaccine was declined, which was not adhered to in this case.
Inaccurate MDS Assessment for Anticoagulant Therapy
Penalty
Summary
The facility failed to accurately assess the need for anticoagulant therapy for two residents during the observation period of the Minimum Data Set (MDS). For Resident #5, the MDS assessment documented no use of anticoagulant therapy, despite the Medication Administration Record (MAR) showing a physician's order for Apixaban, an anticoagulant, to be administered twice daily. Additionally, Resident #5's Care Plan lacked any focus, goals, or interventions related to anticoagulant therapy. The Assistant Director of Nursing (ADON) acknowledged that the MDS was miscoded by not documenting Apixaban as an anticoagulant. For Resident #24, the MDS documented the use of anticoagulant therapy, but the MAR indicated a physician's order for clopidogrel Bisulfate (Plavix), which is not classified as an anticoagulant. The Care Plan for Resident #24 incorrectly focused on anticoagulant therapy with Plavix. The ADON confirmed the MDS was miscoded by documenting Plavix as an anticoagulant. The facility did not have a policy on the accuracy of MDS assessments, as stated by the Administrator.
Lack of Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident on anticoagulant therapy. The resident, who had no cognitive impairment as indicated by a BIMS score of 14, was receiving Apixaban 2.5 mg orally twice daily as per a physician's order. However, the resident's care plan did not include any focus, goals, or interventions related to the anticoagulant therapy. This omission was acknowledged by the Director of Nursing, who confirmed that a care plan should have been created. The facility's Administrator also stated that anticoagulant therapy should have been included in the care plan, but noted that the facility lacked a policy on the development of care plans.
Failure to Apply Edema Wear as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring edema wear, specifically tubi grips, which were to be applied twice daily. The resident, who had moderately impaired cognition and required total assistance with lower body dressing, did not consistently receive the prescribed treatment. Documentation in the Treatment Administration Record (TAR) showed inconsistencies, with some entries left blank and others marked as completed without evidence of application. Interviews with the resident revealed that the tubi grips were not applied daily, and the resident expressed a preference for wearing them. Staff interviews indicated that the resident often removed the tubi grips independently, yet there was no documentation of refusal in the Electronic Health Record or the care plan. The Assistant Director of Nursing acknowledged that the treatment was documented as completed, despite the lack of application, and stated that refusals should have been recorded as such. This discrepancy between the documented records and the actual care provided highlights a failure to meet professional standards of quality in following physician orders.
Failure to Maintain Resident's ADL Abilities
Penalty
Summary
The facility failed to maintain or improve the activities of daily living (ADL) abilities of a resident, who was admitted with diagnoses of dementia, diabetes, stroke, and a history of repeated falls. Upon admission, the resident required setup or clean-up assistance with eating, supervision or touching assistance with toileting hygiene, and walking. However, a subsequent assessment revealed a decline in the resident's ADL abilities, requiring substantial assistance with toileting hygiene and no attempt at ambulation due to medical or safety concerns. The resident's range of motion was also noted to be impaired, and there was no restorative nursing program (RNP) in place during the assessment period. Observations during meal times showed the resident receiving hands-on assistance with transfers and meals. Interviews with staff revealed that the resident had not attended therapy since admission and there was no request for a restorative program evaluation. The Assistant Director of Nursing confirmed that the facility did not offer a restorative program at the time, which contributed to the resident's decline in ADL abilities. The Business Office Manager noted the resident's decline in ADL abilities since admission, attributing it to cognitive decline, which affected the resident's ability to walk and feed themselves.
Failure to Provide Correct Pureed Diet Portions
Penalty
Summary
The facility failed to provide a well-balanced diet that meets the nutritional and special dietary needs of its residents, specifically for one resident on a pureed diet. During an observation, it was noted that Staff H, a cook, used a 4 oz ladle to serve pureed braised beef tips with gravy and green beans, following a regular diet portion size menu instead of the appropriate pureed diet portion sizes. Staff H admitted to not following a chart for special diets and incorrectly assumed that the portion sizes were correct because they matched the regular diet portions. Upon reviewing the Diet Spreadsheet, it was confirmed that the regular diet portion size was 6 oz for braised beef tips with gravy, and Staff H did not measure the portion size after pureeing the food. The Dietary Manager observed the process and acknowledged that the chart for measuring portion sizes for special/altered diets was not utilized. During an interview, the Dietary Manager confirmed that dietary staff lacked the necessary knowledge to determine the correct scoop sizes for pureed diets and that Staff H was not reading the menu correctly. The facility's document titled 'Therapeutic Diets' indicated that diets should be determined in accordance with the resident's informed choices, preferences, treatment goals, and physician's diet order, which was not adhered to in this instance.
Failure to Serve Food at Proper Temperature and Presentation
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges and in an attractive and palatable manner for one resident. During an observation, the Dietary Manager was seen preparing a pureed diet for a resident without documenting the serving temperature of each food item. The manager placed the plated food in a microwave, stirring and reheating it multiple times, which resulted in the food appearing unappealing. There was no documentation of the food temperatures before serving, as confirmed by the Dietary Manager during an interview. The facility's policy requires that food temperatures be taken and documented for all hot and cold foods prior to serving to ensure proper serving temperatures.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices during personal care for a resident, specifically in the area of hand hygiene. The incident involved a resident with no cognitive impairment, as indicated by a BIMS score of 15, who had an indwelling catheter. During a care procedure, two staff members, Staff N and Staff O, assisted the resident with personal care, including peri care and catheter cleaning. However, they did not perform hand hygiene between glove changes, despite having contact with feces and transitioning from dirty to clean tasks. The Assistant Director of Nursing (ADON) was present during the care and acknowledged the missed opportunities for hand hygiene. The facility's Infection Prevention and Control Manual emphasizes the importance of hand hygiene as a primary means of preventing infection transmission. The manual also highlights the necessity of performing hand hygiene even when gloves are used, especially in preventing contamination with C. difficile spores. Despite these guidelines, the staff failed to perform hand hygiene at critical points during the care process, leading to a deficiency in infection control practices.
Failure to Adhere to Vaccination Consent Procedures
Penalty
Summary
The facility failed to implement its policies and procedures regarding influenza vaccinations, resulting in a resident receiving a flu shot despite a clear declination from their power of attorney (POA). Resident #28, who had a severe cognitive impairment and a history of Guillain Barre syndrome, was administered the influenza vaccine against the wishes of their POA. The POA had communicated to the facility that the resident should not receive the flu vaccine due to a previous adverse reaction. Despite this, the vaccine was administered, as documented by the Director of Nursing. The facility's process for obtaining consent for vaccinations was not followed, as the Assistant Director of Nursing (ADON) could not locate any consent or declination documentation from the POA. The facility's Infection Prevention and Control Manual required that residents or their representatives have the opportunity to decline vaccinations, and any declination should be documented in the medical records. However, this procedure was not adhered to, leading to the administration of the vaccine without proper consent and against medical contraindications.
Lack of COVID-19 Vaccine Consent Documentation for Two Residents
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure proper documentation of consent for COVID-19 immunizations in the medical records of two residents. Resident #2, who was rarely or never understood, had no electronic documentation of consent for the COVID-19 vaccine. Similarly, Resident #24, who had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, also lacked electronic documentation of consent for the COVID-19 immunization. The Assistant Director of Nursing (ADON) confirmed the absence of consent documentation for these residents and was unable to provide a policy with administration guidelines for COVID-19 vaccination. The facility's SARS-CoV-2 Infection Policy, dated August 22, 2024, stated that residents should be offered resources and counseled about the importance of receiving the COVID-19 vaccine.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate medication administration documentation and obtain medications as ordered for three residents. Resident #1, who entered the facility with severe cognitive impairment, had an order for Olanzapine IM for agitation, which was not administered as the facility did not have it in their Emergency Kit. The medication was supposed to be delivered from the pharmacy, but there was no documentation in the Progress Notes explaining the absence of administration. The resident was observed receiving medication in a crushed form, requiring prompts to take it. Resident #2, also with severe cognitive impairment, had missing documentation for daily vitals and several medications, including Rexulti and Aspirin, which were coded as unavailable without supporting Progress Notes. The DON acknowledged the use of code 6 without documentation and noted that the facility ran out of medication on specific dates. Staff interviews revealed that missing medications were not a regular occurrence, but the facility did run out of medication on certain occasions. Resident #3, who was cognitively intact, had several medications coded as unavailable on their MAR without supporting documentation. The facility's process for ordering medications involved reviewing them upon admission, but orders were not completed until the resident was admitted. The DON stated that refills were typically completed in 1-2 days, but there was a lack of documentation for certain medications. The facility's pharmacy services manual outlined procedures for contacting the pharmacy and using the E-Kit, but these were not effectively followed in these cases.
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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 Griswold
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlantic Specialty Care | 12.9 mi | ★★★★★ | 9 | 0 |
| Heritage House | 13.2 mi | ★★★★★ | 8 | 0 |
| Oakland Manor | 14.3 mi | ★★★★★ | 31 | 0 |
| Good Samaritan - Red Oak | 15.5 mi | ★★★★★ | 23 | 1 |
| Red Oak Rehab And Care Center | 15.8 mi | ★★★★★ | 8 | 0 |
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