Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Avera Granite Falls Care Center during CMS and state inspections, most recent first.
A resident with impaired cognition and mobility, dependent on staff for transfers, suffered a traumatic hematoma requiring hospitalization after a mechanical lift sling strap was left unsecured and became entangled in the wheelchair wheel. Staff failed to properly secure or tuck the sling straps after transfer, leading to the resident's leg being pulled backward and injured. The incident was not immediately documented, and the injury was discovered later when the resident reported increased pain.
The facility did not consistently track or document staff illnesses, with missing information on illness symptoms, last day worked, symptom resolution, and return-to-work dates for several employees, including nursing assistants and the infection preventionist. Incomplete illness logs and unclear oversight responsibilities contributed to the deficiency.
The facility did not ensure that the infection preventionist was properly trained or that infection control surveillance and documentation were consistently maintained. Staff illness logs were incomplete, and there was a lack of clear oversight and communication among the infection control team, resulting in missing critical information about staff illnesses and return-to-work status.
A resident with multiple chronic conditions received expired bisacodyl suppositories on two occasions due to the facility's lack of an effective system for monitoring medication expiration. A nurse was found with expired medications in the medication room, and the DON confirmed that required audits were not completed for that area. The facility's policy did not address checking for expired medications prior to administration.
A resident who had previously received PPSV-23 and PCV-13 vaccines was not offered the updated PCV20 or PCV21 vaccines as recommended by the CDC. Staff relied solely on the MIIC database for immunization recommendations, which did not always reflect current guidelines, resulting in the resident not being offered the appropriate vaccinations. The DON confirmed the process was not up to date and no relevant policy was provided during the survey.
The facility failed to ensure consistent mail delivery to residents on Fridays and Saturdays, affecting all 48 residents who received personal mail. Mail delivery was placed on hold on Saturdays due to staff unavailability, leading to mail sitting unsecured until Monday. The administrative assistant and SSD were responsible for mail delivery, but if neither was available, mail was not delivered. The facility lacked a policy for mail delivery when both were unavailable, as confirmed by the DON.
A facility failed to provide a dignified dining experience by allowing insulin injections to be administered at the dining table in front of other residents. A resident expressed discomfort with this practice, which was routine and not addressed in her care plan. The DON was aware of the practice and preferred injections be done in a private area, but the facility's policy did not ensure the dignity of other residents present.
A resident in a LTC facility was found to be using a self-release lap belt as a restraint without proper assessment or documentation. The resident, who had moderate cognitive impairment, was unable to self-release the belt, and staff did not recognize it as a restraint. The facility failed to obtain necessary physician orders, conduct a restraint assessment, or update the care plan, leading to a deficiency in compliance with restraint regulations.
A resident in a LTC facility was unable to self-release a lap belt used in her wheelchair, and the facility failed to update her care plan following a decline in her condition after hospitalization. The care plan did not include necessary assessments, consents, or documentation for the use of the lap belt, which was considered a restraint. Staff were unaware of the restraint classification, and the facility's policy requirements for restraint use were not met.
A resident with intact cognition and multiple medical conditions, including diabetes and cataract, required moderate assistance for personal hygiene. Despite expressing a desire for help with shaving facial hair, staff did not provide the necessary grooming support. Observations showed the resident's facial hair remained unshaven, and interviews revealed a lack of attention to this need. The care plan did not include instructions for facial grooming, and no policy was provided by the facility.
A resident with diabetes did not receive timely insulin administration, leading to a deficiency in pharmaceutical services. The morning insulin was delayed, causing high blood sugar levels, and subsequent doses were mishandled due to poor communication and documentation by nursing staff. The facility's policy requires reporting medication errors and notifying the physician, which was not followed.
A resident with a full code status was found unresponsive, and staff failed to initiate CPR as per physician orders. Despite the resident's condition, the LPN did not start CPR and instead called 911. The ambulance crew began CPR upon arrival, but the resident was pronounced deceased shortly after. The facility's policy requiring CPR initiation was not followed.
Failure to Secure Mechanical Lift Sling Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a mechanical lift sling was properly secured and free from entanglement hazards after transferring a resident to a wheelchair. The resident, who had moderately impaired cognition and required maximum assistance with mobility, was dependent on staff for all transfers and used a full-body mechanical lift. The care plan specified the use of a particular sling and required that straps be secured in the wheelchair according to the resident's preference. However, after an outing, a lower sling strap was left unsecured and became caught in the front wheel of the resident's wheelchair, pulling the resident's left leg backward and tightly against the chair. Multiple staff members were involved in the incident. The Activity Director was pushing the resident back to her room when the strap became entangled in the wheelchair wheel. A nursing assistant at the nurses' station heard the resident express pain and observed the entanglement, immediately intervening to stop the wheelchair and loosen the strap. At the time, neither the nursing assistant nor the LPN who was notified observed any visible injury, redness, or swelling on the resident's leg. The incident was reported to the LPN, but no documentation was made in the resident's record at that time. Later, the resident experienced increased pain and developed a traumatic hematoma on her left leg, which required hospitalization, surgical intervention, and a blood transfusion due to a significant drop in hemoglobin. The facility's internal investigation confirmed that the leg strap of the lift sling had not been properly secured or tucked away after the transfer, leading to the entanglement and subsequent injury. Staff interviews corroborated that the sling straps should have been tucked back and under the resident to prevent such incidents.
Failure to Track and Document Employee Illnesses in Infection Control Program
Penalty
Summary
The facility failed to properly track and document employee illnesses, resulting in incomplete records for three staff members, including two nursing assistants and the infection preventionist. The employee illness forms and surveillance logs were missing critical information such as the last day worked, symptom resolution, and return-to-work dates. In some cases, the specific symptoms experienced by staff were not recorded. This lack of documentation occurred despite the facility having a form and process in place for tracking staff illnesses, which was not consistently followed. Interviews revealed that the infection preventionist, who was newly hired and still in training, acknowledged that required documentation had lapsed as COVID-19 protocols changed. The infection preventionist was not yet certified and relied on another RN for assistance, but there was confusion regarding oversight responsibilities. The director of nursing admitted that expectations for oversight were not clearly communicated, and concerns about missing illness logs had been raised previously but not addressed.
Inadequate Infection Control Program Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) was appropriately trained and that the infection control (IC) program was properly overseen by management. The IP, hired in April 2025, was still in training and had not yet started certification classes. During this period, the facility did not maintain adequate daily cumulative infection control surveillance activities, nor did it ensure complete documentation of staff illness incidents, findings, and any corrective actions. Review of staff illness forms and surveillance logs revealed missing information such as last day worked, symptom resolution dates, and return-to-work dates for multiple staff members, including the IP. Required details about symptoms and exposure were also inconsistently recorded. Interviews with the IP, a certified RN, and the DON revealed a lack of clear communication and oversight regarding the infection control program. The certified RN, although available to assist, was not officially providing oversight to the new IP and was unaware of any formal delegation of this responsibility. The DON acknowledged that expectations for oversight were not clearly communicated and that there were concerns about incomplete staff illness logs. The facility's job description for the IP required proficiency in surveillance and collaboration with employee health, but these functions were not being fully met during the period in question.
Failure to Monitor and Prevent Use of Expired Medications
Penalty
Summary
The facility failed to establish an effective system for monitoring expired medications, resulting in the administration of expired medication to a resident. During an observation in the medication room, a registered nurse was found to have a box of bisacodyl suppositories with an expiration date that had already passed, and only a portion of the original supply remained. The nurse confirmed that the resident had not used the suppositories in a long time, yet medication administration records showed that the resident received the expired suppositories on two occasions after the expiration date. Additionally, a plastic cup containing what appeared to be chocolate Ensure was found in the medication room refrigerator without a cover, label, date, or resident name. The resident involved had a history of atrial fibrillation, heart failure, hypertension, peripheral vascular disease, and constipation, and required set-up assistance for care but was able to walk independently. The resident confirmed receiving suppositories recently, despite not having frequent issues with constipation. The director of nursing stated that monthly audits were expected but had not received any from the nurse responsible for the area where the resident resided. The facility's medication administration policy did not include procedures for checking medication expiration dates prior to administration.
Failure to Offer Updated Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered or provided updated pneumococcal vaccinations in accordance with current CDC recommendations. Review of the resident's immunization record showed she had previously received PPSV-23 and PCV-13 vaccines, but there was no evidence she was offered the newer PCV20 or PCV21 vaccines upon admission, as recommended for adults 65 years or older. During an interview, the DON stated that staff relied solely on the Minnesota Immunization Information Connection (MIIC) for recommendations, and if no recommendations were listed, no vaccines were offered. The DON acknowledged that their process was not up to date, as the MIIC did not always reflect current CDC guidelines, and agreed that the resident should have been offered the updated vaccines. No policy regarding this process was provided during the survey.
Inconsistent Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure consistent delivery of mail to residents on Fridays and Saturdays, affecting all 48 residents who received personal mail. During a Resident Council meeting, five residents confirmed that mail was not consistently received on these days. The facility had requested that mail delivery be placed on hold on Saturdays due to the absence of staff available to distribute it, resulting in mail sitting from Friday or Saturday until Monday. The administrative assistant was responsible for mail delivery during the week, but if unavailable, the social services designee (SSD) would deliver the mail. However, if neither was available, mail was not delivered unless someone else chose to do so. The activity director and administrative assistant confirmed that mail delivery had been suspended on Saturdays after the resident council agreed to have it held at the post office to avoid security issues with mail left in an unsecured entry area. The administrator expressed that it was unacceptable to place mail delivery on hold due to staff unavailability. The SSD confirmed that the facility did not have a process for mail delivery when both she and the administrative assistant were unavailable. The facility lacked a policy addressing the delivery of resident mail, as confirmed by the director of nursing.
Lack of Privacy During Insulin Administration in Dining Room
Penalty
Summary
The facility failed to ensure a homelike and dignified dining experience for residents, specifically affecting one resident, R36, and potentially impacting all 21 residents who ate meals in the Neighborhood A dining room. During an observation, a registered nurse (RN-A) administered an insulin injection to a resident (R22) at the dining table in the presence of other residents, including R36. The nurse did not ask R22 to leave the public area for the injection, nor did she consider how it might affect the other residents at the table. Interviews revealed that the practice of administering insulin in the dining room was routine, and no staff had asked the other residents if it bothered them. R36 expressed that watching someone receive an injection during mealtime was bothersome and that it was unpleasant to see another resident pull down their clothing for the injection. Despite these feelings, R36 had not been asked if the practice bothered her, and her care plan lacked any indication of such a discussion. The director of nursing was aware of the practice and preferred that insulin injections be administered in a private area, noting that a room off to the side of the dining room was available for this purpose. The facility's medication policy allowed for medication administration in the presence of other residents if agreed upon by the resident or representative, but it did not address maintaining the rights and dignity of other residents present.
Failure to Properly Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident, identified as R14, was free from the use of physical restraints, specifically a self-release lap belt, which was used as a restraint. Observations and interviews revealed that R14 was unable to self-release the lap belt, which was applied by staff in the morning and removed at night. Despite R14's inability to release the belt, staff did not recognize it as a restraint, believing it was used for safety to prevent falls. R14, who had moderate cognitive impairment and a history of mobility issues, was not aware of the reason for the belt and relied on staff assistance for its application and removal. Interviews with nursing assistants and registered nurses indicated a lack of awareness regarding the classification of the lap belt as a restraint. The staff believed the belt was necessary due to R14's tendency to slouch or slide forward in her wheelchair. However, there were no documented safety concerns or recent falls that justified the use of the belt. The facility's policy required a physician's order and a restraint assessment for any restraint use, but these were not completed for R14. The Director of Nursing confirmed the absence of necessary documentation, including physician orders, care plan updates, and a signed consent from the resident or their representative. The facility's policy on physical restraints outlined the need for clinical justification, physician notification, and regular evaluation of restraint use. However, these procedures were not followed in R14's case. The oversight was attributed to the staff's familiarity with the resident's use of the lap belt and a failure to reassess its necessity following R14's hospitalization. The lack of documentation and proper assessment led to the continued use of the lap belt without appropriate justification or consent, resulting in a deficiency in the facility's compliance with restraint regulations.
Failure to Revise Care Plan for Resident with Lap Belt Restraint
Penalty
Summary
The facility failed to revise the care plan for a resident who utilized a self-release belt but was unable to release it independently. The resident, who had received a new wheelchair in December 2022, was hospitalized for a urinary tract infection and pneumonia, resulting in a decline in cognition, strength, and mobility. Upon return, the resident's care plan was not updated to reflect her inability to self-release the seatbelt, and a restraint assessment was not completed. The resident's significant change Minimum Data Set (MDS) did not identify the use of a seat belt type lap belt, and the care plan failed to include necessary assessments and consents for the use of the device. Observations and interviews revealed that the resident was unable to release the lap belt independently, and staff were applying and releasing the belt for her. The nursing assistant and registered nurse involved were unaware that the lap belt was considered a restraint, and the registered nurse admitted to not completing a restraint assessment or documenting the use of the lap belt. The director of nursing confirmed that the care plan should have been updated to include the use of the lap belt and that necessary documentation and consents were missing. The facility's policy required a signed consent for the use of a restraint device, inclusion of the device in the care plan, and regular assessments and reviews by the interdisciplinary team and physician. The policy also mandated supervision and monitoring by staff, as well as quarterly documentation of attempts for restraint reduction. However, these requirements were not met, leading to the deficiency in the resident's care plan and the improper use of the lap belt as a restraint.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide adequate grooming assistance to a resident, identified as R22, who required moderate assistance for personal hygiene and dressing due to her medical conditions, including diabetes, depression, heart disease, arthralgia, and cataract. Despite having an intact cognition, R22 often forgets to shave her facial hair and expressed a desire for staff assistance, which was not provided. Observations on consecutive days revealed that R22 had a noticeable patch of facial hair on her chin, which remained unshaven, indicating a lack of grooming support from the staff. Interviews with the resident and staff members highlighted a gap in the care plan, which did not include instructions for staff to assist with facial grooming or shaving. A nursing assistant admitted to not noticing the resident's facial hair, and a registered nurse acknowledged the expectation for staff to offer shaving assistance to female residents with facial hair, even if it was not specified in the care plan. The facility was unable to provide a policy regarding this aspect of care by the end of the survey, further underscoring the deficiency in addressing the resident's grooming needs.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to ensure timely administration of insulin for a resident with diabetes mellitus, leading to a deficiency in pharmaceutical services. On a specific day, the resident did not receive her morning insulin until 11:00 a.m., resulting in a blood sugar level exceeding 300. When approached by a different nurse at 11:30 a.m. for her noon insulin, the resident refused, citing the recent administration of her morning dose. The nurse did not follow up with the previous nurse, did not complete a medication error report, and failed to contact the physician for guidance. The incident was further compounded by the actions of another registered nurse who, due to a hectic morning, initially prepared to administer the insulin but forgot to do so after being distracted. This nurse later administered the insulin at 10:30 a.m. but did not update the administration record or report the late administration. The director of nursing expressed an expectation for better communication and adherence to the facility's policy, which mandates reporting medication errors and notifying the physician. The facility's November 2023 Medication Orders Administration Policy requires immediate documentation of medication administration and reporting of errors.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to follow physician orders for a resident who was designated as full code and did not initiate CPR as per the resident's wishes. The resident, who had diagnoses of coronary artery disease, heart failure, high blood pressure, and anxiety, was found without a pulse or respirations. Despite the resident's full code status, staff did not initiate CPR, and the resident expired. The incident resulted in an immediate jeopardy (IJ) situation, which was later addressed by the facility with corrective actions. The resident's physician order indicated a full code status, but the record did not include a corresponding POLST or signed advanced directives. The care plan also did not reflect the resident's code status. On the night of the incident, the resident was found unresponsive by a nursing assistant, who then called for a licensed practical nurse (LPN). The LPN noted a rapid heart rate but did not initiate CPR, instead calling 911 and retrieving an AED. When the ambulance crew arrived, they confirmed the resident's full code status and began CPR, but the resident was pronounced deceased shortly after. Interviews with staff revealed that the LPN was unsure of what to do and did not start CPR, despite knowing the resident was a full code. The Director of Nursing (DON) was not aware that CPR had not been initiated until it was reported by a quality assurance nurse. The facility's policy required staff to start CPR in the absence of obvious signs of clinical death, but this was not followed in this case. The facility later reviewed and revised their policies and provided additional training to staff to prevent future occurrences.
Removal Plan
- Reviewed their policy and systems and made the following changes: Implemented full code residents have a red heart at the foot of their bed.
- Implemented the unit group sheets were all revised to identify full code status.
- NA-A received education, LPN-A was put on administrative leave.
- All nursing staff participated in mock code with local ambulance service.
- All staff received education on implementation of POLST orders/CPR and participated in a mock code drill with local ambulance. They were reeducated again.
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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 Granite Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Home | 1 mi | ★★★★★ | 8 | 0 |
| Clara City Care Center | 12.8 mi | ★★★★★ | 9 | 1 |
| Luther Haven | 13.4 mi | ★★★★★ | 2 | 0 |
| Clarkfield Care Center | 14.2 mi | ★★★★★ | 5 | 0 |
| Renville Health Services | 15.4 mi | ★★★★★ | 6 | 0 |
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