Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grantsbrook Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A GCA used a cellphone to video record a resident during ADL care in the resident’s room without consent while an NA was providing care. The resident was cognitively impaired, dependent for ADLs, and had behavioral symptoms and care rejection. The GCA said she believed she needed proof of what she witnessed, while the NA said she did not know she was being recorded. Facility leaders confirmed recording residents was prohibited and that the recording occurred during care.
A resident with a known shellfish allergy was served shrimp, and the care plan did not address this allergy. Staff interviews revealed confusion over who was responsible for documenting food allergies, resulting in the omission of necessary interventions in the care plan.
Two nurse aides did not wear gowns as required by the facility's Enhanced Barrier Precautions policy while providing incontinence care to a resident with a chronic sacral pressure ulcer. The staff believed enhanced precautions were unnecessary due to the absence of signage and the wound's appearance, despite the resident having an open pressure ulcer covered with a border foam dressing. The Infection Preventionist also did not believe EBP was needed, but the DON later confirmed that EBP should have been in place.
A resident with a known shellfish allergy was served shrimp shortly after admission because staff failed to obtain and document dietary allergies before meal service. The resident, who was cognitively intact, had to inform staff of the allergy at the time of the meal, and the allergy was only added to the medical record after the resident's representative intervened. Interviews revealed inconsistent processes among nursing and dietary staff for identifying and recording allergies upon admission.
The facility failed to remove an expired salad dressing from the walk-in cooler. Despite daily checks and staff training on food storage protocols, the Dietary Manager overlooked the expired item. The Nutrition Consultant and Administrator confirmed that the dressing should have been discarded 7 days after opening.
The facility failed to provide adequate nail care to a resident with dementia who required substantial assistance with personal hygiene. Despite daily baths, the resident was observed with broken and jagged fingernails, and staff did not notice or address the issue during routine care.
The facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to the discharge of a resident from Medicare Part A skilled services. The Social Worker mistakenly provided the wrong form, and the Administrator was unsure which notices were given.
A resident was discharged from hospice services, but the facility failed to complete the required significant change in status MDS assessment within the two-week window. The MDS Coordinator was not made aware of the change until months later, and the necessary assessment was not completed.
The facility failed to accurately code the hospice status of a resident on an MDS assessment. The resident was discharged from hospice services, but the MDS assessment incorrectly indicated they were still receiving hospice care. This error was confirmed by the MDS Coordinator and the Administrator.
The facility's QAA Committee failed to maintain procedures and monitor interventions, leading to recurring deficiencies in Medicaid/Medicare Coverage/Liability Notices and Accuracy of Assessments. Specifically, the facility did not provide a correct SNF-ABN form prior to discharge and failed to accurately code a resident's hospice status on an MDS assessment.
Unauthorized Video Recording During Resident Care
Penalty
Summary
The facility failed to provide personal privacy during ADL care when a GCA used a cellphone to video record a resident while care was being provided in the resident’s room, without resident representative consent. The resident involved had diagnoses including diffuse traumatic brain injury without loss of consciousness and vascular dementia with mood disturbance. The admission MDS indicated the resident was cognitively impaired, had physical and verbal behavioral symptoms directed toward others, rejected care, and was dependent on others for ADLs. According to the investigative summary, staff reported the resident was resistant to care and combative at times. On the day of the incident, an NA asked the GCA to witness care because of the resident’s known behaviors. The GCA entered the room and sat behind the NA while the NA provided care. After the care was completed, the GCA began video recording while the NA was dressing the resident into a gown. The NA stated she did not know the GCA was recording and did not ask her to record the care. The GCA stated she recorded the care because she believed she needed proof of what she witnessed and thought that was what the NA wanted her to do. She also stated she did not tell the NA she was recording and later deleted the video. The DON, Scheduler, Nurse, and Administrator all confirmed that video recording or taking pictures of residents was not allowed in the facility and that the recording occurred during resident care in the room. The report also states the GCA had received orientation training on protecting patient privacy and HIPAA.
Failure to Include Shellfish Allergy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing a resident's shellfish allergy. Upon review, the resident's care plan did not include any focus area, goal, or intervention related to the shellfish allergy, despite the resident being cognitively intact and having a documented history of a severe allergic reaction to shrimp. The resident reported being served shrimp shortly after admission, at which time he informed the aide of his allergy and had the meal tray removed. The resident's representative also contacted the facility to ensure staff were aware of the allergy after learning about the incident. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for documenting food allergies in the care plan. The Regional Registered Dietician was unsure if food allergies should be included in the care plan, while the MDS Nurse and Dietary Manager each believed the other was responsible for this task. The DON confirmed that there was no designated person assigned to ensure food allergies were added to care plans. This lack of clear assignment and communication resulted in the resident's shellfish allergy not being addressed in the care plan.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Nurse Aide #1 and Nurse Aide #2 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy when providing incontinence care to Resident #14, who had a chronic sacral pressure ulcer. Both nurse aides performed hand hygiene and donned gloves but did not wear gowns, as required by the EBP policy for residents with wounds during high-contact care activities such as changing briefs. The aides believed that because there was no EBP signage or PPE on the door and the wound appeared to be covered with a preventative dressing, enhanced precautions were not necessary. Observation revealed that Resident #14 had a clean, dry border foam dressing on the sacrum, and the Infection Preventionist confirmed the presence of a chronic pressure ulcer with a small opening and no drainage. The Infection Preventionist stated she did not believe EBP was needed due to the wound's size and lack of drainage. However, the Director of Nursing later clarified that EBP should have been implemented for the resident due to the chronic wound, and appropriate signage and PPE should have been in place to alert staff.
Failure to Identify and Document Resident Food Allergy Prior to Meal Service
Penalty
Summary
The facility failed to obtain and document a resident's dietary allergies prior to serving food, resulting in a resident being served shrimp despite having a shellfish allergy. The resident, who was cognitively intact, reported that shortly after admission, he was served shrimp and had to inform the aide of his allergy, prompting the removal of the meal tray. The resident had a history of an allergic reaction to shrimp, characterized by throat tightness and difficulty breathing. The resident's representative later contacted the facility to ensure staff were aware of the shellfish allergy, after which the allergy was added to the medical record. Interviews with facility staff revealed inconsistencies in the process for identifying and documenting allergies upon admission. The admitting nurse did not record any allergies, as none were listed on the hospital discharge paperwork. The Dietary Manager did not recall meeting with the resident's family, and the process for gathering allergy information varied among staff. The Director of Nursing and Regional Registered Dietician both indicated that allergies should be identified and documented within 24-48 hours of admission, but this did not occur prior to the resident being served a meal containing shellfish.
Expired Food Item Found in Walk-In Cooler
Penalty
Summary
The facility failed to remove an expired food item stored in the refrigerated walk-in cooler. During an initial tour of the kitchen, a 1-gallon container of salad dressing, which was half full and dated as opened several months ago, was found. The Dietary Manager, who was present during the inspection, acknowledged that staff were trained on food storage protocols, including dating, labeling, and discarding outdated foods. Despite daily checks of the refrigerated coolers, the expired salad dressing was overlooked. The Nutrition Consultant confirmed that the salad dressing should have been discarded 7 days after opening. The Administrator also acknowledged that the salad dressing was too old and should have been discarded earlier.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to Resident #167, who was admitted with a diagnosis of dementia and required substantial assistance with personal hygiene. Despite being moderately cognitively impaired and not exhibiting any behaviors or rejection of care, Resident #167 was observed on multiple occasions with broken and jagged fingernails. The resident stated that her fingernails had been in this condition for a while and that no one had offered to clip them, even though she received daily baths. Interviews with Nurse Aides (NAs) who provided care to Resident #167 revealed that they had not noticed the condition of her fingernails and had not been asked by the resident for nail care. The Director of Nursing (DON) also confirmed the presence of rough and jagged fingernails upon close inspection and acknowledged that the issue should have been addressed if noticed by staff. Observations and interviews indicated that the facility staff, including NAs and the DON, failed to notice and address the condition of Resident #167's fingernails during routine care. Despite having access to nail care supplies and protocols for providing nail care, the staff did not take the necessary steps to ensure Resident #167's fingernails were properly maintained. This oversight resulted in the resident having multiple broken and jagged fingernails, which could have been easily addressed during her daily personal hygiene routine.
Failure to Provide Required SNF-ABN Form
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to the discharge of a resident from Medicare Part A skilled services. Resident #40, who was admitted to the facility, had her Medicare Part A skilled services end on February 16, 2024, but remained in the facility with benefit days remaining. A review of records revealed that Resident #40 was not given the required CMS-10555 SNF-ABN form. An interview with the Social Worker indicated that she mistakenly provided the resident with the CMS-R-131 form instead. The Administrator confirmed that an attempt was made to provide notices to the resident, who was refusing therapy services, but he was unsure which notices were actually provided.
Failure to Complete Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who was discharged from hospice services. Resident #55 was admitted to the facility with hospice services in place and was discharged from hospice on November 2, 2023. However, the facility did not complete the required significant change in status MDS assessment within the two-week window following the hospice discharge. The MDS Coordinator stated that she was not made aware of the change in status until February 2024, well past the required timeframe for completing the assessment. She acknowledged that a significant change in status MDS assessment should have been completed when the resident was discharged from hospice services. The Director of Nursing (DON) confirmed that Resident #55's hospice status was discussed during a morning meeting in November, and the MDS Coordinator was present at these meetings. Despite this, the MDS Coordinator did not follow up to complete the necessary assessment. The Administrator also stated that a significant change in status MDS assessment should be completed when a resident elects to receive or discharge from hospice services. This oversight resulted in the failure to complete the required assessment for Resident #55, who had been off hospice for an extended period without the necessary documentation being updated.
Incorrect Coding of Hospice Status on MDS Assessment
Penalty
Summary
The facility failed to accurately code the hospice status of a resident on a Minimum Data Set (MDS) assessment. Resident #55 was admitted with hospice services in place but was discharged from hospice services on 11/2/23. However, the MDS assessment dated after this discharge incorrectly coded the resident as still receiving hospice care. This error was confirmed during an interview with the MDS Coordinator, who acknowledged the mistake. The Administrator also confirmed that the hospice status should be accurately reflected in the resident's MDS assessments.
Recurring Deficiencies in QAA Committee's Monitoring and Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that were previously put in place following the recertification and complaint investigation surveys. This failure was evident in the re-cited deficiencies in the areas of Medicaid/Medicare Coverage/Liability Notices (F582) and Accuracy of Assessments (F641). Specifically, the facility did not provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services for one resident. The Administrator acknowledged that the issue last year was incomplete notices, while this year the form was incorrect, indicating a perceived difference in the issues that were not effectively tracked by the QAA Committee. Additionally, the facility failed to accurately code the hospice status of a resident on a Minimum Data Set (MDS) assessment. This deficiency was also noted in a previous survey, indicating a recurring issue. The Administrator admitted that it was challenging to review issues from three years ago and felt that the situations were different, making it difficult to track the entire process. This pattern of deficiencies demonstrates the facility's inability to sustain an effective Quality Assurance Program.
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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 Grantsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverpoint Crest Nursing And Rehabilitation Center | 12.2 mi | ★★★★★ | 9 | 0 |
| Pruitthealth-trent | 14 mi | ★★★★★ | 6 | 2 |
| Pruitthealth-neuse | 14.1 mi | ★★★★★ | 2 | 0 |
| Bayview Nursing & Rehabilitation Center | 15.9 mi | ★★★★★ | 2 | 0 |
| Cherry Point Bay Nursing And Rehabilitation Center | 18.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.