Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Grants Wellness & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident with aphasia, dysphagia, and dementia had MDS assessments that documented clear speech and no communication difficulty, even though the resident’s daughter and an LPN stated the resident had been non-verbal and unable to speak clearly. The MDS Coordinator acknowledged the MDS was inaccurate and should have reflected the resident’s non-verbal status.
Improper Foley Catheter Bag Positioning: A resident with an indwelling Foley catheter, obstructive uropathy, and dementia had the drainage bag attached above the level of the bladder on observation, with urine seen flowing back toward the resident instead of draining into the bag. The resident’s care plan and facility policy both required the catheter bag and tubing to be kept below the bladder, and an LPN and the DON confirmed that the bag should not be positioned above the bladder.
Surveyors found that multiple residents were kept in cold rooms on one unit where thermostats in individual rooms did not function and temperatures were controlled from the nurse’s station, with staff acknowledging frequent complaints about the cold and the lack of temperature logs. In addition, a resident with atopic dermatitis, type 2 DM with neuropathy, varicose veins with inflammation, and dementia was observed multiple times lying directly on a bare plastic mattress without sheets or blankets, despite CNA, RN, and DON expectations that beds be remade immediately after linens are removed and that residents not remain on uncovered mattresses.
A resident with diabetes, prior TIA and stroke, cognitive communication deficit, and depression had multiple MDS assessments in which Section C (Cognitive Patterns) was repeatedly left incomplete. Across several assessments, items determining whether BIMS should be conducted, the BIMS questions themselves, the staff assessment for mental status, and short- and long-term memory fields were left unanswered or dashed, resulting in no BIMS score while some cognitive items were still coded (e.g., memory and decision-making). The MDS Coordinator confirmed responsibility for these assessments and acknowledged that Section C was expected to be fully completed but was not.
A resident with Type 2 DM, neuropathy, paraplegia, and reduced mobility had a physician order for daily diabetic foot checks, including skin assessment, shoe inspection, and pedal pulse checks, but this care was not documented as completed over an extended period. The resident’s care plan did not include diabetic foot care despite the order. A later podiatry consult identified thickened, painful toenails, nail dystrophy, localized edema, and slightly diminished foot and ankle ROM, and the podiatrist performed nail debridement and recommended ongoing daily foot checks. The DON acknowledged that it was expected for physician orders to be followed and confirmed the ordered foot care was not provided as required.
The facility's Legionnaires Water Management Program lacked essential procedures, control limits, monitoring protocols, and intervention strategies to prevent the introduction and spread of Legionella in the water system. Leadership, including the Administrator, DON, and Infection Control Preventionist, were unaware of these deficiencies, potentially affecting all residents.
A resident with severe cognitive impairment and neurological disease was observed in the dining room with an actively bleeding hand wound, blood on his hands, face, and clothing, and was left to feed himself with bloody hands. Staff served his meal and walked away without addressing the bleeding, and the DON confirmed this was unacceptable and that the wound should have been cleaned and covered.
Two residents were administered psychotropic and related medications, including antidepressants, anticonvulsants, antianxiety, and antipsychotics, without documented informed consent forms in their medical records. The DON confirmed that such consent should have been obtained and documented to ensure residents or their guardians were aware of the reasons, risks, and benefits of each medication.
Two residents were admitted with complex medical conditions, but the facility did not complete baseline care plans within 48 hours for one, and for the other, the care plan failed to address several key diagnoses such as dementia with psychotic disturbance, infection, and blindness. The DON confirmed these omissions and delays did not meet expectations for timely and comprehensive care planning.
A resident with blindness and depression did not have a care plan addressing activities, despite documented needs and expressed interest in participating in activities like bingo if assisted. The DON confirmed the Activities Department was responsible for this care plan, but it had not been developed. The resident was observed attempting to engage in activities without support.
The facility did not ensure the safe operation of essential kitchen equipment by failing to replace a broken plastic light cover over the stove. The dietary manager noted the cover had been broken since September 2023 and had not submitted a formal repair request, relying instead on verbal requests. The cover was held together with old, dirty tape, with a piece missing.
A facility failed to accommodate a resident's needs by not ensuring the call light was within reach and lacking signage in Navajo-Dine. The resident, with a history of falls, had the call light under the bed during multiple observations. A CMA confirmed the need for the call light to be accessible. Additionally, required signage in Navajo-Dine was missing, as confirmed by Social Services.
The facility failed to provide a home-like environment for 33 residents due to mice droppings found in various areas, including dining rooms and resident rooms. Staff reported the issue to management, but the problem persisted, indicating inadequate cleaning and pest control measures.
The facility failed to respect resident privacy and dignity by not knocking on bedroom doors before entering. A nurse entered a resident's room without knocking while the resident was asleep and later returned with a CMA, again without knocking. The nurse also entered another resident's room without knocking to perform personal care. The facility's policy requires staff to knock and announce their presence, but staff were in a hurry looking for supplies.
A facility failed to maintain infection control practices for a resident with a Foley catheter. Observations revealed that the resident's catheter bag was resting on the floor due to its attachment to the bed's bottom rail. A registered nurse confirmed that the catheter bag should not be on the floor.
Inaccurate MDS Assessment for a Non-Verbal Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for one resident reviewed for MDS accuracy. The resident was admitted with diagnoses of aphasia, dysphagia, and dementia, but the Quarterly MDS and two Comprehensive MDS assessments documented that the resident had clear speech and did not have difficulty communicating. During interview, the resident’s daughter stated the resident had been non-verbal and unable to speak since 2024. An LPN also stated the resident was non-verbal and could not speak clearly. The MDS Coordinator stated she was responsible for completing the resident’s MDS assessments and acknowledged that the assessments were inaccurate and should have reflected the resident’s non-verbal status.
Improper Foley Catheter Bag Positioning
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an indwelling Foley catheter. The resident was admitted with obstructive uropathy and dementia, had a physician order for an indwelling urinary catheter dated 01/13/2026, and the care plan dated 02/02/2026 directed staff to keep the catheter collection bag and tubing below the level of the bladder. The facility’s catheter care policy also stated that the drainage system and bag should be positioned using gravity to facilitate drainage and that the collection bag should be kept below the level of the bladder. During observations on 04/29/2026 at 11:01 AM and 04/30/2026 at 12:27 PM, the resident’s catheter collection bag was attached to the footboard of the bed in a position higher than the bladder, and urine flow was observed returning toward the resident instead of draining into the collection bag. An LPN stated the bag should never be positioned above the bladder and that doing so could prevent proper drainage and place the resident at risk for infection. The DON stated it was her expectation that all residents with urinary catheter collection bags have the bag positioned below the bladder to ensure proper urine flow.
Failure to Maintain Comfortable Temperatures and Provide Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not maintaining appropriate room temperatures for several residents and not providing bed linens for one resident. Surveyors observed that one resident was sleeping in a room that was noticeably colder than the common area, with the room thermostat set to 59°F and a wall furnace present but not functioning when the thermostat was adjusted. Another resident reported that his room was often cold despite the thermostat being set to 78°F. A third resident, sharing the cold room, was heard moaning in discomfort; a CNA stated this resident was moaning because she was cold and did not like being cold. Staff interviews revealed that CNAs and the Maintenance Supervisor believed the room thermostats did not work and that the 300-unit was often colder than other areas. The Maintenance Supervisor confirmed that room temperatures on the 300-unit were controlled by a thermostat at the nurse’s station, that he was aware of recent complaints, and that he did not keep logs of temperature readings. The RN and DON both acknowledged ongoing complaints about cold temperatures on the 300-unit, with the RN noting the nursing station vent constantly blew cold air and that residents had recently complained about cold rooms. The deficiency also includes the facility’s failure to provide bed linens for a resident with multiple chronic conditions, including atopic dermatitis, type 2 diabetes mellitus with diabetic neuropathy, varicose veins with inflammation, and unspecified dementia. This resident was repeatedly observed lying directly on a bare mattress without linens at multiple times throughout the same day. CNA staff reported that all CNAs are responsible for making resident beds and that beds should be re-made immediately after linens are removed. The RN stated that resident beds should be made without unnecessary delay, that residents should not lie directly on the plastic mattress surface because prolonged contact could disrupt the skin, and that residents can be cold without a blanket. The DON stated it was her expectation that all residents’ beds be made immediately after linens are removed and acknowledged that residents cannot rest comfortably without linens and that delays in making beds could contribute to worsening skin issues.
Incomplete MDS Cognitive Assessments for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete completion of the Minimum Data Set (MDS) cognitive assessment (Section C) for one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, a personal history of TIA and cerebral infarction without residual deficits, a cognitive communication deficit, and depression. These conditions were documented on the resident’s face sheet and establish that the resident had relevant cognitive and neurological history at the time the MDS assessments were due. Multiple MDS assessments for this resident, each with different assessment dates, showed repeated omissions and unanswered items in Section C (Cognitive Patterns). On one MDS, the item asking whether the Brief Interview for Mental Status (BIMS) should be conducted (C0100) was left unanswered, and all BIMS items (C0200–C0500) were unanswered, resulting in no BIMS score, while the staff assessment for mental status (C0600) was also dashed. Despite these omissions, short-term memory (C0700) and cognitive skills for daily decision making (C1000) were coded as “memory ok” and “modified independence.” On subsequent MDS assessments, C0100 was sometimes coded “yes,” but the BIMS items (C0200–C0500) were dashed, C0600 remained dashed, and short-term and long-term memory items (C0700, C0800) were also dashed, again resulting in the absence of a BIMS score. Across several MDS assessments, this pattern of incomplete coding persisted: key cognitive assessment items were either left unanswered or dashed, including the decision to conduct BIMS, the BIMS questions themselves, the staff assessment for mental status, and memory items. During an interview, the MDS Coordinator stated she was responsible for completing these MDS assessments for the resident and acknowledged that it was her expectation that the assessments, including Section C, be fully completed and not dashed or left unanswered. The documented record review and the MDS Coordinator’s statements together show that the facility did not ensure an accurate and fully completed MDS cognitive assessment for this resident.
Failure to Provide Ordered Diabetic Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered diabetic foot care for one resident with multiple high-risk conditions. The resident was admitted with Type 2 diabetes mellitus with diabetic autonomic neuropathy, paraplegia, cognitive communication deficit, reduced mobility, and unsteadiness on feet. Review of the resident’s care plan dated 08/05/25 showed that diabetic foot care was not included. A physician order dated 09/11/25 directed daily diabetic foot care and checks, including observation of the feet, toes, ankles, and soles for alterations in skin integrity, color, temperature, and cleanliness, inspection of shoes for proper fit and excessive wear, and checking pedal pulses every night shift. Review of the Treatment Administration Record from 09/11/25 through 01/14/26 revealed that the ordered diabetic foot care was not completed by nursing staff for the entire period reviewed. A podiatry consultation on 01/14/26 documented diagnoses of Type 2 diabetes mellitus with hyperglycemia, onychogryphosis, nail dystrophy, pain in both toes, localized edema, and slightly diminished range of motion in the foot and ankle joints without pain. The podiatrist performed debridement and trimming of thickened, painful toenails and recommended daily foot checks, supportive shoes, and moisturizing lotions with precautions. During an interview on 01/22/26, the DON stated it was her expectation that physician orders, including diabetic foot care, be followed and confirmed that the ordered foot care for this resident was not followed as prescribed.
Inadequate Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement an adequate Legionnaires Water Management Program (LWMP) as part of its infection prevention and control program. Record review showed that the LWMP, last revised in June 2020, lacked essential procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system. The policy did not specify control limits or parameters, did not include monitoring procedures or documented environmental testing protocols for Legionella, and did not establish acceptable control limits for the measures being monitored. Additionally, there were no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case in the facility. During an interview with facility leadership, including the Administrator, DON, Corporate Nurse, Corporate Maintenance Director, and the Infection Control Preventionist, it was revealed that they were unaware of the inadequacies in the LWMP. They did not know that the plan lacked procedures for control measures, acceptable control limits and parameters, monitoring procedures, testing protocols, or established interventions for non-compliance or cases of legionellosis. These failures had the potential to affect all residents in the facility.
Failure to Provide Dignified Care for Resident with Active Bleeding Wound
Penalty
Summary
A resident with a history of cognitive communication deficit and degenerative disease of the nervous system, and who was assessed as having severe cognitive impairment, was observed sitting in the dining room during lunch with an actively bleeding wound on his right hand. The resident had blood on both hands, his face, and clothing, and was seen feeding himself with his bloody hands, including picking butter out of single-serve butter cups. Staff served the resident his meal tray and then walked away without addressing the bleeding wound or cleaning the resident. The Director of Nursing confirmed that the resident had an open, actively bleeding wound and blood on his hands and clothing, and acknowledged that it was not acceptable for the resident to be in the dining room in that condition. The DON stated that the wound should have been cleansed and covered, and that staff should have attended to the resident's wound before serving his meal. The failure to provide care with dignity and respect was directly observed and verified during the survey.
Failure to Obtain and Document Informed Consent for Psychotropic and Related Medications
Penalty
Summary
The facility failed to ensure that residents or their guardians were fully informed about the medications they were receiving, including the reasons for use, risks, and benefits. For two of three residents reviewed for unnecessary medications, there was no documentation in the electronic medical record of signed consent forms for prescribed medications such as antidepressants, anticonvulsants, antianxiety, and antipsychotic drugs. Specifically, one resident was prescribed Escitalopram, Depakote, Quetiapine, and Hydroxyzine for conditions including depression, anxiety related to traumatic brain injury, and agitation, but no consent forms were found in the record for any of these medications. Similarly, another resident was prescribed Citalopram and Hydroxyzine for depression and anxiety related to dementia, but again, no signed consent forms were present in the medical record. During interviews, the DON confirmed that there should have been signed consent forms for these medications. The lack of documented consent indicates that residents or their responsible parties were not adequately informed about the medications being administered.
Failure to Develop and Implement Timely and Comprehensive Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two out of three residents reviewed. For one resident with multiple complex diagnoses, including urinary tract infection, diabetes, depression, blindness, and traumatic brain injury, the baseline care plan was not completed until four days after admission, exceeding the required 48-hour timeframe. This delay was confirmed by record review and interview with the Director of Nursing, who acknowledged the care plan should have been completed within the specified period. For another resident with a history of cerebrovascular disease, Klebsiella pneumoniae infection, anemia, diabetes, hyperlipidemia, dementia with psychotic disturbance, blindness, hypertension, chronic kidney disease, and urinary tract infection, the baseline care plan developed did not address several critical conditions, including dementia with psychotic disturbance, Klebsiella pneumoniae, blindness, and sequelae of cerebrovascular disease. The Director of Nursing confirmed that these conditions should have been included in the baseline care plan and that it is her expectation for care plans to be both timely and comprehensive.
Incomplete Care Plan for Resident with Blindness and Depression
Penalty
Summary
The facility failed to ensure a comprehensive care plan was complete for one resident with diagnoses of blindness and depression. Record review showed that, despite the resident's admission and documented needs, there was no care plan addressing activities for this individual. Interviews revealed that the resident listens to music and TV for entertainment, would participate in bingo if assisted, and walks in the hallway to stay occupied. The DON confirmed that the Activities Department is responsible for creating such care plans and was unsure why one had not been developed. Observations showed the resident attempting to engage in activities, such as entering a bingo game but leaving after not receiving assistance.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition by not replacing a broken plastic light cover located directly over the cooking area of the stove. During an initial tour of the kitchen, it was observed that the light in the stove hood had a broken plastic cover, with tape holding part of it together, and a piece of the cover was completely missing. The tape was hanging loosely and appeared old and dirty. In an interview, the dietary manager revealed that the light cover had been broken since he started working at the facility in September 2023. He admitted that he had not submitted a formal work order to repair or replace the light cover, although he had verbally requested the repair. The dietary manager was uncertain about if or when the light cover would be repaired, confirming the presence of loose and dirty tape holding the cover together.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs, specifically regarding the accessibility of the call light and the availability of signage in the resident's preferred language, Navajo-Dine. Observations revealed that the resident's call light was consistently out of reach, being found under the bed on multiple occasions. This was confirmed by a Certified Medical Assistant who acknowledged the resident's need for assistance and the importance of having the call light within reach due to the resident's history of falls. Additionally, the care plan indicated that signage should be available in both English and Navajo-Dine, but observations showed a lack of such signage in the designated area, which was confirmed by Social Services.
Facility Fails to Maintain a Home-like Environment Due to Mice Infestation
Penalty
Summary
The facility failed to maintain a comfortable and home-like environment for all 33 residents, as evidenced by the presence of mice droppings in multiple areas of the facility. Observations conducted on various dates revealed mice droppings in the main conference room, main dining area, secondary dining area, and several resident rooms in the 400 hall. These findings indicate a lack of adequate cleaning and pest control measures, which are essential for ensuring a safe and comfortable living environment for the residents. Interviews with staff members, including a Certified Medical Assistant and a housekeeper, confirmed the presence of mice and their droppings throughout the facility. The staff reported that they had informed management about the issue, and the housekeeper mentioned that she attempts to clean the droppings daily. Despite these efforts, the problem persisted, suggesting that the facility's current cleaning and maintenance practices were insufficient to address the infestation effectively.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and privacy by not knocking on their bedroom doors before entering. This deficiency was observed in the interactions involving two residents. During an observation, a Registered Nurse (RN) entered a resident's room without knocking while the resident was asleep. The RN also entered multiple empty rooms without knocking and later returned to the same resident's room with a Certified Medical Assistant (CMA), again without knocking. In another instance, the RN entered a different resident's room without knocking to perform personal care. An interview with the CMA revealed that the facility's policy requires staff to knock and announce their presence before entering a resident's room, but the staff were in a hurry looking for supplies for another resident.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who was reviewed for catheter care. During observations on two consecutive days, it was noted that the resident's urine catheter bag was improperly positioned, resting on the floor due to its attachment to the bottom rail of the bed, which was in the lowest position. This improper positioning of the catheter bag was confirmed by a registered nurse, who acknowledged that the catheter bag should not be resting on the floor.
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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 Grants
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laguna Rainbow Nursing Center | 22 mi | ★★★★★ | 8 | 0 |
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