Below average — CMS composite of the measures below.
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 Granville Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to maintain food service safety standards, with soiled dishwashing areas and improperly dried containers in the main kitchen, and soiled refrigerator gaskets and floors in the nourishment rooms. The Food Service Director acknowledged the oversight in cleaning schedules and noted issues with the dishwasher's sanitizing temperature.
The facility failed to provide sufficient nursing staff, resulting in delayed care and unmet staffing needs on multiple occasions. Residents reported long wait times for assistance, particularly on weekends. The Director of Nursing acknowledged the staffing challenges, citing a small pool of additional staff due to the facility's remote location.
A resident with severe cognitive impairment and moderately impaired vision did not receive necessary follow-up optometry care or replacement glasses after their glasses were broken. Despite a scheduled follow-up, there was no evidence of further consultations, and the DON was unaware of the issue.
The facility failed to comply with NFPA 101, 2012 Edition, regarding exit discharges. The B-Wing west exit discharge was grass, not an all-weather surface, and several exits were not marked to indicate egress direction. The facility did not provide evidence of corrective actions or an approved waiver for delays due to winter weather.
The facility failed to maintain its emergency generator fuel reserve as required by NFPA 110 standards. The fuel reserve was not tested in 2023, and a 2024 analysis showed excessive particle count and water contamination. There was no evidence of treatment or retesting, and the facility did not implement its Electronic Plan of Correction by the specified date.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. From early to mid-December, the facility consistently fell below required staffing levels, leading to significant delays in assistance for residents. Interviews with staff and residents highlighted the impact of understaffing, with reports of long wait times for care and missed therapy sessions. The facility's administrator acknowledged the staffing challenges, citing recent staff departures and the remote location as contributing factors.
The facility's Emergency Preparedness Plan was not updated annually as required, containing outdated information such as instructions for elevator use during a fire, despite the facility having no elevators. Additionally, a training posttest from 2018 was not replaced with a current version. The administrator acknowledged these issues during the survey.
The facility's emergency preparedness plan was found deficient as it lacked documentation on identifying the resident population and their unique needs, strategies to address these needs, services available during an emergency, and continuity of care plans. This deficiency could impact all residents.
The facility did not provide emergency lighting in accordance with NFPA 101 Life Safety Code on two of three units and the core area. Observations revealed that light switches did not provide emergency lighting when off in specific areas, and emergency lighting was absent along certain egress paths. A broken light fixture cover was also noted, exposing a bulb. These issues were confirmed through staff interviews.
The facility failed to provide adequate care and documentation for residents, including not administering tuberculosis tests, failing to notify providers of critical blood sugar levels, and exceeding prescribed medication limits. Additionally, vital signs were not properly monitored or documented, affecting residents with various medical conditions.
Several residents in the facility reported that their meals were often cold, unattractive, and not palatable, with discrepancies between meal tickets and the food served. One resident experienced significant weight loss due to the unappealing food, while another noted a lack of snacks at night. Temperature testing confirmed that meals were not served at appropriate temperatures, indicating a failure to adhere to the facility's policy on providing nourishing and well-balanced meals.
The facility failed to maintain fire-rated doors in accordance with NFPA standards, as observed with a kitchen door and a soiled utility room door that did not self-close and latch. A note on the kitchen door indicated awareness of the issue, and interviews confirmed plans to address the deficiency, but these were not implemented at the time of the survey.
A survey found that exit passageways in a facility were improperly used for storage, violating NFPA 101 Life Safety Code. The kitchen storeroom exit was cluttered with bins for shredding, containers for soiled items, and milk crates, while the employee entrance exit was used to store equipment. An administrator acknowledged the issue.
The facility failed to maintain the automatic sprinkler system in accordance with NFPA standards. Observations showed boxes stored too close to sprinkler deflectors in the kitchen and dust-coated sprinkler heads in the laundry area, indicating non-compliance with fire safety regulations.
A resident with impaired vision did not receive timely optometry services as required by facility policy. Despite the resident's need for regular eye care, no follow-up consultations were documented after an initial visit in March 2023. Interviews revealed a gap in communication and scheduling, resulting in a deficiency in maintaining the resident's vision care.
A resident with a history of lumbar fracture and cancer experienced unmanaged pain due to the facility's failure to adhere to pain management protocols. Despite a care plan, the resident received excessive acetaminophen and inappropriate oxycodone dosages, leading to severe pain and a family member calling 911 for hospital transport. The facility did not reassess pain within the required timeframe, and documentation was incomplete.
A resident with broken front teeth did not receive timely emergency dental services, despite experiencing slight pain. The facility's policy required both routine and emergency dental services, but the resident had not been scheduled for a dental appointment. Interviews revealed that the resident's dental needs were not promptly addressed, with the Finance Director planning to add the resident to the list for the next dental visit.
A resident experienced significant weight loss due to the facility's failure to conduct weekly weight checks as ordered by the dietician. Despite a care plan addressing nutritional issues, the resident's weight dropped significantly, exacerbated by dissatisfaction with the facility's food. Communication lapses and lack of adherence to the weight management policy contributed to the deficiency.
Deficiencies in Food Service Safety Standards
Penalty
Summary
The facility failed to maintain food service safety standards in the main kitchen and two resident unit nourishment rooms. In the main kitchen, the dishwashing machine's temperature display panel and the floors beneath it were found to be soiled with food particles or dirt. Additionally, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried, resulting in moisture accumulation. In the A-Unit nourishment room, the refrigerator door gaskets were soiled with food particles, while in the B-Unit nourishment room, both the refrigerator and the floor were soiled with food particles or dirt. During interviews, the Food Service Director acknowledged that maintaining cleanliness is a joint effort between the nursing staff and kitchen staff. They admitted that the cleaning schedule and checklist for the unit's nourishment areas did not include the gasket area, which contributed to the oversight. Furthermore, the director noted that the dishwasher was not reaching the proper temperature for sanitizing, necessitating repairs. Although the maintenance director had repaired the dishwasher, the area was not cleaned afterward, leading to the observed deficiencies.
Deficiency in Staffing Levels Leads to Delayed Resident Care
Penalty
Summary
The facility was found to be deficient in providing sufficient nursing staff to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the recertification survey, it was observed that the facility did not meet its assessed minimum staffing needs on multiple occasions between February 15, 2025, and April 13, 2025. Specifically, the facility's staffing schedule showed that on ten occasions, the number of Certified Nurse Aide (CNA) hours provided was significantly below the required hours based on the facility's census. For example, on March 11, 2025, with a census of 88 residents, the facility required 215.6 hours of direct CNA care but only provided 136 hours. Residents reported during interviews that the facility was short-staffed at times, leading to long wait times for care and call bells not being answered promptly. A group resident meeting revealed that staffing was particularly low on weekends, with only one or two aides per unit. The Director of Nursing acknowledged awareness of the federal regulation regarding required CNA hours per census and stated that staffing adjustments were attempted when there were call-ins. However, the facility faced challenges in filling staffing gaps due to a small pool of additional staff, attributed to their remote location.
Failure to Provide Vision Care and Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and assistive devices to maintain vision. The resident, who was admitted with diagnoses including severe cognitive impairment, had moderately impaired vision and used corrective lenses. A consult form indicated that the resident was seen by an optometrist with a follow-up scheduled for later in the year. However, a handwritten note revealed that the resident's glasses were broken, and there was no documented evidence of further optometry consultations. An email from the optometry service confirmed that the resident had not been seen since the initial visit. During an interview, the Director of Nursing was unaware of the issue and acknowledged that the resident should have had a follow-up appointment and received new glasses.
Non-Compliance with NFPA 101 Exit Discharge Requirements
Penalty
Summary
The facility was found to be non-compliant with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19.2.7 and 7.7, during a recertification survey. Specifically, the exit discharges from three resident units were not maintained as required. The B-Wing west exit discharge was observed to be grass instead of an all-weather surface, which is necessary for safe egress. Additionally, the exit discharges from the A-Wing west exit, B-Wing west exit, C-Wing north exit, and C-Wing south exit were not marked to clearly indicate the direction of egress travel to a public way. During a Life Safety Code Post-Survey Review, it was noted that the facility did not provide evidence of installing an all-weather surface on the B-Wing west exit discharge or implementing the Electronic Plan of Correction. The facility had requested a waiver due to winter weather conditions preventing the completion of the required work. However, the facility did not provide an approved time-limited waiver from the Centers for Medicare & Medicaid Services, and the Electronic Plan of Correction was not fully implemented by the documented Credible Allegation Date.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility has requested a time limited waiver for the installation of a permanent all-weather surface as winter weather conditions will prevent completion at this time. The all-weather surface will be installed on the exit discharge from the B-Wing west exit. The facility began the process of vendor quotes on (MONTH) 13, 2025 and have one thus far. Several other vendors have been contacted to review the scope of work. The facility will continue to obtain quotes through the month of (MONTH) as more providers become available with a vendor decision by (MONTH) 1, 2025. Work will be scheduled for a (MONTH) 9, 2025 start and should be completed within one week from start to finish. Completion date set for no later than (MONTH) 18, 2025. During this period the Administrator will check-in with the Sanitarian the first of each month to update progress on the project. During construction, periodic inspections of all exit discharges to ensure that they are clear at all times as well as staff education on same will be completed by the Maintenance Director and/or Administrator. Until the permanent all-weather surface can be installed, a temporary walkway will be put in place from the B-Wing west exit to the public way. All staff to be in-serviced on fire safety. A copy of the resident safety plan, facility life safety floor plan will be submitted to [email protected] by (MONTH) 29, 2025. Appropriate evacuation route/discharge signage was ordered and scheduled to be fully installed to mark the direction of egress travel from the four noted areas of exit discharge by (MONTH) 29, 2025. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed an audit of all exit discharges to ensure all exit discharges were clearly marked to a public way and all-weather discharge passageway surfaces were intact. No additional areas of concern were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Education will be provided to all maintenance staff on maintaining exit discharges with all-weather surfaces and marking exit discharges to make clear the direction of egress travel to the public way. Appropriate direction of egress signage will be installed for the four noted exits to clearly indicate the direction of egress pathways to the public way by (MONTH) 29, 2025. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The maintenance director or maintenance assistant will audit exit passageways for appropriate signage and all-weather surface integrity weekly for two months and monthly thereafter for four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly and additional recommendations for interventions and duration of audits will be given as needed. This task has also been added to the weekly environmental rounding schedule. Responsible Party: Director of Maintenance
Failure to Maintain Emergency Generator Fuel Reserve
Penalty
Summary
The facility failed to maintain its emergency generator fuel reserve according to the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3. Specifically, there was no documented evidence that the emergency generator fuel reserve was tested in 2023. A Fuel Analysis Report dated June 24, 2024, indicated that the fuel reserve failed analysis due to excessive particle count and water contamination. The report suggested using portable filtration or a more aggressive approach to filtration and investigating the source of water contamination. However, there was no documented evidence that these suggestions were followed or that the fuel reserve was treated to reduce contamination levels. During a Life Safety Code Post-Survey Review survey, it was found that the facility did not provide evidence of retesting the emergency generator fuel reserve until it passed the fuel quality test. The facility's Electronic Plan of Correction stated that corrective actions would be taken if the fuel reserve failed retesting, but the facility did not ensure the plan was fully implemented by the Credible Allegation Date. An interview with the administrator revealed that the results of the retesting were not yet available, indicating a lack of timely follow-up on the deficiency.
Plan Of Correction
Plan of Correction: Approved February 14, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) Per the vendor suggestions, the facility will use portable filtration or a more aggressive approach to filtration to address the high particle count in the fuel reserve and will investigate and resolve the source of the water contamination in the fuel reserve. Should the fuel reserve fail retesting, corrective actions will be taken with additional retesting until the fuel reserve passes the fuel quality test as required by the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition 8.3. The facility maintenance director scheduled the vendor to test the generator fuel reserve and treat for contamination as needed. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The facility audit for other emergency generator fuel reserves found that there was another emergency generator fuel reserve tank on the grounds. This tank will be drained as the generator is not connected to the building in any way and is not needed. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Facility Maintenance Director was educated by the administrator on having the generator fuel reserve tested annually and to complete recommendations given by the vendor. The generator fuel reserve testing has been added to the preventative maintenance schedule to be completed annually. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the annual fuel reserve testing will be reviewed by the Quality Assurance Performance Improvement Committee annually and additional recommendations for interventions will be given as needed. Responsible Party: Director of Maintenance
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of understaffing from December 1, 2024, to December 18, 2024. The staffing schedule analysis revealed that the facility consistently fell below the required minimum staffing levels, with Certified Nurse Aides (CNAs) providing fewer hours of direct care than necessary for the resident census. This deficiency was corroborated by interviews with nursing staff and residents, who reported inadequate staffing levels leading to delays in care. Residents reported significant delays in receiving assistance, with some waiting over an hour for help. One resident mentioned waiting two hours to be taken to the bathroom, which sometimes resulted in missing therapy sessions. Observations on December 17, 2024, showed multiple call lights activated with no staff present, further indicating insufficient staffing. Interviews with CNAs and a Licensed Practical Nurse (LPN) highlighted the stress and overwork due to the lack of staff, with CNAs frequently working double shifts to cover the shortfall. The facility's administrator acknowledged the staffing issues, attributing them to the remote location and recent staff departures. Despite efforts to employ agency and contract workers, the facility struggled to maintain adequate staffing levels. The administrator expressed optimism about improving staffing levels, but the deficiency persisted during the survey period, impacting the residents' care and well-being.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action: The facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby. 2. All residents and staff have the ability to be affected by this deficient practice. Plan to prevent reoccurrence: The facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby. 3. The facility systemic changes: Increased their certified nursing assistant pay rates on 12/22/24 in an effort to attract more staff. The facility has recruited additional certified nursing assistants from out-of-state who will begin between (MONTH) and February. Should the certified nursing assistant staffing levels fall below the minimum established levels, the Administrator or Director of Nursing will implement the emergency staffing plan. The Administrator, Director of Nursing, and Scheduler will meet 3 times per week to review upcoming certified nursing assistant schedules. The Administrator will organize a recruitment and retention committee to come up with new ideas to recruit and retain certified nursing assistants. 4. The facility emergency staffing plan and ideas from the recruitment and retention committee will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations. Responsible Parties: Administrator
Outdated Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain an updated Emergency Preparedness Plan as required by regulations. During the recertification survey, it was found that the plan was not reviewed and updated at least annually, and updated copies were not maintained in the designated locations. Specifically, the emergency plan included outdated information, such as instructions for a fire emergency that mentioned not using elevators, despite the facility being a single-floor building without elevators. Additionally, the plan contained a training posttest dated July 2018, which was outdated and not replaced with a current version. During an interview, the administrator acknowledged the outdated posttest and fire plan, indicating they would be purged and replaced with current documents.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The reference to elevator use was removed from the Emergency Plan tab 21 on 12/17/2024. The updated posttest was added to the Emergency Plan tab 22 on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The administrator has been educated by the regional administrator on completing a comprehensive annual review of the emergency plan. The emergency plan will be reviewed annually and as needed if changes occur. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The Emergency Plan will be updated where necessary during the annual review. Emergency plan changes/updates will be reviewed for recommendations by the Quality Assurance Performance Improvement Committee annually and as needed when changes occur. Responsible Party: Administrator
Emergency Preparedness Plan Lacks Key Elements
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified due to the absence of documented evidence in the emergency preparedness plan regarding the identification of the resident population served and their unique needs. Additionally, the plan lacked strategies to address these needs, a description of the types of services the facility could provide during an emergency, and how the facility would maintain continuity of care to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility.
Plan Of Correction
Plan of Correction: Approved January 23, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The Emergency Preparedness Plan was updated to reflect the types of services the facility could provide to their unique population of residents in the event of an emergency on 12/17/2024 and how the facility will maintain continuity of care to adequately protect the health and safety of our residents in the event of any limitations or cessation of normal operations during an emergency. The number of days of emergency supply of food, water, medical supplies, pharmaceutical supplies, generator fuel, disposable paper supplies, linen needs, etc. will be detailed in the updated plan. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are deemed not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The facility will complete a comprehensive review of the emergency plan annually and update where necessary to ensure it includes identification of the resident population and their needs, strategies used to address the needs of their residents, and a description of the types of services the facility can provide during an emergency. The administrator was educated by the regional administrator on completing a comprehensive annual review of the emergency plan. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The annual review of the emergency plan and all other emergency plan updates will be reviewed by the Quality Assurance Performance Improvement Committee annually and as needed when updates occur. Responsible Party: Administrator
Failure to Provide Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8, on two of three units and the core area. Specifically, during observations, it was noted that the light switches controlling normal and emergency lighting for the means of egress and exit access did not provide lighting when the switch was in the off position in the A-Wing TV Lounge, the core area main dining room, and the C-Wing Physical Therapy room. Additionally, emergency lighting was absent along the path of egress to the public way from the C-Wing RN station exit and along the south driveway. Furthermore, the light fixture cover at the C-Wing north exit discharge was broken, exposing the light bulb. These deficiencies were confirmed through interviews with the Maintenance and Life Safety Consultant and the Administrator.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility will install emergency lighting along the egress path from C-wing nursing station exit and along the south driveway leading to the public way. The light fixture cover at the C-Wing north exit discharge was replaced on 12/18/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed external rounds of the facility to ensure emergency lighting was present along all means of egress to the public way. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Monthly monitoring of lighting and fixtures at exit discharges and paths leading to the public way has been added to the preventative maintenance schedule. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The monthly preventative maintenance monitoring of lighting will be presented to the Quality Assurance Performance Improvement Committee monthly for four months for review and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for all ten residents reviewed for quality of care. Specifically, the facility did not administer and read the purified protein derivative test for tuberculosis for two residents, and failed to notify a provider when a resident's blood sugar was critically low. Additionally, the facility did not monitor the vital signs of a newly admitted resident as required. One resident was administered an excessive amount of Acetaminophen, exceeding the prescribed limit, and was left in distress without adequate pain management, leading to a call to 911 for hospital transport. The facility also documented vital signs for this resident after they had already been discharged. Furthermore, the facility failed to obtain and document monthly vital signs according to provider orders for several residents, with instances of duplicate vital signs being recorded, indicating a lack of proper monitoring and documentation. The deficiencies highlight a pattern of inadequate care and documentation practices across multiple units within the facility, affecting residents with various medical conditions, including diabetes, hypertension, and mental health disorders. These failures demonstrate a significant lapse in adhering to established care protocols and ensuring the well-being of the residents.
Plan Of Correction
Plan of Correction: Approved February 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action: Resident #365 no longer resides in facility. Resident #368 has reached compliance upon return from hospital with two-step Purified protein derivative plant and read per facility policy and completed on 1/9/2025. Provider notified on 1/9/2025 of incident with no new orders recommended. The Medical provider was notified on 1/9/2025 of residents #638, 29, 89, 73 that facility failed to monitor vital signs per provider order with no new order recommended. Licensed staff responsible for failure to notify medical provider of resident blood sugar outside parameters was counseled and reeducation completed on 1/10/2025 by the Assistant Director of Nursing. 2. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence: Nurse management conducted a 90-day look back from 10/9/24 through 1/9/25 for residents with active orders for blood sugar monitoring. As a result of the audit, no issues noted. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence, the previous 30 days of admissions were reviewed for compliance with purified protein derivative placement and results documented per policy. Audit completed on 1/10/2025. A total of 30 residents were reviewed. Out of the 30, 8 residents were discharged, 2 were compliant, and 20 were identified to be out of compliance. A [MEDICATION NAME] screen was completed for those residents per policy. The results of the [MEDICATION NAME] screen were reported to the medical provider for further review. No further directives given. Nursing management conducted a full house review on 1/17/2025 on residents with active orders containing Tylenol to determine the potential for the resident to exceed the recommended limit. Results of the review concluded one resident was identified at risk to potentially exceed the daily recommended limit. Those residents identified were submitted to the medical provider for review with one resident with new orders. A full house review was conducted on 1/16/2025 on residents’ vital signs per the provider order. The results of those residents with orders for monthly vital signs concluded all residents to be out of compliance. Results submitted to the medical provider with new order for one resident. Results of resident review for new admission vital sign orders concluded 23 residents reviewed. Review of audit concluded 14/23 residents were identified to be out of compliance. Any residents identified as having vital sign omissions received updated vitals and results reviewed with the medical provider. 3. The systemic changes: The facility reviewed the policies titled Vital Signs, Diabetes Mellitus Guidelines, and [MEDICAL CONDITION]. They were reviewed by medical with no revisions necessary. The facility educator re-educated licensed staff on vital signs, diabetes mellitus guidelines, and [MEDICAL CONDITION] policies with emphasis on notifying the provider with results of blood sugar outside parameters, administration and timely result documentation per MD order of Purified protein derivative, daily recommended Tylenol consumption not to exceed recommended limit, and obtaining and monitoring of resident-specific vital sign order for frequency. This education was accompanied by a post-test to ensure retention. All results of blood sugar, results of the [MEDICATION NAME] skin test, and results of vital signs will be documented in the medication administration record. The facility supervisor will complete a 24-hour look back of all new Tylenol orders to ensure there is no potential to exceed the recommended daily limit. The facility supervisor will complete a 24-hour look back on residents' blood sugars to ensure residents identified with blood sugars outside parameters were reviewed and submitted to the medical provider. The facility supervisor will complete a 48-hour look back on residents who received a [MEDICATION NAME] skin test to follow up and document [MEDICATION NAME] skin test read. The facility supervisor will complete a 24-hour look back of those residents with active vital sign orders to determine vital signs obtained per provider order. Any result out of compliance, the supervisor will notify the medical provider for further directives and will document the outcome in the medical record. 4. Quality assurance: The Unit managers will audit all new admissions' Purified protein derivative status to ensure compliance is met. This will be audited weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Assistant Director of Nursing will submit weekly immunization documentation tracker form weekly. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit residents' blood sugars. This audit will look for any documented value outside parameters to ensure the medical provider was notified. This will be conducted weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit compliance with vital signs completion weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. Unit managers will audit all active Tylenol orders to ensure residents do not exceed the daily limit. This audit will be done weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Director of Nursing will oversee all audits. Responsible Party: Director of Nursing.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents. Specifically, four residents complained about the quality of the food, noting that it was often cold, unattractive, and not palatable. Additionally, discrepancies were found between the meal tickets and the actual food served to the residents, with some items missing from the trays. This issue was observed during a recertification and abbreviated survey, where residents expressed dissatisfaction with the temperature and presentation of their meals. Resident #107, who had intact cognitive ability, reported that their meals were consistently cold and unappealing. During an observation, it was noted that the resident's lunch tray did not match the meal ticket, missing several items. Temperature testing of the meal revealed that the food was not served at the appropriate temperature, with pasta noodles and beef stroganoff being below the expected temperature. Despite these issues, the resident stated that the replacement meal was satisfactory. Resident #97, who had a history of dementia and protein-calorie malnutrition, also reported that the food was cold and visually unappealing. This resident experienced significant weight loss, which was attributed to their lack of appetite due to the unappealing food. Resident #75 expressed similar concerns, noting that the food was cold and lacked flavor, and they were not provided with snacks at night. Resident #8 reported receiving food they did not like and that meals were often served cold. These deficiencies highlight the facility's failure to adhere to its policy of providing nourishing, palatable, and well-balanced meals that meet residents' preferences and dietary needs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 1. The Registered Dietician and Food Service Director met with residents #97, 75, 8, and 107 to review meal preferences and dislikes. Revisions were updated in the menu software program. Resident #75 was provided a new lunch tray and a night snack has been scheduled per resident preference. The facility hired a new Food Service Director on 1/2/2025. 2. All residents have the potential to be affected by the deficient practice. The facility did an audit of 10 consecutive meals on the units to ensure residents' food was warm, palatable, and presentable. This audit also included checking that meal tickets were accurate and the preferences were served. 3. The Policy titled "Food Service" has been reviewed with no revisions necessary. The Registered Dietician or the staff educator will provide re-education to dietary staff on the policy titled "Food Service." The emphasis is on meal production to include tray accuracy as well as residents’ personal food preferences and meal temperatures. The Food Service Director or Supervisor will facilitate a meal production meeting daily with dietary staff and report to the registered dietician should any deviations to the menu be needed. Facility nursing staff will be re-educated on the Food Service policy with emphasis on tray accuracy, residents’ personal food preferences, and food temperatures. 4. The Registered Dietitian or Food Service Director will conduct reviews on 15 trays for accuracy, temperatures, and resident preferences weekly x 4 weeks and monthly x 3 months. The Food Service Director or Registered Dietitian will conduct a review on 15 trays per week on tray accuracy, appearance, and palatability weekly x 4 weeks, then monthly x 3 months. The Food Service Director or Registered Dietitian will review food temperature logs daily for 30 days, then weekly thereafter to ensure safe food temperatures are maintained. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. 5. Responsible party: Food Service Director
Failure to Maintain Fire-Rated Doors
Penalty
Summary
The deficiency involves the failure to maintain the means of egress in accordance with adopted regulations, specifically concerning fire-rated doors. During observations on multiple occasions, it was noted that a 1½-hour rated kitchen door and an A-Wing 1½-hour rated soiled utility room door did not self-close and latch as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition Chapter 5. A note was posted on the kitchen door instructing individuals to ensure the door was closed tightly, indicating a known issue. The facility's Fire/Smoke Door Inspection document, dated 12/29/2023, confirmed that fire-rated doors should self-close and latch, yet this was not occurring. Interviews conducted with a Maintenance and Life Safety Consultant and the Administrator revealed acknowledgment of the issue, with plans to adjust the doors to self-close and seat properly to the frame and to include them in a preventative maintenance program. However, these actions were not in place at the time of the survey, leading to the citation.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The kitchen door was adjusted for proper closure and latching on 12/13/2024. The signage was removed which was temporarily placed there until maintenance could make the adjustments. The A-Wing soiled utility door was adjusted on 12/17/2024 for proper closure and latching. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. An audit of all self-closing fire-rated doors will be conducted to ensure they all self-close and latch appropriately. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) All facility wide self-closing doors have been placed on the preventive maintenance program for monitoring and adjustments as/if needed. Education to be provided to maintenance staff on the location of and the requirements to ensure fire-rated doors self-close and latch. In addition, education will be provided to dietary, nursing and housekeeping staff on which doors are to be self-closing and to report to the maintenance staff (via work orders) when these doors do not self-close. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) As part of the facility wide preventive maintenance program, all self-closing fire-rated doors will be checked with findings documented on the paper checklist. The entire facility preventive maintenance (which includes the aforementioned doors) program which details, daily, weekly, monthly, quarterly, semi-annual and annual activities will be submitted to the QAPI Committee beginning in January, 2025 to ensure all preventive maintenance activities have been completed and any needed corrective action has been completed. Responsible Party: Director of Maintenance
Improper Storage in Exit Passageways
Penalty
Summary
During a recertification survey, it was observed that the exit passageways in a facility were not maintained according to the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.3.2.3. Specifically, the exit passageway from the kitchen storeroom was used as storage space for plastic bins designated for confidential shredding, two 33-gallon containers for soiled mop heads and cloth rags, and empty milk crates. Additionally, the employee entrance exit passageway was used to store equipment. These observations were made on December 17, 2024, at 2:10 PM. During an interview conducted at 2:59 PM on the same day, an administrator acknowledged the issue and stated that they would prioritize keeping the exit passageways clear.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) All items were removed from both exit passageways on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator completed rounds of the facility to ensure all exit passageways were maintained free of obstructions. No other areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The maintenance director and food service director were educated by the administrator on maintaining exit passageways via a physical tour of the areas. Education was given on maintaining exit passageways clear and to use the newly designated alternate storage areas. The maintenance director or administrator will complete a weekly audit of the kitchen storeroom exit and employee entrance exit to ensure the passageways are free of any stored items or equipment blocking the passageway. Any noncompliance will be corrected upon identification. The audit will be completed weekly for 8 weeks and monthly for 2 months thereafter. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The facility will ensure that the exit passageways are kept clear at all times via the weekly environmental rounding schedule with any violations immediately addressed. Findings of the weekly and monthly audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly, and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance
Sprinkler System Maintenance Deficiency
Penalty
Summary
The automatic sprinkler system in the main kitchen of the facility was not maintained according to the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition. Specifically, observations revealed that boxes were stored within 18 inches of the bottom of sprinkler deflectors in the kitchen walk-in refrigerator and walk-in freezer. Additionally, three sprinkler heads in the laundry dryer area were found to be coated with dust or lint. These deficiencies were identified during observations conducted on two separate occasions, indicating a failure to adhere to fire safety regulations as required by the NFPA standards.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The items on the top storage of the main kitchen were removed on 12/17/24. The three sprinkler heads in the laundry dryer area were cleaned on 12/17/24. Education was provided to all dietary staff relative to appropriate storage areas by Regional Dietician on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The maintenance director or designees audited storage areas to ensure nothing is stored within 18 inches of the bottom of the sprinkler. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Weekly audits of storage in the kitchen to be conducted by Food Service Director or maintenance director weekly times 4 weeks and monthly times 2 months. The laundry room sprinkler heads have been placed on the monthly preventive maintenance schedule for routine cleaning. The food service director and maintenance director were educated on storing items at below 18 inches from sprinkler deflector. The maintenance director was educated on keeping all sprinklers free from dust and lint. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the weekly audits and monthly preventative maintenance of sprinkler heads will be reviewed by the Quality Assurance Performance Improvement Committee monthly for 3 months and additional recommendations for interventions and duration of audits will be given as needed. Responsible Parties: Administrator, Dietician, Food Service Director and Director of Maintenance.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability of a resident, identified as Resident #70, who was reviewed for communication. Resident #70, who was admitted with chronic obstructive pulmonary disease, hypertension, and seizures, was documented as having impaired vision and using corrective lenses. The facility's policy required timely medical care, yet the resident's medical record showed no optometry consults or a comprehensive care plan for vision after a scheduled follow-up in March 2023. Interviews revealed that the resident expressed a desire to see an eye doctor, and a registered nurse acknowledged the need for optometry visits every 6-12 months. However, there was a lack of documented follow-up or scheduling for optometry services. The medical records staff indicated they rely on nurse managers to email them for scheduling appointments, but no such communication was documented for Resident #70, leading to a deficiency in providing necessary vision care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action: Resident #70 was seen by optometry on 3/25/2024 with recommendations to follow up in 1 year. Medical records clerk was re-educated on scanning consults into resident’s chart timely on 1/13/2025. 2. Plan to prevent reoccurrence: Medical records completed a full house review of facility resident’s optometry consults from the previous 12 months to identify any additional missed scanned consults. This audit was completed on 1/17/2025. Results of the audit will be provided to medical provider for review. 3. The facility systemic changes: Education was given to medical records on 1/13/2025 by the Director of Nursing to ensure they are following the consultation policy. Medical records will document and monitor vision consults utilizing a consultation tracker form to ensure completed consults are scanned into resident chart. 4. Medical records coordinator will conduct a review of residents’ vision consults weekly x 4 weeks then monthly x 3 months. Results will be submitted to the Director of Nursing for final review. The results of the reviews will be brought to QAPI for review and determination of frequency reviews and any additional recommendations. Responsible Party: Director of Nursing
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, resulting in a significant deficiency. The resident, who was admitted with a history of lumbar vertebra fracture, uterine cancer, and bone cancer, was not administered pain medication in a manner that effectively managed their pain. Despite having a comprehensive care plan that included administering medications as ordered and notifying the physician if interventions were unsuccessful, the facility did not adhere to these guidelines. The resident expressed severe pain, rated at 10 out of 10, and the family member had to call 911 to have the resident transported back to the hospital. The facility's policies on medication administration and pain management were not followed. The Medication Administration Record showed that the resident received excessive acetaminophen, exceeding the prescribed limit of 3000 milligrams in 24 hours, within just over 13 hours. Additionally, the facility failed to administer the appropriate dosage of oxycodone for the resident's reported pain level. The resident's pain was not reassessed within the 30-60 minute window as required by the facility's policy, and there was a lack of documentation for some medication administrations. Interviews with family members and staff revealed that the resident was in distress due to unmanaged pain and other unmet needs, such as soiled clothing and lack of food. The Director of Nursing acknowledged that Tylenol was administered for severe pain, but did not confirm if this was appropriate. The facility's failure to manage the resident's pain effectively and adhere to their own policies resulted in the resident being sent back to the hospital for proper care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Resident #112 no longer resides in facility. Registered Nurse #4 no longer employed at facility. 2. All residents have the potential to be affected by the deficient practice. Nursing managers conducted a 90-day look back audit from 10/13/2024 - 1/13/2025 of all residents’ pain scales to determine other residents who have triggered for pain and received appropriate pain relief. 3. The Facility systemic changes: The policy titled Pain Management was reviewed by administration with no revisions necessary. The Facility educator will re-educate licensed staff on the policy titled “Pain Management.” Re-education will focus on provider notification with any resident reports of increased pain that is not being relieved with current interventions for further directive. 4. The Nurse Managers will conduct reviews of those residents who have triggered for pain to ensure appropriate intervention and provider notification. Pain medication reviews will be completed weekly x 4 weeks then monthly x 3 months. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible Party: Director of Nursing
Failure to Provide Emergency Dental Services
Penalty
Summary
The facility failed to provide or obtain emergency dental services for a resident who had broken a front tooth. The resident, who had diagnoses including hypertension, chronic obstructive pulmonary disease, and depression, was observed with broken top front teeth and reported having broken them two weeks prior without having seen a dentist. The facility's policy, last revised in 2019, stated that both routine and emergency dental services were available to meet the oral needs of each resident, yet this was not adhered to in the case of the resident. Interviews conducted during the survey revealed that the resident had not been scheduled for a dental appointment despite experiencing slight pain. A Licensed Practical Nurse indicated that the information would be passed to the Finance Director, who was responsible for arranging dental appointments. The Finance Director acknowledged that the resident had last seen a dentist several months prior and would be added to the list for the next dental visit, indicating a delay in addressing the resident's immediate dental needs.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action taken: Resident #75 was immediately referred to dentist on 12/18/2024 and evaluated on 12/19/2024. 2. Plan to prevent reoccurrence: All residents have the potential to be affected by the deficient practice. Nursing conducted a full house audit on 1/16/2025 to ensure no other residents had any broken teeth or emergency dental care needs. None were noted. 3. The facility systemic changes: The policy titled Dental Services was reviewed by administration with no revisions. The Facility educator will re-educate licensed staff on policy titled “Dental Services.” The education will focus on actions needed when someone needs emergency dental care. 4. The Unit Managers will conduct a review of oral inspection for broken teeth and any emergent dental care not previously noted. This audit will be conducted weekly x 4 weeks then monthly x 3 months. Results will be submitted at QAPI for review and determination recommendation of frequency reviews required. Responsible party: Director of Nursing
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #97, who was under review for nutrition. The resident, who had a diagnosis of malnutrition and dementia, experienced significant weight loss without the required weekly weight monitoring as ordered by the dietician. The facility's policy mandated weekly weight checks for four weeks following admission and more frequently if clinically indicated, but this was not adhered to for the weeks of 11/25/2024 and 12/09/2024. Resident #97 was admitted with a history of malnutrition and had a care plan focused on addressing nutritional problems, including unintentional weight loss. Despite the care plan's goal to maintain stable weight, the resident's weight dropped from 119 pounds in August to 107 pounds by December, indicating a significant weight loss of over 10 percent. The resident expressed dissatisfaction with the facility's food, describing it as cold and unappealing, which contributed to their reduced intake and subsequent weight loss. Interviews and record reviews revealed that the dietician had ordered weekly weights due to the resident's significant weight loss, but these orders were not consistently followed. The registered nurse responsible for monitoring weights did not receive the necessary communication from the dietician, resulting in missed weight checks. This oversight was compounded by the absence of active orders for weekly weights in the resident's records, highlighting a breakdown in communication and adherence to the facility's weight management policy.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action taken: the weekly weight order was obtained and entered for resident #97. The resident’s weight was obtained and the facility provider notified. The Registered Dietitian met with resident #97 regarding food preferences and dietary supplements. 2. All residents have the potential to be affected by the deficient practice. Plan to prevent reoccurrence: Registered Dietitian completed a full house of those residents who were recommended to have weekly weights. Those residents found to have weight omissions will have weights obtained and evaluated by the Registered Dietitian and nursing. 3. The facility systemic changes: The policy titled Weight Management was reviewed with no revisions necessary. The Director of Nursing re-educated the Registered Dietitian on 1/13/2025 on facility policy titled Weight Management with the focus on ensuring the recommended weight order is in place. 4. The Registered Dietitian will conduct an audit on all residents with weekly weights to ensure physician order [REDACTED]. Results of the reviews will be reviewed by the DON and Registered Dietitian weekly. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible party: Registered Dietitian
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Granville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Slate Valley Center For Rehabilitation And Nursing | 5.6 mi | ★★★★★ | 0 | 0 |
| Washington Center For Rehab And Healthcare | 15.2 mi | ★★★★★ | 11 | 0 |
| Fort Hudson Nursing Center Inc | 18.3 mi | ★★★★★ | 0 | 0 |
| The Pines At Glens Falls Ctr For Nursing & Rehab | 19.3 mi | ★★★★★ | 15 | 0 |
| Mountain View Center Genesis Healthcare | 20.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Granville Center For Rehabilitation And Nursing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.