Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Ganado Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to provide an ongoing activities program consistent with residents’ assessments, care plans, and the posted calendar. Weekend days had no scheduled activities, and on multiple weekdays, listed activities such as bingo, "pretty nails," and "appetizer hour" did not occur. Two residents with dementia, depression, and mobility limitations, whose MDS assessments and care plans emphasized the importance of group and favorite activities, reported that scheduled activities were not held and that there were no weekend activities. Resident Council minutes repeatedly documented that bingo was residents’ favorite activity and that they wanted more of it, yet bingo was inconsistently provided. The ADM and Activity Director acknowledged that the Activity Director had been absent due to physical issues, did not work weekends, had no assistant or formal backup plan, and was unaware that activities were not being held, despite facility policy requiring an ongoing, week-long activity program tailored to residents’ interests and needs.
Surveyors found that the facility failed to ensure breakfast menus reflected resident preferences and input, resulting in the same breakfast being served every day over an extended period. Observations showed a repetitive meal of eggs, sausage or bacon, toast, gravy, and cereal, while the written menu also listed the same core items daily. Several residents with moderate cognitive impairment and conditions such as dementia, severe protein-calorie malnutrition, and renal disease reported boredom with the unchanging breakfast and a desire for more options, despite care plans directing staff to determine and honor food preferences. Resident Council notes documented concerns about breakfast variety, and the Dietary Manager acknowledged receiving complaints but stated cooks had to follow the existing menu and that she had not consulted the dietitian about adjusting it. The report notes this practice could result in psychosocial harm and/or weight loss.
Staff failed to follow infection prevention and control practices during incontinent care and eye drop administration for several residents. CNAs did not fully sanitize their hands, including between fingers, while providing pericare to residents who were bowel incontinent and in some cases had indwelling catheters. In one instance, a CNA handled a soiled brief and then applied a clean brief without changing gloves or performing hand hygiene. Another CNA touched a bed remote with gloved hands and then proceeded with care without changing gloves or sanitizing hands, and did not sanitize between glove changes. A medication aide touched the med cart, keys, bedside table, and bed remote with gloved hands and then administered eye drops to a resident’s face without changing gloves or performing hand hygiene, contrary to facility policies and infection control expectations.
A resident with dementia, urinary incontinence, and obstructive/reflux uropathy was observed receiving incontinent care that did not follow the facility’s perineal care policy. During care, a CNA used a back-and-forth wiping motion with multiple passes over the same area instead of the required front-to-back technique from the urethral to rectal area. The resident’s care plan called for monitoring for s/sx of UTI, and the facility’s policy specified wiping from clean to dirty areas, but the observed practice did not comply with these standards.
A resident with severe cognitive impairment and mental health diagnoses was receiving Depakote 125 mg twice daily for mood stabilization without a documented associated diagnosis, and the medication was not addressed in the resident’s care plan, which focused on adverse medication effects and behavior monitoring. Review of records and staff interview showed that the Depakote order lacked an indicated diagnosis despite a facility policy requiring residents to remain free from unnecessary medications, including those used without adequate indications.
The facility did not ensure that meals were served at safe and appetizing temperatures, as several residents with moderate cognitive impairment and various medical conditions reported that their food was consistently cold. One resident on a renal diet who ate in a room at the end of the hall stated that meals delivered to the room were cold, while another resident on a regular diet who usually ate in the dining room also reported cold food. A third resident with neurologic conditions and an ADL self-care deficit, who always ate in her room, stated that all three daily meals were served cold and therefore unpalatable. The Dietary Manager reported that no residents had informed her of cold meals, despite a written policy stating that food would be served at a safe temperature.
Surveyors found that an opened jar of marmalade labeled to be refrigerated after opening was stored in a dry goods pantry instead of under refrigeration. A dietary staff member and the Dietary Manager both confirmed the jar had been opened, partially consumed, and improperly stored despite the label instructions. Review of the facility’s food storage policy indicated storage areas must preserve the condition of food and supplies, but this standard was not followed for the marmalade, potentially affecting all residents receiving meals and snacks.
Unlocked Shower Room Cabinet Contained Razors and Germicidal Wipes An unlocked cabinet in a shower room at the end of the 300 hall contained approximately eight razors and a container of germicidal wipes labeled not a skin or baby wipe and keep out of reach of children. The Maintenance Director confirmed the cabinet should have been locked so the items were out of reach of residents. The facility policy stated it is committed to maintaining a safe, clean, and hazard-free physical environment for all residents, staff, and visitors.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses was able to exit the facility unsupervised through an unsecured sliding door with a malfunctioning alarm. The resident, who had no prior history of elopement or wandering, was found outside by another resident and returned to the facility. The deficiency was attributed to the failure to maintain a secure environment and provide adequate supervision.
The facility failed to secure medications properly, as observed during medication administration for two residents. A medication aide left a cart unlocked and out of sight, while another left blister packs unsecured on top of a cart. Both aides acknowledged their mistakes, citing forgetfulness and nervousness. Facility policies require medication carts to be locked and in view during administration.
The facility failed to maintain a safe environment in a spa/shower room, where a toilet was found to be loosely affixed to the floor, moving approximately two inches to the side. This was confirmed by the Administrator, who acknowledged the risk of injury. The facility's Preventive Maintenance Policy was not effectively implemented.
A resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was found invalid due to missing witness signatures, despite being signed by the resident and physician. This oversight was confirmed by the Regional Compliance RN and DON, indicating a failure to adhere to the facility's policy requiring two witness signatures for validity.
A facility failed to ensure proper pharmaceutical services by storing an expired medication, Lorazepam, in the Narcotics refrigerator. The ADON acknowledged the medication was expired and should have been discarded. Facility policy requires expired drugs to be removed, and a pharmacist's review recommended pulling expiration dates 2-3 months in advance.
A medical assistant failed to sanitize blood pressure cuffs and a stethoscope between use on two residents, despite knowing the protocol and having received recent infection control training. The facility's policy requires such equipment to be cleaned between uses to prevent cross-contamination, as confirmed by the Registered Clinical Nurse.
The facility failed to discard an expired food item in the kitchen's reach-in refrigerator, as observed during a survey. A container of pineapple was found with a use-by date that had passed, and the kitchen staff did not perceive a concern since it had not been served. This oversight contradicts the facility's policy and FDA guidelines, which require perishable items to be used within seven days.
The facility failed to post daily nurse staffing information for two days due to confusion over responsibilities and lack of a clear policy. The MDS Nurse and ADON were responsible for updating the information, but delays occurred due to scheduling issues and other duties. The RCN noted no company-wide requirement for posting responsibilities, and the facility relied on a checklist for postings.
Failure to Provide Ongoing, Scheduled Activities Program Based on Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing activities program that followed the posted calendar and met residents’ assessed interests and care plan goals. The February activity calendar showed no activities scheduled on weekends, and surveyor observations on a Sunday afternoon found no activities occurring. On subsequent weekdays, activities listed on the calendar, such as bingo and other group events, were not provided as scheduled, with no alternative or backup activities implemented when the Activity Director was absent. Two residents with moderate cognitive impairment and depression, both care planned to benefit from and be encouraged to attend group and individual activities, reported that scheduled activities were not occurring. One resident, with diagnoses including dementia, major depressive disorder, and mobility limitations, had an MDS indicating that doing favorite activities and participating in groups were very important, and her care plan called for out-of-room social, spiritual, and stimulating activities at least twice weekly. She stated there was no bingo on a day it was scheduled and that there were no weekend activities, noting the Activity Director had not worked for several days. Another resident, with Alzheimer’s disease, dementia, major depressive disorder, and mobility issues, had an MDS indicating that keeping up with the news, doing things with groups, doing favorite activities, and going outside were very important, and his care plan directed encouragement to participate in exercise and activity programs. He reported that “pretty nails” and “appetizer hour” did not occur as scheduled and that there had been no activities all week or on weekends. Interviews with the ADM and the Activity Director confirmed that the Activity Director had been physically unable to work during the survey week and did not work weekends, and that there was no assistant or formal backup plan to ensure activities occurred when she was absent. The ADM stated he would get staff together to ensure residents received scheduled activities if the Activity Director could not work, but observations showed that scheduled activities such as bingo were not consistently provided. The Activity Director stated she was unaware that activities were not being held, that one-to-one activity notes were not kept at the facility, and that she did not have a backup plan for her absence, despite facility policy requiring an ongoing activity program based on residents’ interests and needs, including programming throughout the entire week and for residents unable to participate in groups. Resident Council minutes from several months documented that residents’ favorite activity was bingo and that they wanted more bingo, including twice weekly, yet bingo and other posted activities were not reliably provided as scheduled.
Failure to Provide Breakfast Variety and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus reflected the needs and preferences of the resident population, particularly regarding breakfast variety, despite policy stating that every attempt would be made to honor resident food preferences. Facility menus in effect from November 2025 through May 2026 listed the same breakfast each day: choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine, jelly, and whole milk. Observations on three separate mornings showed that residents were consistently served scrambled eggs, toast, sausage patties, bacon, gravy, and cereal, indicating that the same breakfast meal pattern was being followed daily. The Dietary Manager confirmed that the current menu had been in effect for a couple of months and that cooks were required to follow the menu as written. Multiple residents with moderate cognitive impairment and various medical conditions reported dissatisfaction with the lack of breakfast variety. One resident with Alzheimer’s disease, dementia, major depressive disorder, and a care plan identifying potential risk for malnutrition stated she had the same breakfast every day, found it boring, and said dietary staff had not asked for her preferences, despite her dietary profile noting she liked breakfast and her care plan calling for updating food preferences as needed. Another resident with degenerative disease of the basal ganglia and altered mental status reported being served sausage and eggs every day since admission and expressed a desire for more options, even though her care plan required staff to anticipate and meet her ADL self-care needs. Additional residents with diagnoses including severe protein calorie malnutrition, atrial fibrillation, renal osteodystrophy, pleural effusion, and emphysema also reported being tired of the same breakfast of eggs and sausage every morning and wanting variety, despite care plans directing staff to determine and provide food preferences within dietary limitations. Resident Council meeting notes for February 2026 documented a concern under Nutrition Services regarding breakfast variety, and the resident who had reported boredom with breakfast was in attendance at that meeting. The Dietary Manager acknowledged that a few residents had complained about having the same breakfast every day and stated she had not discussed any deviation from the set menu with the consultant dietitian, resulting in menus that did not incorporate resident input or provide variety as requested. The report states this practice could affect residents who consume breakfast and could result in psychosocial harm and/or weight loss.
Inadequate Hand Hygiene and Glove Use During Care and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during personal care and medication administration for multiple residents. For one resident with epilepsy, Down syndrome, Alzheimer’s disease, type 2 diabetes mellitus, hypothyroidism, and hyperlipidemia, who was severely cognitively impaired, dependent on staff for care, and always incontinent of bowel with an indwelling catheter, two CNAs provided incontinent care without fully sanitizing their hands. During care, both CNAs used hand sanitizer but did not sanitize between their fingers, contrary to the facility’s infection control policy, which requires covering all surfaces of the hands and fingers when performing hand hygiene. Another deficiency occurred during incontinent care for a cognitively intact resident with type 2 diabetes mellitus, hypertension, chronic kidney disease, hypothyroidism, and hyperlipidemia, who was dependent on staff for toileting hygiene, had an indwelling catheter, and was always incontinent of bowel. While removing a soiled brief, a CNA touched the soiled brief and then, without changing gloves or performing hand hygiene, handled and applied a clean brief to the resident. This action conflicted with the facility’s infection control policy, which requires hand hygiene after handling soiled items such as linens and catheter-related supplies. A third incident involved a resident with convulsions, hypothyroidism, hyperlipidemia, dementia, hypertension, and obstructive and reflux uropathy, who was severely cognitively impaired and always incontinent of bowel and bladder. During incontinent care, a CNA washed her hands and donned gloves, then used the gloved hand to touch the bed remote to adjust the bed, which she later acknowledged was considered dirty. She did not change gloves or sanitize her hands before proceeding with care and did not sanitize her hands between glove changes, despite facility policy requiring hand hygiene after removing gloves and after handling soiled or used items in the resident’s environment. The final deficiency involved medication administration for a resident with hemiplegia, type 2 diabetes mellitus, hyperlipidemia, hypertension, and dementia, who required extensive to total assistance with activities of daily living. While administering eye drops, a medication aide wore gloves and used the same gloved hand to touch the medication cart key, the medication cart, the resident’s side table, and the bed remote, all of which she later identified as dirty or contaminated surfaces. She did not change gloves or sanitize her hands before touching the resident’s face and administering the eye drops. This sequence of actions occurred despite the facility’s eye ointment administration policy requiring handwashing and donning gloves in connection with medication administration and the broader infection control expectations described by the DON.
Improper Perineal Care Technique During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the provision of incontinent care and catheter-related infection prevention for one resident. The resident had multiple diagnoses including convulsions, hypothyroidism, hyperlipidemia, dementia, hypertension, and obstructive and reflux uropathy, and was documented on the quarterly MDS as severely cognitively impaired with always incontinent bowel and bladder. The resident’s care plan included a problem of bladder incontinence with an intervention to monitor and document for signs and symptoms of UTI, such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During an observation of incontinent care, a CNA was seen using a back-and-forth wiping motion instead of a front-to-back motion while cleaning the resident’s perineal area. The CNA later stated she should have wiped front to back instead of using a back-and-forth motion and performing multiple passes on the same area. The DON stated that staff should not use a back-and-forth motion during incontinent care and should perform a front-to-back pass with a wipe and change wipes before another pass to prevent fecal matter from entering the urinary tract. Review of the facility’s perineal care policy showed it directed staff to gently perform perineal care by wiping from the clean urethral area to the dirty rectal area. Despite this policy and documented annual training and proficiency checks, the observed care did not follow the required front-to-back technique.
Depakote Administered Without Documented Indication or Care Plan Inclusion
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medication by administering Depakote without an associated diagnosis or adequate indication for its use. A resident admitted with diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood, Generalized Anxiety Disorder, and Insomnia had a quarterly MDS showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan, initiated for adverse medication effects and behavior monitoring, did not address that the resident was receiving Depakote. The medication order for Depakote Sprinkles 125 mg, to be given orally twice daily for mood stabilization, lacked an associated diagnosis. During interview, the DON acknowledged that the Depakote order should have had an associated diagnosis and that it did not, despite the facility’s Unnecessary Medications policy stating that each resident must remain free of unnecessary medications, including drugs used without adequate indications for their use. This deficient practice was identified for one resident reviewed for unnecessary medications and had the potential to affect all residents receiving prescription medications, as it demonstrated a failure to ensure that prescribed drugs had documented, adequate indications in accordance with facility policy.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for multiple residents. One resident with end stage renal disease, anxiety disorder, and heart failure, who was on a renal diet with regular texture and large portions and was independent with eating, reported that he ate in his room at the end of the hall and that his food was cold. Another resident with major depressive disorder, dementia, and anemia, who was on a regular diet with regular texture and typically ate in the dining room, stated that her food was cold. Both residents had moderately impaired cognition per their BIMS scores and no documented weight loss, and their care plans and dietary profiles reflected regular or renal diets with regular textures and preferences for meals. A third resident with degenerative disease of the basal ganglia, altered mental status, and a history of transient cerebral ischemic attack, who had moderate cognitive impairment and an ADL self-care performance deficit, was ordered a regular diet with regular texture and consistency and reported always eating in her room. She stated that all three of her daily meals were served cold and that receiving cold food made the meals unpalatable, despite generally enjoying their taste. During an interview, the Dietary Manager stated that no residents had informed her that meals were served cold. The facility’s policy on Daily Food Temperature Control, dated 2012, stated that the facility would assure that food is served at a safe temperature, but resident interviews indicated that this was not consistently achieved.
Improper Storage of Opened Refrigerated Food Item in Dry Goods Pantry
Penalty
Summary
Surveyors identified a deficiency in food storage practices when an eighteen-ounce jar of marmalade labeled "refrigerate after opening" was found stored in a non-refrigerated dry goods pantry after it had been opened and partially consumed. During observation in the kitchen, the opened jar remained in the dry storage area instead of being placed under refrigeration as required by the product label. In interviews, a dietary staff member confirmed the marmalade had been improperly stored and acknowledged it should have been refrigerated but could not explain why it had not been. The Dietary Manager also confirmed that the opened marmalade, which required refrigeration after opening, was stored in the dry goods pantry instead of being refrigerated. Review of the facility’s 2012 "Food Storage and Supplies" policy showed that all facility storage areas were to be maintained in an orderly manner that preserves the condition of food and supplies. This deficient practice was determined to have the potential to affect all residents who consume meals and/or snacks provided by the facility, as it involved improper storage of a food item used in resident meal service.
Unlocked Shower Room Cabinet Contained Razors and Germicidal Wipes
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible in 1 of 4 shower rooms reviewed. Observation of the shower room at the end of the 300 hall found an unlocked cabinet containing approximately eight razors for shaving and a container of germicidal wipes labeled "not a skin or baby wipe" and "keep out of reach of children." No residents were observed in the hallway near the shower room at the time of the observation. During interview, the Maintenance Director confirmed that the cabinet containing the razors and germicidal wipes should have been locked so the items were out of reach of residents. Record review of the facility policy stated that the facility is committed to maintaining a safe, clean, and hazard-free physical environment for all residents, staff, and visitors.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, dementia, osteoarthritis, dystonia, dysphagia, psychosis, and major depressive disorder, was assessed with a BIMS score of 3, indicating severe cognitive impairment. Prior to the incident, the resident had no documented history of wandering or elopement risk, and the care plan did not include interventions for elopement prevention. On the day of the incident, the resident was able to exit the facility through an unlocked sliding door at the end of a hallway. This door was typically secured with a keypad lock, but on the day in question, it was found to be unlocked, and the alarm system was not functioning. The facility could not determine the exact cause of the malfunction but suspected it was related to weather conditions. The resident was found outside the facility by another resident and was returned to the building within approximately ten minutes of last being seen by staff. The incident was identified as non-compliance and Immediate Jeopardy, as the failure to secure the door and supervise the resident allowed the elopement to occur. The deficiency was based on direct observation, interviews, and record review, which confirmed that the resident was able to leave the facility unsupervised due to the malfunctioning door alarm and lack of adequate supervision.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional principles. During medication administration for a resident, a medication aide left the medication cart unlocked outside the resident's room and out of sight. The cart contained medication blister packs, bottles, and vials for residents on the hall. The medication aide admitted to forgetting to lock the cart, acknowledging the risk of medications being accessed by unauthorized individuals. The facility's policy requires medication carts to be locked when not in direct use and in full view of the nurse during administration. In another instance, a medication aide prepared medications for a resident and left blister packs unsecured on top of the medication cart while administering the medications inside the resident's room. The aide acknowledged the mistake, attributing it to nervousness during the surveyor's presence. The facility's policy and a pharmacist's review emphasize the importance of securing medications and removing expired or discontinued drugs. The Registered Nurse Coordinator confirmed that medications should always be secured inside the locked cart.
Unsafe Toilet in Spa/Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of the three spa/shower rooms reviewed. Specifically, the toilet in the spa/shower room on the 200 hallway was observed to be loosely affixed to the floor, allowing it to move approximately two inches to the side. This condition was confirmed by the Administrator during an interview, who acknowledged the potential risk of injury to anyone attempting to use the toilet. The facility's Preventive Maintenance Policy, dated 2003, emphasizes the importance of regular inspections and maintenance to prevent equipment failures, but this policy was not effectively implemented in this instance.
Invalid DNR Order Due to Missing Witness Signatures
Penalty
Summary
The facility failed to ensure the validity of a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order, which was not signed by two witnesses as required. This oversight was identified during a review of the resident's records, which included a face sheet indicating the resident's DNR status, a comprehensive care plan, and an order summary report. Despite the resident and their physician having signed the OOH DNR form, the absence of the required witness signatures rendered the document invalid. Interviews with the Regional Compliance RN and the Director of Nursing (DON) confirmed the deficiency, acknowledging that the missing witness signatures meant the resident would receive CPR in the event of cardiac arrest, contrary to their documented wishes. The facility's policy on DNR orders clearly states that two witness signatures are necessary for the form to be valid, highlighting a failure in adhering to established procedures.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for a resident by storing an expired medication, Lorazepam, in the Narcotics refrigerator within the main medication storage room. During an observation, it was found that the medication had an expiration date of March 12, 2024, but was still present in the storage room on November 13, 2024. The Assistant Director of Nursing (ADON) acknowledged that the medication was expired and should have been discarded according to the pharmacy expiration date. The ADON explained that expired or discontinued medications should be removed by nurses or medication aides during their medication cart checks, and the Supply Nurse and Director of Nursing (DON) should dispose of any expired medications during re-supply. The facility's policy, as part of the Pharmacy Policy & Procedure Manual, states that drugs should not be kept after their expiration date. A review of the Pharmacist's Monthly Medication Review for October 2024 indicated that medications should be pulled from carts or the med room on the same day they are discontinued or expired, with a recommendation to pull expiration dates 2-3 months in advance to prevent expired administration.
Failure to Sanitize Equipment Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA) who did not sanitize blood pressure cuffs and a stethoscope between use on different residents. During an observation, the MA was seen taking the blood pressure of one resident using both a wrist and manual blood pressure cuff, and then proceeded to use the same equipment on another resident without sanitizing them in between. This practice was acknowledged by the MA, who admitted to forgetting to sanitize the equipment despite being aware of the protocol and having received infection control training within the year. The Registered Clinical Nurse (RCN) confirmed that the MA should have sanitized the equipment between uses to prevent cross-contamination. The facility's policy, updated in March 2023, requires non-invasive resident care equipment to be cleaned daily or as needed between uses. The RCN also mentioned that infection control training is provided to staff annually and as needed, with competency checks in place. This incident highlights a lapse in adherence to the facility's infection control protocols, potentially placing residents at risk for infection.
Expired Food Item Not Discarded in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not discarding an expired food item in the reach-in refrigerator. During an observation, a plastic container labeled as pineapple was found with a use-by date that had passed. The kitchen staff member, identified as [NAME] A, acknowledged that all kitchen staff were responsible for removing expired items but did not see a concern since the pineapple had not been served. This oversight in food safety practices was noted during an interview with the RCN, who also did not perceive an impact from the expired item remaining in the refrigerator. The facility's policy on food storage, dated 2012, requires perishable items to be dated once opened and used within seven days. This policy aligns with the Food and Drug Administration Food Code, which mandates that refrigerated, ready-to-eat, time/temperature control for safety food must be clearly marked and consumed or discarded within seven days. The failure to comply with these standards could potentially affect residents receiving meals from the facility's kitchen, as they may be at risk of consuming expired food items.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information for two consecutive days, from October 15 to October 16, 2024. During an observation on October 17, 2024, it was noted that the posted document was outdated, showing information from October 14, 2024. The MDS Nurse, responsible for updating the daily census and nurse staffing document, stated that the document was not updated due to the unavailability of the scheduling book on the morning of October 17, 2024. The MDS Nurse and the ADON shared the responsibility of posting the information, but there was confusion about who was the backup for this task, leading to the oversight. Interviews with the RCN and ADON revealed that the facility lacked a clear policy on staffing postings, relying instead on a checklist for required postings. The ADON admitted to being late on October 15, 2024, and being occupied with medication administration on the mornings of October 16 and 17, 2024, which contributed to the delay or omission of the postings. The RCN mentioned that there was no company-wide requirement for who should post the daily census and nurse staffing information, and she did not perceive any impact from the postings being late or missed, as staff used a sign-in sheet for assignments.
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What surveyors actually found near you
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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 Ganado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southbrooke Manor Nursing And Rehabilitation Cente | 11.1 mi | ★★★★★ | 2 | 0 |
| S.p.j.s.t. Rest Home 3 | 12.4 mi | ★★★★★ | 8 | 0 |
| Paradigm At The Prairies | 18.3 mi | ★★★★★ | 15 | 2 |
| Port Lavaca Nursing And Rehabilitation Center | 28.7 mi | ★★★★★ | 0 | 0 |
| Lavaca Bay Nursing And Rehabilitation Center | 29.2 mi | ★★★★★ | 17 | 0 |
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