Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granite Mesa Health Center during CMS and state inspections, most recent first.
A CMA left a charting computer on a medication cart unlocked and unattended with a resident’s medication administration information visible on the screen, allowing potential viewing by unauthorized individuals. Staff, including the CMA, RN, LVN, DON, and Administrator, acknowledged that all personnel who use charting computers are responsible for locking or minimizing screens when stepping away and that failing to do so can expose private medical information. Although leadership reported that HIPAA training is provided at hire and annually via computer modules, a review of in‑service records for the prior six months did not show documented HIPAA training for the CMA before this event, despite a written confidentiality policy stating that all resident health information is confidential and protected by HIPAA.
Call lights were left out of reach for multiple residents, including residents with dementia, Alzheimer’s disease, cognitive communication deficits, weakness, and mobility limitations. Observations found call devices on the floor, on the far side of the bed, or hanging off the bed while residents were in bed or in wheelchairs and unable to access them. Interviews with residents and staff confirmed that the call lights were not consistently placed within reach, despite facility policy stating the device should be left within the resident’s reach before staff exited the room.
Admission MDSs for three residents did not accurately reflect current tobacco use. Although each resident’s chart and smoking assessment identified them as smokers, the MDSs marked tobacco use as no or left it off entirely. Care plans also referenced smoking-related supervision needs, including smoking aprons and staff observation, and interviews confirmed that residents smoked with staff assistance.
Resident Council Meeting Privacy Breach: The facility failed to provide private space and maintain confidentiality during a resident council meeting held in the dining room. Two staff members entered through the dining room doors while the meeting was in progress, and the Activities Director stated no sign had been posted because the meeting date was changed and this was an oversight. The Resident Council President and Secretary stated only invited staff were allowed, and the Activities Director was invited to take notes.
A facility failed to ensure PASSAR screenings were updated for two residents with mental health diagnoses. One resident had bipolar disorder documented after an earlier negative Level 1 PASSAR, but no new screening was completed. Another resident had major depressive disorder and anxiety, yet the Level 1 PASSAR remained negative. The MDSC, DON, and ADM all stated these diagnoses should have triggered positive Level 1 PASSAR results and that the screenings were not accurate.
Two residents did not have fluids within reach despite facility expectations and policy requiring sufficient hydration. One resident with dementia and mobility limitations could see her water but could not reach it because the cup was more than 5 feet away, and another resident with severe cognitive impairment was observed asleep in bed with no hydration within reach. Staff, including the RN leadership and ADM, stated residents should always have fluids nearby and that nursing staff and the hospitality aide were responsible for monitoring hydration.
Failure to perform hand hygiene during puree food preparation: DA A was observed preparing pureed meatballs, noodles, and broccoli without washing her hands between multiple food handling and kitchen tasks, including use of the puree machine, steamer, spatula, and wiping counters. The ADM, DA A, and DM stated staff were trained on infection control and hand hygiene, and facility policy required hand hygiene before and after handling food and between tasks.
Inaccurate smoking assessment documentation was found for a resident whose record stated he did not smoke, even though he was observed smoking outside with staff and another resident. The resident’s care plan identified a smoking-related injury risk and included a smoking plan, supervision, and smoking policy interventions, while the ADM, MDSN, and DON gave inconsistent explanations for how the assessment was completed and monitored.
A resident with multiple medical conditions did not have several doses of prescribed medications and required treatments documented in the electronic health record by nursing staff. Although staff later stated that the medications and treatments were administered, they failed to sign off in the MAR/TAR as required, resulting in incomplete and inaccurate medical records.
A resident with a history of stroke and muscle wasting received a nebulizer treatment for shortness of breath, but the administering RN did not document the resident's response or perform a follow-up assessment, and no vital signs were recorded after the treatment, contrary to facility policy and professional standards.
A resident with multiple sclerosis was subjected to verbal abuse and neglect by a CNA, who refused to assist with transfers and toileting, leading to an accident. Despite the resident's complaints and corroborating staff reports, the facility's response was inadequate, resulting in an Immediate Jeopardy situation.
The facility failed to maintain the required RN coverage for at least 8 consecutive hours a day, 7 days a week, on 19 occasions. The DON often covered these shifts, despite the facility's census exceeding 60 residents, which is against regulations. This placed residents at risk of missed care and assessments. The facility lacked a specific policy for RN coverage and faced challenges in hiring additional RNs.
A facility failed to maintain resident dignity and privacy, as observed with a resident left in soiled clothing for hours and staff entering rooms without knocking. Despite policies requiring knocking and changing soiled clothes, these practices were not consistently followed, leading to a deficiency in resident care.
The facility failed to accurately document psychiatric and mood disorders in the MDS for four residents, leading to discrepancies between their care plans and actual diagnoses. Despite being prescribed medications for anxiety and depression, these conditions were not consistently reflected in the MDS, potentially affecting care planning. Staff interviews revealed confusion over responsibility for ensuring accurate documentation.
The facility failed to provide personalized activity programs for two residents with severe cognitive impairments, leading to unmet social and recreational needs. Despite care plans indicating the need for staff assistance and engagement in activities, both residents were observed spending significant time in the hallway with minimal interaction. Staff interviews revealed a lack of consistent implementation of activities tailored to the residents' preferences, resulting in a deficiency in meeting their physical, mental, and psychosocial well-being needs.
A long-term care facility failed to protect three residents from the misappropriation of their hydrocodone/APAP tablets, leading to a risk of not receiving prescribed medications. Discrepancies in medication logs and missing tablets were discovered during a drug diversion investigation. A medication technician, responsible for administering the medications, was found to have access to the medications and was suspended and terminated following the investigation.
A long-term care facility failed to prevent drug diversion, resulting in the misappropriation of hydrocodone-acetaminophen prescribed to three residents for pain management. Discrepancies in medication administration logs and improper handling of these logs were discovered, leading to an investigation by the DON. A medication technician was suspended and terminated following the investigation, which highlighted the facility's failure to adhere to its drug diversion prevention procedures.
The facility failed to provide necessary hygiene services to a resident with severe cognitive impairment, leaving him with dried blood on his sheet and gown for an extended period. Staff delayed changing the linens and gown, despite recognizing the importance of maintaining a clean and dignified environment.
The facility failed to provide necessary ADL assistance, resulting in a resident not receiving scheduled showers and another resident being exposed due to an improperly fastened gown. Staff inconsistencies and lack of awareness contributed to these deficiencies.
Unsecured Medication Cart Computer Screen Exposes Resident PHI
Penalty
Summary
The deficiency involves the facility’s failure to maintain secure and confidential clinical records for one resident when a CMA left a charting computer screen unlocked and unattended on the medication cart, displaying that resident’s medication administration information. During observation, the surveyor noted that the computer on the 400 Hall medication cart was open and unlocked with the resident’s medication information visible, and the cart was unattended, making the information viewable to unauthorized individuals. The resident’s specific medical history or condition at the time was not described, but the information displayed related to medication administration. In interviews, the CMA acknowledged having received HIPAA in‑service training a few months earlier, which included instructions not to discuss private clinical information with unauthorized individuals and to lock the computer screen when stepping away, and admitted fault for not locking the computer. RN, LVN, the DON, and the Administrator each stated that staff who use charting computers and handle residents’ private information are responsible for closing or locking the screen when leaving it unattended, and that leaving a screen open could expose residents’ private medical information and violate privacy. The DON and Administrator reported that HIPAA in‑services are provided at hire and annually through computer modules and that staff are instructed to lock or minimize screens when stepping away; however, record review of HIPAA in‑services for the prior six months did not show documented HIPAA training for the CMA before this incident. The facility’s Resident/Patient Confidentiality policy stated that all resident health information is confidential and protected by HIPAA law and must not be disclosed by staff, volunteers, or vendors.
Call lights left out of residents’ reach
Penalty
Summary
The facility failed to ensure that residents had call lights within reach and that the communication system allowed residents to call for staff assistance from their bedside for 5 of 10 residents reviewed for call lights. During observations and interviews, Resident #13, a 68-year-old female with anxiety, dementia, schizoaffective disorder, bipolar type, hypertension, anemia, muscle wasting, and muscle weakness, was found asleep in her wheelchair with the call light placed on the far-right side of the bed, out of reach. Resident #31, a male with unspecified dementia, muscle wasting, muscle weakness, osteoarthritis, and gait and mobility abnormalities, stated he was waiting for help and said staff did not answer his call light; his call light was observed on the floor between the wheelchair tire and seat while he was lying in bed with his legs hanging halfway off the bed. Resident #47, a female with Alzheimer’s disease, need for assistance with personal care, pain in the right wrist, and muscle wasting/atrophy, was observed lying in bed awake and stated she could not locate the call light button; the button was on the right side of the bed on the floor, out of reach. Resident #48, a female with unspecified dementia, cognitive communication deficit, anxiety disorder, muscle weakness, lack of coordination, and anorexia nervosa, stated she often used her call light when she needed to be changed, but a flat call light pad was observed on the floor on the right side of the bed, out of her reach. Resident #67, a 62-year-old female with alcoholic cirrhosis, thrombocytopenia, blindness in the left eye, dementia, muscle weakness, pneumonia, anxiety disorder, and unsteadiness on feet, was sitting in her wheelchair on the right side of her bed while her call light button hung off the left side of the bed, out of reach. Staff interviews reflected that all staff were responsible for ensuring call lights were within residents’ reach, and the facility policy stated the call device should be placed within the resident’s reach before leaving the room. In-services on call lights and rounding were also documented.
Admission MDSs Did Not Reflect Smoking Status
Penalty
Summary
The facility failed to ensure that the admission MDS accurately reflected the smoking status for 3 of 3 residents reviewed for assessment accuracy: Resident #1, Resident #26, and Resident #70. Record review showed each resident had an admission MDS that did not indicate current tobacco use, while other facility records identified them as smokers. The facility’s smoking residents list also identified all three residents as smokers. Resident #1 was a male admitted with diagnoses including peripheral vascular disease, adult failure to thrive, localized swelling, tinea unguium, muscle weakness, lack of coordination, and gait and mobility abnormalities. His admission MDS showed a BIMS score of 14 and marked current tobacco use as no. However, his care plan identified a potential for injury related to smoking, and his smoking assessment stated that he smoked. During interview, he stated that he went out to smoke with staff three times a day and that staff watched residents while they smoked. Resident #26 was a female admitted with diagnoses including COPD, protein-calorie malnutrition, heart disease, fall, muscle wasting, cannabis dependency, metabolic encephalopathy, and lack of coordination. Her admission MDS showed a BIMS of 10 and did not include current tobacco use. Her care plan identified a potential for injury related to smoking and noted the need for a smoking apron. Her smoking assessment stated that she smoked three times a day and required supervision and a smoking apron. Resident #70 was a male admitted with diagnoses including lack of coordination, hypertension, muscle wasting, muscle weakness, type 2 diabetes mellitus with diabetic neuropathy, tinea unguium, heart disease, below-knee leg absence, and malaise. His admission MDS showed a BIMS of 99 and checked current tobacco use as no, while his smoking assessment stated that he smoked three times a day. The MDSN, DON, and ADM each stated that the residents’ smoking status was missed on admission and that the MDS did not reflect the residents’ smoking status.
Resident Council Meeting Privacy Breach
Penalty
Summary
The facility failed to provide a resident council meeting with private space and failed to ensure confidentiality during the meeting held in the dining room. During observation of the resident council meeting, two staff members, a Hospitality Aide and a Dietary Aide, entered through the dining room entry doors while the meeting was in progress. The report states that staff entered uninvited during the resident council meeting, exposing residents to loss of privacy and dignity. During interview, the Activities Director stated she had been trained in Resident Rights and in Abuse, Neglect, and Exploitation through Relias online training and in-services. She stated residents have the right to make complaints and speak privately, and that a sign should be posted on the dining room doors so uninvited staff would not enter during meetings. She said no sign was posted before the meeting because it had been changed from one date to another and this was an oversight. The Activities Director stated she was responsible for ensuring residents had a private place to meet, and that only invited staff members were to be present. The Resident Council President stated only invited staff were allowed to enter the meetings, and the Resident Council Secretary stated the meetings were always held in the dining room and that the Activities Director was invited to take notes.
PASSAR screenings not updated for residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for level II resident review when there was a significant change in status. During record review and interviews, the facility identified that Resident #4 had a diagnosis of bipolar disorder documented after an earlier Level 1 PASSAR screening dated 07/17/2013, yet no new Level 1 PASSAR was completed after the later diagnosis. Resident #4’s records also showed bipolar disorder on the quarterly MDS, a BIMS score of 06, and a care plan noting resistive behavior related to bipolar disorder. Resident #99’s records showed diagnoses including major depressive disorder and generalized anxiety disorder, with the quarterly MDS reflecting anxiety disorder and depression and the care plan noting anxiety medication and antidepressant use. The Level 1 PASSAR screening dated 08/21/2023 indicated no evidence of mental illness, intellectual disability, or developmental disability, and the MDSC stated the screening was negative because a Level 1 PASSAR document had not yet been sent off. The MDSC stated that Resident #99’s diagnosis of major depressive disorder would indicate a positive Level 1 PASSAR and that the PASSAR being incorrect could negatively affect the resident by not receiving designated services. Interviews with the MDSC, DON, and ADM confirmed that PASSAR screenings were expected on admission and when diagnoses changed, and that the MDSC was responsible for completing or verifying them. The MDSC, DON, and ADM each stated that Resident #4’s bipolar disorder diagnosis should have resulted in a positive Level 1 PASSAR and that a new PASSAR should have been completed after the diagnosis was added. The ADM also stated Resident #99’s major depressive disorder should have indicated a positive Level 1 PASSAR, but was unsure why the screening was negative. The facility document titled Nursing Facilities Responsibilities Related to PASSAR stated that individuals must have a completed PL1 before admission and that if PL1 identifies MI, ID, or DD, a LIDDA or LMHA completes and enters a PE.
Fluids Not Kept Within Reach of Two Residents
Penalty
Summary
The facility failed to ensure sufficient fluid intake was offered to maintain proper hydration and health for two residents. For Resident #10, record review showed a 92-year-old female with diagnoses including Alzheimer’s disease, muscle wasting and atrophy, muscle weakness, anxiety disorder, need for assistance with personal care, hypertension, and gout. Her MDS indicated she was unable to complete the interview and had functional limitation in range of motion in the lower extremities with wheelchair use needed. Her care plan included encouraging adequate nutrition and hydration. During observation and interview, she was lying in bed awake and stated she could see her water across the room but could not reach it; the water cup was located more than 5 feet away from her bed. For Resident #47, record review showed a 100-year-old female with diagnoses including Alzheimer’s disease, muscle wasting and atrophy, muscle weakness, anxiety disorder, need for assistance with personal care, and hypertension. Her MDS showed a BIMS score of 00 and indicated severe problems with thinking and memory. Section GG reflected that she needed set-up or clean-up assistance while eating food and/or liquid once the meal was placed before her. During observation, she was lying in bed asleep with a blanket covering her from chin to toe, and no hydration was observed within her reach. An interview with the Restorative Nursing Assistant stated fluids should be placed within reach of residents and staff were responsible for ensuring call lights and fluids were within reach. Interviews with the ADON, CNA, and ADM confirmed that staff were expected to keep fluids within reach of residents and monitor hydration during rounds. The ADON stated she did not know why the two residents were not provided fluids within reach and said it must have been between visits from the hospitality aide. The ADM stated nursing staff were responsible for monitoring that fluids were provided and within reach, and that the hospitality aide was the primary person responsible for making sure all residents had hydration nearby. The facility policy stated each resident would be provided with sufficient fluid intake to maintain proper hydration and health, and that fluids would be offered or provided between meals for dependent residents unless contraindicated.
Failure to Perform Hand Hygiene During Puree Food Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food Safety and Nutrition Services. During observation of DA A preparing puree food, she did not wash her hands before starting the puree process for the meatballs. She then handled multiple food preparation tasks, including putting meatballs into the steamer, wiping the counter, using the puree machine for noodles, placing foil-wrapped noodles into the steamer, adding water to the steamer, and wiping the counter again, without washing her hands between tasks. She also prepared broccoli by placing it in the puree machine, using a spatula for the broccoli, covering the pureed broccoli with foil, and wiping down the counter, again without washing her hands between tasks. During interviews, the ADM, DA A, and the DM all stated they were trained on infection control and hand hygiene, and that staff were expected to wash hands between tasks and when entering the kitchen. The DM stated DA A needed more training. Record review showed the facility's infection control and hand hygiene policies required staff to follow hand hygiene standards and wash hands before and after handling food.
Inaccurate Smoking Assessment Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 1 of 4 residents reviewed. Resident #1’s smoking assessment, dated 11/21/2025, documented that the resident did not smoke, even though other records and observations showed that he was a smoker. His face sheet identified him as a [AGE]-year-old male admitted on [DATE], with diagnoses including peripheral vascular disease, adult failure to thrive, localized swelling, tinea unguium, muscle weakness, lack of coordination, and abnormalities of gait and mobility. His admission MDS showed a BIMS score of 14 and marked current tobacco use as no, while his care plan dated 12/02/2025 identified a potential for injury related to smoking and included interventions for a smoking plan, smoking policy education, supervision, and storage of smoking materials. During observation on 12/30/2025 at 2:00 p.m., Resident #1 was seen outside smoking with Resident #26 and staff, and both residents wore smoking aprons. In interview, Resident #1 stated he goes out to smoke with staff three times a day and that staff stay with the residents the whole time. Resident #26 also stated she smokes three times a day and that staff always make residents wear smoking aprons. The ADM stated he assumed Resident #1’s smoking assessment was marked nonsmoker by mistake, and the MDSN and DON stated the assessment should reflect the resident’s smoking status and capacity, but neither could explain why Resident #1 was documented as a nonsmoker.
Failure to Document Medication and Treatment Administration in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, there were multiple instances where medications and treatments administered to the resident were not documented in the electronic health record system. The missing documentation included several dates where medications such as Levothyroxine and Midodrine, as well as catheter care and placement checks, were not signed off by the responsible nursing staff. This lack of documentation was identified through a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), which showed unsigned entries for the administration of prescribed medications and completion of required treatments. The resident involved had complex medical needs, including hypothyroidism, hemiplegia, insomnia, diabetes insipidus, and muscle weakness. Physician orders were in place for thyroid replacement therapy, blood pressure medication, and catheter care, all of which required consistent administration and monitoring. Despite these orders, the MAR and TAR revealed that on several occasions, the required medications and treatments were not documented as given. Written statements from the involved nursing staff indicated that the medications and treatments were administered, but the staff forgot to document these actions in the records at the time of administration. Interviews with facility leadership confirmed that it was the expectation for nursing staff to document all administered medications and treatments in the MAR/TAR immediately after completion. The absence of documentation meant that it could not be confirmed whether the care was provided, as the records would indicate the tasks were not completed. The facility's policy also required that each medication order be documented with the date, time, and signature of the person administering the medication, which was not followed in these instances.
Failure to Document and Assess Resident After Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dysphagia, and muscle wasting was not properly monitored following the administration of a nebulizer treatment. The resident had a physician's order for Ipratropium-Albuterol inhalation solution to be given three times daily for shortness of breath. On the date in question, the medication administration record showed the resident received the nebulizer treatment, but there was no documentation of the resident's response to the therapy or any follow-up assessment by the administering RN. Additionally, no vital signs were recorded after the treatment, despite facility policy requiring pulse checks before and after aerosol drug delivery. Interviews with facility staff, including the nurse practitioner and DON, confirmed the expectation that residents should be assessed and have their vitals monitored after receiving respiratory treatments. The RN involved acknowledged she did not follow up with the resident after administering the nebulizer treatment and admitted she should have performed an assessment. Facility policies reviewed also supported the need for thorough documentation and monitoring following respiratory care interventions.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, specifically from being yelled at, humiliated, and denied care by a CNA. The resident, who has multiple sclerosis and other conditions affecting mobility and coordination, reported that the CNA yelled at her and refused to assist with transfers and toileting, leading to an accident. The resident expressed feeling uncomfortable and anxious about the CNA's presence, as the CNA's behavior made her feel bad about her inability to perform certain tasks independently. Interviews with other staff members corroborated the resident's claims, with one RN stating that the CNA had a history of talking down to residents and refusing to provide necessary care. The RN also reported that the CNA was often unreachable during shifts and was seen using her phone instead of attending to residents. Despite these concerns being raised with the Executive Director (ED), the ED's response was limited to providing customer service training to the CNA, without addressing the specific allegations of abuse and neglect. The facility's social worker admitted to not following up on the resident's grievance, and the ED did not recall the specifics of the complaint, indicating a lack of effective communication and response to the resident's concerns. The failure to adequately address the resident's grievances and the CNA's behavior resulted in the identification of an Immediate Jeopardy situation, highlighting the risk of abuse and psychosocial harm to residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. This deficiency was observed on 19 specific days between July 4, 2024, and October 2, 2024. During these days, there was no RN scheduled, and the Director of Nursing (DON) often covered the shifts when available. However, the facility's average daily occupancy exceeded 60 residents, which meant the DON should not have been serving as the charge nurse. The absence of an RN on these days placed residents at risk of missed nursing assessments, interventions, care, and treatment. Interviews with staff revealed that the facility relied on two full-time RNs working 12-hour shifts, and when they were unavailable, the DON would step in to cover the RN duties. The staffing coordinator communicated the absence of an RN through a messaging app and attempted to fill the gap with agency RNs when possible. Despite these efforts, there were still days without RN coverage, and the DON admitted to misinterpreting the policy regarding her role and the required RN coverage. The facility did not have a specific policy for RN coverage, instead relying on the regulatory language from CMS. Both the DON and the Administrator acknowledged their misunderstanding of the requirement that the DON's hours could not count towards the mandatory RN coverage due to the facility's census. The Administrator also noted the difficulty in hiring RNs, despite ongoing recruitment efforts, and expressed a desire to consider a waiver for RN coverage.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple observations and interviews. Resident #46, who has severe cognitive impairment and requires substantial assistance, was repeatedly observed with food spilled on her clothes for extended periods after meals. Despite being in a public area, staff did not offer to change her clothes, which could have contributed to a diminished sense of dignity and self-worth. Interviews with staff confirmed that residents should not remain in soiled clothing, yet Resident #46 was left unchanged for hours. Additionally, the facility did not consistently respect residents' rights to privacy. During meal service, staff members were observed entering the rooms of Resident #56, Resident #76, and Resident #78 without knocking. Interviews with these residents revealed mixed feelings about the lack of knocking, with some expressing a desire for staff to always knock before entering, regardless of the circumstances. Staff interviews confirmed that the policy requires knocking and announcing oneself before entering a resident's room, but this practice was not consistently followed. The facility's failure to adhere to its own policies regarding resident dignity and privacy was further highlighted by interviews with the Director of Nursing (DON) and the Administrator (ADM). Both acknowledged the importance of knocking and changing residents' clothes when necessary, attributing lapses to staff becoming too familiar with residents. Despite training on resident rights, the facility's practices did not align with its policies, resulting in a deficiency in maintaining a dignified and respectful environment for its residents.
Inaccurate MDS Documentation for Psychiatric Disorders
Penalty
Summary
The facility failed to ensure accurate assessments of psychiatric and mood disorders for four residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #33's quarterly MDS did not reflect her anxiety disorder, despite having physician orders for medications like Xanax and Venlafaxine for anxiety and depression. Her psychiatric progress notes and care plan indicated diagnoses of major depressive disorder and generalized anxiety disorder, yet these were not accurately captured in the MDS. Similarly, Resident #46's MDS failed to include an anxiety disorder diagnosis, even though she was prescribed Alprazolam and Citalopram for anxiety and depression. Her psychiatric progress notes and care plan confirmed the presence of anxiety, but this was not reflected in the MDS. The lack of accurate documentation could lead to inadequate care planning and treatment. Resident #69 and Resident #433 also experienced similar issues with their MDS documentation. Resident #69's MDS did not list any psychiatric or mood disorders, despite being on medications for anxiety and depression. Resident #433's admission MDS omitted anxiety and depression diagnoses, even though her care plan and psychiatric evaluation indicated these conditions. Interviews with staff revealed a lack of clarity and responsibility in ensuring accurate MDS documentation, contributing to these deficiencies.
Failure to Provide Personalized Activity Programs for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessment, care plan, and preferences of two residents, leading to unmet recreational and social needs. Resident #46, a female with severe cognitive impairment, dementia, Parkinson's disease, and major depressive disorder, was not consistently engaged in activities despite her care plan indicating a need for staff assistance and escort to activities. Her participation records showed minimal involvement in activities, with only one recorded attendance at a religious service over a two-month period. Resident #71, also with severe cognitive impairment and diagnosed with dementia and generalized anxiety disorder, lacked a documented participation record for two months. Despite having interests in crafts, music, and TV, there was no evidence of her engagement in these activities. Observations revealed that both residents spent significant time sitting in the hallway in their wheelchairs, with minimal interaction or engagement in activities, contrary to their care plans and preferences. Interviews with staff and family members highlighted a lack of awareness and implementation of personalized activities for these residents. Staff acknowledged the importance of activities for socialization and mental health but failed to ensure consistent participation. The activity director and other staff members were aware of the residents' preferences but did not effectively facilitate their involvement in suitable activities, resulting in a deficiency in meeting the residents' physical, mental, and psychosocial well-being needs.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect three residents from the misappropriation of their hydrocodone/APAP tablets, a Schedule II controlled opioid medication used to treat pain. This deficiency was identified through interviews and record reviews, revealing that the residents were at risk of not receiving their prescribed medications. The misappropriation involved discrepancies in medication administration logs and missing tablets, which were discovered during a drug diversion investigation initiated by the Director of Nursing (DON). Resident #1, a female with dementia and muscle weakness, was prescribed hydrocodone-acetaminophen for chronic pain. Her medication administration log showed inconsistencies, with a document found in the shred bin indicating fewer tablets than recorded. Resident #2, a male with moderate cognitive impairment and osteoarthritis, also had discrepancies in his medication records, with zero tablets left in one blister pack. Resident #3, a female with moderate cognitive impairment and chronic pain, had similar issues, with her medication log found in the shred bin showing fewer tablets than expected. The investigation revealed that Medication Technician A (MT A) was responsible for administering medications to these residents. MT A's signature matched the medication administration sheets, and she was scheduled to work on the hall where the residents resided. The DON discovered that MT A had access to the medications and found new medication administration logs started for each resident in the medication cart. Despite being trained on medication administration and drug diversion, MT A did not respond when confronted about the missing medications, leading to her suspension and eventual termination.
Medication Misappropriation and Drug Diversion in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of property, specifically regarding the administration of prescribed medications. This deficiency was identified for three residents who were prescribed hydrocodone-acetaminophen for pain management. The facility did not adhere to its procedures designed to prevent drug diversions, which placed residents at risk of not receiving their prescribed medications. Resident #1, a female with dementia and muscle weakness, was prescribed hydrocodone-acetaminophen to manage chronic pain. However, discrepancies were found in the medication administration logs, indicating that the resident did not receive the correct amount of medication. Similarly, Resident #2, a male with osteoarthritis and muscle wasting, and Resident #3, a female with osteoporosis and COPD, also experienced discrepancies in their medication logs, suggesting that their medications were misappropriated. The investigation revealed that medication administration logs were improperly handled, with some found in a locked shred bin, and discrepancies in the medication counts were noted. The Director of Nursing (DON) initiated an investigation after being alerted to the issue, which led to the suspension and eventual termination of a medication technician (MT A) who was responsible for administering medications to the affected residents. The facility's failure to follow its drug diversion prevention procedures resulted in the misappropriation of medications, impacting the residents' care.
Failure to Maintain Resident Hygiene and Dignity
Penalty
Summary
The facility failed to ensure a resident who was unable to conduct activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #6, who had severe cognitive impairment and was dependent on personal hygiene assistance, was found with dried blood on his sheet and gown. The blood resulted from the removal of an IV, and staff did not promptly change the resident's sheets and gown, leaving the resident in an unsanitary condition for an extended period. Interviews with staff revealed that the blood on Resident #6's sheet and gown was noticed at approximately 12:45 pm, but the necessary changes were delayed. LVN H stated that the sheets and gown would be changed after completing an incident report on another resident. CNA F and the Administrator acknowledged the importance of changing the resident's linens and gown to prevent infection and maintain dignity, but the task was not completed in a timely manner. The facility's policies and procedures for nursing services and ADLs emphasize the importance of maintaining a clean and dignified environment for residents. The job description for the Restorative Nursing Assistant includes responsibilities such as changing bed linens and assisting with bathing. Despite these guidelines, the facility did not adhere to its own standards, resulting in a failure to provide necessary care and services to Resident #6, thereby compromising his quality of life and personal hygiene.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain personal hygiene. Specifically, Resident #3 did not receive scheduled showers since her admission, and Resident #5 was not assisted in closing his gown, leading to exposure of his buttocks to another resident on at least two occasions. These deficiencies were identified through observation, interviews, and record reviews conducted by surveyors. Resident #3, a [AGE] year-old female with a recent right hip fracture, had not received a shower or bed bath since her admission. Despite her care plan indicating the need for staff assistance with bathing and dressing, staff failed to offer her a shower or bed bath. Interviews with staff revealed inconsistencies in the shower schedule and lack of awareness about Resident #3's hygiene needs. The shower log confirmed that Resident #3 had not been given a shower since her admission. Resident #5, a [AGE] year-old male with a recent stroke and left-sided deficits, was observed wearing a hospital gown that was not properly fastened, resulting in exposure of his buttocks. Despite his care plan indicating the need for assistance with dressing, staff did not help him close his gown. Interviews with staff and Resident #5 revealed that he wore the gown due to difficulty in dressing and accidents, but staff failed to assist him in ensuring his gown was properly closed. This led to at least two instances of exposure, causing potential embarrassment and discomfort for both Resident #5 and other residents.
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 55 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 Marble Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Brixton At Horseshoe Bay | 5.4 mi | ★★★★★ | 0 | 0 |
| Avir At Burnet | 12.2 mi | ★★★★★ | 5 | 0 |
| Avir At Kingsland | 12.9 mi | ★★★★★ | 18 | 0 |
| Bertram Nursing And Rehabilitation | 16.9 mi | ★★★★★ | 5 | 0 |
| Avir At Johnson City | 22.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Granite Mesa Health Center.
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.