Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Grancare Nursing Center during CMS and state inspections, most recent first.
Unsafe food storage and improper glove use were observed in the kitchen and during meal service. Surveyors found expired and undated food items in coolers, freezers, dry storage, and unit refrigerators, including produce, dairy items, meats, and resident food. During lunch service, a CK-K used the same gloves while handling food, utensils, cups, trays, countertops, and other surfaces, then left the steam table to open a package of cups and resumed serving with the same gloves.
A facility failed to maintain an infection prevention and control program when its water management plan omitted key water system components, two drinking fountains were left unplugged and without signage to keep residents and visitors from using them, and staff did not follow EBP during care for a resident with a Foley catheter and multiple diagnoses including MS, paraplegia, and MDRO resistance. During peri care and transfer, two CNAs removed gloves too early and did not perform observed hand hygiene after PPE removal, which the DON confirmed was not consistent with required PPE use.
A resident with Alzheimer's disease, legal blindness, severe cognitive impairment, and a history of falls was observed twice with the call light on the bed and not within reach while seated in a wheelchair. Facility policy required the room service light to be within reach at all times, and CNAs stated it should be clipped to the wheelchair even though the resident did not usually use it. The DON stated the resident could not use the call light but it still should have been within reach.
PASARR screening was not completed correctly for a resident with major depressive disorder and antidepressant use. The admission PASRR Level I Screen failed to identify the mental illness and did not accurately list nortriptyline and mirtazapine as antidepressants, so a PASRR Level II Screen was not done to determine whether placement was appropriate and whether specialized services were needed.
The facility failed to report allegations of abuse for two residents to the State Agency as required. One resident reported inappropriate comments by a CNA, and another resident's family alleged a staff member pushed the resident. Investigations were conducted, but the incidents were not reported within the required timeframe, leading to a deficiency.
The facility failed to store and prepare food in a sanitary manner, with surveyors finding unlabeled and expired food items in unit refrigerators. Additionally, staff did not follow safe food cooling protocols, as observed during the reheating of meals. The Dietary Manager acknowledged the issues and mentioned efforts to remind staff about proper procedures.
The facility failed to provide proper written transfer notices to two residents who were hospitalized. One resident did not receive a notice due to a misunderstanding of policy regarding return times, while another received an incomplete notice lacking State Agency contact information. These deficiencies indicate non-compliance with the facility's Discharge or Transfer Policy.
A resident transferred to the ER with UTI symptoms did not receive a required bed-hold notice. The facility's policy mandates providing a bed-hold notice upon hospital discharge, but the DON indicated it was only given if the resident returned after midnight. As the resident returned before midnight, no notice was provided, violating the policy.
Unsafe Food Storage and Improper Glove Use During Meal Service
Penalty
Summary
Food was not stored and prepared in a safe and sanitary manner in the facility kitchen and unit refrigerators/freezers. During an initial kitchen tour, the Dietary Manager confirmed the facility followed the Wisconsin Food Code, and surveyors observed expired and undated food items in the reach-in cooler, reach-in freezer, and dry storage area. In the cooler, surveyors found baby carrots with use-by dates of 1/4/26 and 12/12/25, as well as an unlabeled bag of grapes that appeared to contain mold. Surveyors also observed multiple items without delivery dates, open dates, or use-by dates, including vegetables, fruit, eggs, hot dogs, and chicken breasts. In the freezer and dry storage area, surveyors found additional undated food items such as green beans, cauliflower, bread, whipped topping, ice cream cups, sugar, and flour. Undated food items were also observed in unit refrigerators. In the Caring Drive refrigerator, surveyors found prune juice concentrate, an open bottle of ketchup, Snack Pack pudding packs, and a half container of vanilla ice cream without dates. In the Grand Ave refrigerator, surveyors observed prune juice concentrate, grape juice concentrate, and an undated container of resident food. In the therapy unit refrigerator, surveyors found prune juice concentrate and grape juice concentrate without dates. The Dietary Manager confirmed that foods delivered, opened, and used to serve residents should include the delivery date or use-by date stamped by the vendor, and verified that the items observed in the cooler and freezer did not contain delivery dates and/or use-by dates. During lunch service, a CK-K was observed wearing the same gloves while performing multiple tasks without changing them. The CK-K obtained food temperatures, touched a thermometer, recorded temperatures with a pen, handled bowls, plates, crackers, and small cups, scooped cheese from a bin, touched the inside of the bin with gloved hands, placed cornbread on plates, and handled trays, countertops, service areas, scoops, and ladles. When the CK-K ran out of small cups, the CK-K left the steam table, opened a package of cups on a supply cart, and then returned to meal service using the same gloves. The CK-K continued serving residents and repeated the same pattern of handling food, utensils, and surfaces with the same gloved hands.
Infection Control Lapses in Water System Oversight and PPE Use
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. Survey review of the facility’s Water Safety and Management Plan found that the water system diagrams did not include the water fountain, rehabilitation ice machine, rehabilitation tub room, or two drinking fountains. The plan also indicated the facility did not have a water fountain, even though Surveyor observed one mounted on a wall in the facility. The Maintenance Director reviewed the diagram with Surveyor and identified the missing components, stated he cleaned and maintained the water fountain and two ice machines quarterly without documentation at the time of interview, and stated he flushed the rehabilitation tub room weekly even though it was not listed on the weekly flush log. Surveyor also observed that the Caring Hall drinking fountain had its water shut-off valve turned off, and water only came to the surface of the spout without coming out. The Caring Hall and Grand Hall drinking fountains were unplugged from their outlets. The Maintenance Director verified the shut-off valve was off, turned it back on, and stated he was not aware it had been shut off. He also verified the two drinking fountains were not plugged in and stated the compressors were not functioning, leaving the water at room temperature. He further stated the drinking fountains were used daily by housekeeping to fill cat water dishes. The Maintenance Director confirmed there was no sign telling residents or visitors not to use the drinking fountains and nothing in place to prevent their use. Surveyor also observed staff providing care to a resident on enhanced barrier precautions who had diagnoses including history of urinary tract infections, multiple sclerosis, paraplegia, resistance to multiple antibiotics, and candidiasis, and whose MDS assessment showed a BIMS score of 14 out of 15. During peri care and transfer, one CNA removed gloves prematurely, repositioned the resident, handled the Hoyer sling and catheter bag, and later removed the gown and washed hands only after leaving the room. The second CNA also removed gloves during the transfer, repositioned the resident, removed the sling and lift, and exited without observed hand hygiene. Both CNAs acknowledged gloves and hand hygiene should have been used as required, and the DON verified the staff removed gloves prematurely and should have worn gloves and a gown for the entirety of direct patient care and completed hand hygiene upon exiting the room.
Call Light Not Kept Within Reach for Resident With Severe Cognitive and Vision Impairment
Penalty
Summary
The facility did not ensure a call light was within reach for one resident, R22, during observations on 1/5/26 and 1/6/26. The facility policy dated 10/19/15 stated that each neighbor in their room or in bed must have the room service light placed within reach at all times. On 1/5/26 at 10:01 AM, the surveyor observed R22 in a wheelchair in the room with the call light on the bed and not within reach. On 1/6/26 at 3:50 PM, the surveyor again observed R22 in a wheelchair with the call light on the bed and not within reach. R22 was admitted with diagnoses including Alzheimer's disease, legal blindness, spinal stenosis, and segmental and somatic dysfunction of the sacral region. R22 had an activated POAHC, a BIMS score of 6 out of 15, and a care plan noting poor vision, occasional confusion, and a history of falls. CNA-E and CNA-F both stated the call light should be within reach and clipped to R22's wheelchair, and each clipped it to the wheelchair after the surveyor pointed it out. R22's record also showed a fall on 11/29/25 in which R22 used the remote control for an electric recliner in a way that caused sliding to the base of the chair, and the investigation noted R22 did not call for assistance. DON-B stated R22 could not use the call light but it still should have been within reach.
PASARR Screening Not Completed for Resident With Major Depressive Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed correctly for one resident, R8, who was admitted with diagnoses including major depressive disorder, migraine with aura, and atrial fibrillation. R8 was responsible for own medical decisions and had an MDS BIMS score of 14 out of 15, indicating intact cognition. The facility’s PASRR Level I Screen dated 3/24/23 did not identify major depressive disorder and did not identify nortriptyline as an antidepressant medication; it listed mirtazapine as an other drug rather than as an antidepressant. Because the Level I Screen was inaccurate, a PASRR Level II Screen was not completed to determine whether nursing home placement was appropriate and whether specialized services were required. Record review also showed a hospital record from an overnight stay documenting major depressive disorder and orders for nortriptyline and Remeron for depression. The MDS Coordinator stated the resident’s MDS assessment was coded to indicate PASRR Level II conditions were met due to serious mental illness and antidepressant medication orders, and confirmed the resident had been admitted with major depressive disorder and prescribed nortriptyline and Remeron. The Neighbor Advocate acknowledged the admission PASRR Level I Screen had been filled out incorrectly and stated it should have included the diagnosis of major depressive disorder and both antidepressant medications, which would have required a PASRR Level II Screen.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (SA) for two residents, R1 and R4, as required by federal regulations. R1, who had moderately impaired cognition due to Alzheimer's and Parkinson's diseases, reported an incident involving inappropriate comments made by a Certified Nursing Assistant (CNA) during personal care. Although R1 did not report any inappropriate physical contact, the comments were deemed concerning. The facility initiated an investigation but did not report the incident to the SA within the required timeframe, as the Nursing Home Administrator (NHA) mistakenly believed the incident was not reportable. In the case of R4, who also had moderately impaired cognition and multiple health issues, a grievance was filed by R4's family alleging that a staff member pushed R4 down when R4 attempted to stand without assistance. The facility conducted an investigation and determined that the staff member was attempting to assist R4 to prevent a fall, and there was no misconduct. However, the incident was not reported to the SA because the Social Worker (SW) and NHA concluded it was not an allegation of abuse, despite the grievance being filed by R4's decision maker. Both incidents highlight the facility's failure to adhere to the policy of reporting all allegations of abuse to the SA within the specified timeframe. The facility's policy requires immediate reporting of such incidents, but in both cases, the facility did not comply with these requirements, leading to a deficiency in reporting suspected abuse or neglect.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as observed by surveyors. During inspections of unit refrigerators, it was found that food items intended for resident consumption were not labeled with open or expiration dates, and some were beyond their labeled discard dates. This issue was noted in three out of three unit refrigerators. Specific items included an open, unlabeled bottle of Pepsi, undated containers of milk, and various other food items without proper labeling or dating. The Dietary Aide acknowledged that these items should not have been in the refrigerator/freezer and should be discarded. Additionally, the facility did not adhere to safe food cooling protocols. The surveyor observed that staff did not follow the necessary procedures for reheating food in a microwave. For instance, a pureed patty melt was reheated without stirring or allowing it to cool for two minutes before checking the temperature, which was found to be 164 degrees Fahrenheit. Another instance involved reheating resident food brought from outside the facility without checking the temperature before serving. The Dietary Aides involved were unaware of the proper reheating procedures. The Dietary Manager confirmed the issues with unlabeled, undated, and expired food items and mentioned efforts to remind staff about proper labeling and dating. The facility's Food Handling Policy Strategy outlines the importance of maintaining food temperatures to prevent the growth of pathogenic microorganisms, but these guidelines were not followed, leading to potential risks for the residents.
Failure to Provide Proper Transfer Notices
Penalty
Summary
The facility failed to provide proper written transfer notices to two residents who were hospitalized, as required by their Discharge or Transfer Policy. Resident 9 was transferred to the emergency room due to urinary tract infection symptoms but did not receive a written transfer notice. The Director of Nursing (DON) indicated that a transfer notice is only given if a resident returns after midnight, which was not the case for Resident 9. This misunderstanding led to the omission of the required documentation. Resident 16 was transferred to the hospital with diagnoses of hyperkalemia and diabetic ketoacidosis. Although a written transfer notice was provided and signed, it lacked the necessary contact information for the State Agency. The DON was unaware of the requirement to include this information, which resulted in incomplete documentation. These deficiencies highlight a lack of adherence to the facility's policy and regulatory requirements regarding transfer notices.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident (R9) who was transferred to the emergency room due to symptoms of a urinary tract infection. According to the facility's Bedhold policy, effective since December 26, 2016, a bed-hold notice should be provided to residents upon discharge to the hospital, and Social Services should confirm with the resident's representative within twenty-four hours if they wish to hold the bed. However, R9's medical record did not indicate that such a notice was provided. The Director of Nursing (DON) stated that a bed-hold notice is only given if the resident returns after midnight, which was not the case for R9, who returned before midnight. Consequently, R9 did not receive the necessary bed-hold notice, contrary to the facility's policy.
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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 Green Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Bay Health Services | 0.4 mi | ★★★★★ | 0 | 0 |
| Ccc Of West Green Bay | 0.6 mi | — | 0 | 0 |
| Odd Fellow Home | 3.1 mi | ★★★★★ | 5 | 0 |
| Woodside Lutheran Home | 3.4 mi | ★★★★★ | 13 | 0 |
| Edenbrook Of Green Bay | 5.9 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.