Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granite Rehabilitation And Wellness during CMS and state inspections, most recent first.
A facility failed to provide adequate meal assistance and hydration monitoring for residents with weight loss and feeding assistance needs. Two residents with diagnoses including malnutrition, CVA, and Alzheimer’s disease were left with meal trays at the bedside or were not stayed with after being awakened for meals, despite needing setup, cueing, or hands-on help. One resident lost 7.57% of body weight in less than 3 months and another lost 10.11% in 1 month, and weekly weight monitoring was not followed. In the secure unit, residents were not offered drinks for an extended period, and staff reported fluids were generally only provided at meals.
Unsafe resident supervision, wheelchair securement, and water temperatures: A resident with severe cognitive impairment tripped and fell outside after exiting without the expected supervision, sustaining a laceration above the eye. Another resident with repeated falls slid out of a wheelchair during van transport when the resident was not properly secured and the van braked abruptly; staff noted the seatbelt setup did not prevent movement. Surveyors also found shower rooms and multiple resident bathroom sinks with water temperatures well above safe levels, including readings up to 143.2 degrees F.
Fluctuating Shower Water Temperatures in Multiple Shower Rooms: Residents reported that shower water was often cold, too hot, or changed repeatedly during bathing. Surveyor observations confirmed major temperature swings in all 3 shower rooms, including the second floor shower room where the maintenance assistant acknowledged resident complaints and said residents were often taken to another floor for showers.
A resident with a BIMS score of 12, spinal fusion, repeated falls, pain, unilateral extremity impairment, wheelchair use, and dependence for transfers slid out of a wheelchair during van transport after a sudden stop. A social services staff member without nursing background physically assisted the resident to the van floor and back into the wheelchair before the resident was assessed at the facility; the DON confirmed residents should be assessed before being moved after a fall and that the staff member was not trained to assess or assist with transfers.
Outdated thickened orange juice was found in the kitchen refrigerator used for resident drinks, and another case was observed in dry storage. The FANS Manager confirmed the beverages were for resident use, including for a resident who received thickened liquids, and acknowledged the juice cups were expired and should not be served.
A resident with severe dementia and behavioral symptoms, including wandering and aggression, did not receive appropriate behavioral health care and services. The care plan lacked comprehensive, individualized interventions, and staff primarily relied on redirection and medication without documented non-pharmacological strategies. The resident's escalating behaviors led to a physical assault on staff and another resident, resulting in police involvement and arrest.
A resident with severe cognitive impairment and multiple health conditions became physically aggressive, assaulted an LPN, and was arrested for aggravated assault. The facility issued an immediate discharge notice and transferred the resident to a detention center but failed to ensure the receiving facility could meet the resident's needs or to communicate required information as outlined in policy. Documentation from a healthcare provider justifying the discharge was also lacking.
The facility failed to provide adequate nursing staff, leading to long wait times for resident assistance and missed care activities like showers. Observations and interviews revealed that staffing levels were below required levels, with only two CNAs available for a large number of residents. Payroll data showed low weekend staffing and a one-star staff rating, while Hospitality Aides were incorrectly counted as nursing staff despite being unable to provide direct care.
A facility failed to identify and monitor target symptoms for a resident receiving psychotropic medications, despite the resident being cognitively intact and having multiple mental health diagnoses. The care plan and medication records lacked evidence of specific target symptoms and monitoring processes, confirmed by the DON. This deficiency was contrary to the facility's policy on psychotropic drugs.
The facility failed to ensure medications were not expired in the 2nd floor medication room. An observation revealed expired Bisacodyl suppositories in the refrigerator, despite the manufacturer's instructions not to use them past the expiration date. An RN confirmed these medications were available for resident use, contrary to the facility's policy requiring visible expiration dates and adherence to them.
A facility failed to create a care plan for a resident with PTSD and bipolar disorder, despite recommendations for individual therapy. The resident, who was cognitively intact, did not receive behavioral health support, and the social services assistant was unaware of the need for such services. The facility's trauma-informed care policy, requiring evaluations and care plan updates, was not adhered to.
A resident with anxiety disorder and schizophrenia, who was cognitively intact, reported dissatisfaction with the activities offered by the facility, stating that they did not align with their interests. The resident's care plan noted minimal activity involvement, and the activity director could not specify the one-to-one activities provided. The facility's policy required activities to meet residents' needs and interests, but this was not effectively implemented for the resident.
A facility failed to provide necessary behavioral health services to a resident with PTSD and other mental health disorders. Despite recommendations for individual therapy, the resident did not receive the required services due to delays and lack of alternative arrangements when the initial provider was unavailable. The care plan lacked development for addressing these needs, and the social services assistant was unaware of the requirement for behavioral health services, indicating a failure in policy implementation.
A resident with moderate cognitive impairment and an indwelling catheter received improper care from a CNA, who mishandled the catheter drainage bag and used a contaminated glove to obtain wipes during perineal care. These actions violated infection prevention protocols, as confirmed by the DON.
The facility's main kitchen was inadequately staffed, resulting in late and cold meals, poor food quality, and dissatisfaction among residents. Observations and interviews revealed consistent delays in meal service, with meals often being served cold or improperly cooked. The dietary department faced significant staff turnover and was still training new staff, contributing to the ongoing issues.
The facility failed to promptly resolve grievances related to food service, with residents reporting issues such as cold meals, incorrect orders, and significant delays in service. Despite acknowledging these issues, the facility had not fully implemented a performance improvement plan, leaving grievances unresolved.
The facility failed to provide showers according to resident preferences, with several residents receiving bed baths instead. Observations noted inadequate hygiene, with some residents having noticeable body odors. Interviews revealed misunderstandings among staff regarding shower protocols, particularly for residents on COVID precautions, leading to a high number of refusals and documented bed baths.
The facility failed to provide palatable and timely meals, with residents reporting issues such as cold, tasteless food, incorrect orders, and small portions. Observations confirmed delayed meal services, and interviews revealed dissatisfaction with the food quality and service. Staffing issues in the dietary department contributed to these ongoing problems.
A staff member failed to correctly don PPE before caring for a resident on droplet/contact precautions, wearing a gown open in the front. The staff member was not concerned due to the resident's lack of symptoms. Interviews indicated a need for education on proper gown use, and the facility's policy requires gowns to protect skin and clothing during care.
Inadequate Meal Assistance and Hydration Monitoring
Penalty
Summary
The facility failed to ensure adequate nutrition interventions and monitoring for two residents who had documented weight loss and needed assistance with meals. One resident had a BIMS score of 8, diagnoses including CVA and malnutrition, and required meal setup with cueing. Observations showed the resident asleep with a meal tray left at the bedside without staff assistance, and on another occasion staff delivered the tray, woke the resident, and left the room before activity staff later assisted with eating. The resident’s record showed a weight decrease from 173 pounds to 159.9 pounds in less than 3 months, and nutrition evaluations documented the need for meal setup and cueing. A second resident had a BIMS score of 14, diagnoses including Alzheimer’s disease, weakness, and malnutrition, and required partial to moderate assistance with eating once the meal was placed before the resident. Observations showed two CNAs woke the resident for dinner but did not stay to assist, and another observation showed a meal tray left at the bedside without staff assistance while trays were being delivered to other residents. The resident’s record showed a weight decrease from 188 pounds to 169 pounds in one month, and a nutrition evaluation documented the need for meal setup and assist as needed for eating. Facility policy required weekly weights for residents with significant weight loss, but there was no evidence the resident was weighed again until nearly two weeks after the initial weight. The facility also failed to provide sufficient fluids to residents in the secure unit. During extended observation, residents seated in the dayroom were not offered drinks for more than two hours. Staff interviews indicated drinks were only provided at mealtimes, the hydration station was outside the locked unit, and staff could not always leave the unit to obtain drinks because they were often the only aide present. The FANS manager stated her expectation was that fluids be offered every hour and confirmed routine fluids were not being offered.
Unsafe resident supervision, wheelchair securement, and water temperatures
Penalty
Summary
The facility failed to ensure resident safety related to falls and environmental hazards. One resident with severe cognitive impairment, including Alzheimer’s disease and non-Alzheimer’s dementia, was found outside ambulating when a visitor witnessed the resident trip and fall. The resident sustained heavy bleeding above the left eye and was noted by EMS to have a rock in the skin at the laceration site. Facility staff assisted the resident to standing, assessed the resident, called 911, and documented that the resident had a history of confusion and wandering. Interviews with staff and the resident’s representative indicated the resident had been expected to go outside and was not supposed to do so without supervision, yet the resident was able to exit after a visitor entered a code and let the resident out. A second resident with a BIMS score indicating cognitive intactness, diagnoses including repeated falls, pain, and spinal fusion, and dependence on staff for transfers fell from a wheelchair during transport in the facility van. The resident reported not being properly secured in the wheelchair and described sliding out when the driver braked abruptly. The incident report stated the resident was positioned in a wheelchair with a full body lift sling underneath and slid forward when the van stopped suddenly. The staff member driving the van stated the resident slid out after braking and believed the seatbelt catch did not function correctly. Observation of the van showed wheelchair securement straps were present, but the seatbelt used was a traditional shoulder-style belt that could lengthen and retract without restriction, and the additional strap that would secure the mounting bracket was not in use at the time of the incident. The facility also failed to maintain safe water temperatures on multiple units and in resident bathrooms. Observation showed the first-floor shower room reached 130.5 degrees F during continuous water flow, and the second-floor shower room reached 125.1 degrees F. The maintenance assistant reported that water temperatures in 11 resident room bathroom sinks exceeded 110 degrees F during continuous flow, with readings as high as 143.2 degrees F. These findings were confirmed during survey observation and interview.
Fluctuating Shower Water Temperatures in Multiple Shower Rooms
Penalty
Summary
The facility failed to provide residents with a comfortable and homelike environment in 3 of 3 showering areas because the shower water temperatures fluctuated during use. Resident #71 reported that the showers were usually cold and sometimes changed from cold to very hot and back to cold during the entire shower. During resident council, Resident #55 stated that the second floor shower room was too cold or too steamy. Surveyor observations confirmed the temperature fluctuations in each shower room. On the second floor, water temperatures varied from 68.3°F to 102.6°F during a 5-minute continuous flow, and the maintenance assistant confirmed residents had complained about the fluctuating temperatures and were often taken to another floor for showers. On the first floor, temperatures fluctuated from 107.2°F to 130.5°F during a 5-minute continuous flow. On the third floor, temperatures fluctuated from 70.9°F to 92.2°F during a 5-minute continuous flow. A recheck of the second floor shower room later showed temperatures fluctuating from 82°F to 125.1°F during a 5-minute continuous flow, again verified by the maintenance assistant.
Failure to Assess and Safely Handle Resident After Van Fall
Penalty
Summary
The facility failed to ensure treatment and care were provided according to orders, resident preferences, and goals for a resident who had a significant change MDS showing a BIMS score of 12 out of 15, indicating cognitive intactness, and diagnoses including other fusion of the spine, repeated falls, and pain. The resident also had upper and lower extremity impairment on one side, used a wheelchair, and was dependent on staff for transfers. The resident reported that while riding in the facility van, the resident slid out of the wheelchair and landed between the two front seats, stating that the wheelchair was not properly secured at the time of the incident. An incident report documented that the resident was being transported back from the hospital by a social services staff member when a vehicle in front of the van stopped abruptly, causing the van to stop suddenly and the resident to slide forward in the wheelchair. The staff member then pulled over, assisted the resident to the van floor in a controlled fashion, and physically assisted the resident back into the wheelchair before continuing to the facility, where the resident was assessed on arrival. The social services staff member stated he did not have a nursing background and confirmed the resident was not assessed until the van returned to the facility. The DON stated residents should be assessed prior to moving after a fall and confirmed the staff member did not have training to assess or physically assist with transfers of a resident.
Outdated Thickened Juice Found in Resident Beverage Storage
Penalty
Summary
The facility failed to ensure outdated food was disposed of in the main kitchen. During observation, five sealed cups of thickened orange juice with a best-buy date of 11/8/25 were found in the refrigerator used to store drinks provided to residents. A case of thickened orange juice cups was also observed in the dry storage room and was thrown away by the FANS Manager. The FANS Manager stated that all drinks in the refrigerator were for resident use and that resident #27 received thickened liquids, and further confirmed that the juices were outdated and should not be served to residents. Review of the facility's Food Storage policy stated that the manufacturer's expiration date, when available, is the use-by date for unopened items.
Failure to Provide Adequate Behavioral Health Services for Resident with Dementia
Penalty
Summary
A facility failed to ensure that a resident with severe dementia received appropriate behavioral health care and services to attain their highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including severe early onset Alzheimer's dementia with mood disturbance, anxiety, and major depressive disorder, exhibited significant cognitive impairment and behavioral symptoms such as wandering, intrusive behaviors, and increasing aggression. Despite these symptoms, the care plan lacked comprehensive, resident-centered interventions, particularly non-pharmacological strategies, and there was no evidence of a thorough assessment addressing the resident's wandering and behavioral issues. Documentation revealed ongoing behavioral incidents, including the resident entering other residents' rooms, touching belongings, urinating in inappropriate places, and escalating physical and verbal aggression toward staff and other residents. Staff notes indicated the resident was difficult to redirect, required frequent cueing, and became more agitated as the day progressed. Multiple staff interviews confirmed that interventions were limited to redirection and medication administration, with no documentation of attempted or implemented non-drug interventions or a behavioral care plan tailored to the resident's needs. The situation culminated in a serious incident where the resident physically assaulted a staff member and attempted to harm another resident, resulting in the police being called and the resident being arrested for aggravated assault. Interviews with facility leadership and staff confirmed gaps in documentation, assessment, and care planning, as well as a lack of clear communication and follow-through regarding behavioral interventions. The facility did not provide evidence of a systematic approach to managing the resident's behavioral health needs, contributing to the actual harm experienced.
Failure to Ensure Safe and Orderly Discharge Following Resident Assault
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including diabetes, dementia, anxiety disorder, and depression, was admitted to the facility and later became involved in a serious incident. The resident entered another resident's room, became physically aggressive, and assaulted an LPN by stepping on her foot and attempting to strangle her. The police were called, and the resident was arrested for aggravated assault and removed from the facility. Documentation shows that the facility issued an immediate discharge notice to the resident, citing endangerment to the safety and health of individuals in the facility. The facility's records indicate that after the resident's arrest, the discharge notice was delivered to the local detention center and sent to the resident and their representative by mail. The facility also notified the resident's son/POA about the arrest and discharge. However, there was no evidence in the medical record that the facility ensured the receiving facility (the detention center) could meet the resident's needs or that appropriate information was communicated to the receiving provider. Additionally, there was no documentation from a healthcare provider justifying the necessity of the discharge. A review of the facility's transfer and discharge policy requires that, in cases of discharge for safety reasons, the facility must document the transfer or discharge in the medical record and communicate appropriate information to the receiving care institution or provider. The policy outlines specific information that must be provided, such as practitioner contact information, resident representative information, advanced directives, special instructions, care plan goals, and other necessary information. The facility failed to meet these requirements in this case, as confirmed by interviews with the DON and ED, who stated that no further documentation was available.
Staffing Deficiency in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for assistance, with some waiting up to 40 minutes for call lights to be answered. Several residents mentioned that they did not receive scheduled showers due to staffing shortages. Observations on different floors confirmed that the number of Certified Nursing Assistants (CNAs) was below the required levels, with only two CNAs available to care for a large number of residents. Interviews with staff, including CNAs and an LPN, corroborated the residents' claims, revealing that the staffing levels were inadequate to provide timely care. The facility's staffing issues were further highlighted by the review of payroll-based journal data, which showed low weekend staffing and a consistent one-star staff rating over four quarters. The facility's daily staff postings inaccurately included hours from Hospitality Aides, who are not qualified to provide direct patient care, as part of the nursing staff hours. The Director of Nursing confirmed that Hospitality Aides were counted as part of the nursing staff, despite their inability to provide direct care. The facility's self-assessment indicated a need for 160 CNA care hours, but the actual average was only 148 hours, further demonstrating the staffing deficiency.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for a resident receiving psychotropic medications. The resident, who was cognitively intact with a BIMS score of 12 out of 15, had diagnoses including anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. The resident was prescribed risperidone for schizoaffective disorder and buspirone for anxiety disorder. However, the care plan did not specify target symptoms for each medication, and the medication administration records for June, July, and August 2024 lacked evidence of a process to monitor these symptoms. An interview with the Director of Nursing confirmed that the facility had not identified medication-specific target symptoms, which hindered their ability to evaluate the effectiveness of the medications. The facility's policy on psychotropic drugs, last revised in October 2022, emphasized the importance of validating appropriate diagnoses and recognizing the underlying causes of symptoms to treat conditions appropriately. Despite this policy, the facility did not adhere to these guidelines, resulting in a deficiency in monitoring and managing the resident's psychotropic medication regimen.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that medications available for resident use were not expired in one of the three storage areas, specifically the 2nd floor medication room. During an observation of the medication storage room refrigerator, a box of Bisacodyl suppositories was found with an expiration date that had already passed. The manufacturer's literature indicated that the medication should not be used after the expiration date, which was clearly marked on the carton and blister pack. An interview with an RN confirmed that all medications stored in the refrigerator were available for resident use. The facility's policy on floor stock medications required that expiration dates and lot numbers be clearly visible, and that medications should not be used beyond the expiration date on the original container or one year from the date of opening, whichever comes first.
Failure to Develop Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with post-traumatic stress disorder (PTSD) and bipolar disorder. The resident, who was cognitively intact with a BIMS score of 12 out of 15, had multiple diagnoses including anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. A PASRR Level II review recommended individual therapy for the resident. However, the care plan, last revised on June 30, 2024, did not include any interventions related to the resident's behavioral health needs for PTSD or bipolar disorder. Additionally, an interview with the social services assistant revealed that the resident did not receive any behavioral health support, and the assistant was unaware of the requirement for residents to receive such services. The facility's policy on trauma-informed care, last revised in October 2022, mandates that upon new admissions, a trauma-informed care evaluation is completed by a Licensed Nurse. Based on the evaluation, appropriate provider and IDT notifications should be made to support the care of residents with a history of trauma, and the care plan should be updated to include goals and interventions, including non-pharmacological means. This policy was not followed, contributing to the deficiency.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities of interest for a resident who was cognitively intact and diagnosed with anxiety disorder and schizophrenia. The resident expressed dissatisfaction with the activities offered, stating that the facility did not provide activities they would like to attend, nor did it offer one-to-one activities, which the resident indicated would be appreciated. The resident's care plan, last revised in February 2024, noted little or no activity involvement due to the resident's wishes not to participate, but it also mentioned that the resident enjoys music. Interventions included encouraging participation and inviting family members to attend activities with the resident. The activity director was unable to specify what one-to-one activities were performed for the resident, despite claiming that such activities were conducted. The facility's policy on activities, last revised in July 2015, stated that activities should include individual, small and large groups, one-to-one, and independent activities to meet residents' needs, abilities, and interests. However, the policy was not effectively implemented for this resident, as evidenced by the lack of suitable activities and the resident's expressed dissatisfaction.
Failure to Provide Behavioral Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with multiple mental health disorders, including post-traumatic stress disorder (PTSD). The resident, who was cognitively intact with a BIMS score of 12 out of 15, had a PASARR Level II review recommending individual therapy. Despite this, the facility did not ensure the resident received the required mental health services. Initial attempts to schedule services with a behavioral health facility were made in April, but the process was delayed due to incomplete paperwork. By July, it was discovered that the behavioral health facility was not accepting new patients, and no alternative arrangements had been made. Additionally, the resident's care plan, last revised in June, lacked any development for addressing behavioral health needs related to PTSD or bipolar disorder. The social services assistant admitted to being unaware of the necessity for residents to receive behavioral health services, indicating a gap in the facility's understanding and implementation of required care. The facility's policies on trauma-informed care and mental health rehabilitation services were not effectively followed, as evidenced by the lack of appropriate care planning and coordination for the resident's mental health needs.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention practices during the care of a resident with moderate cognitive impairment and an indwelling catheter. The resident, who was dependent on staff for toileting hygiene, was observed being assisted by a CNA who improperly handled the catheter drainage bag. The CNA placed the drainage bag on her gown above the resident's bladder, causing urine to flow backward toward the bladder, and later placed it under the resident's wheelchair. This improper handling of the catheter drainage bag was confirmed by the Director of Nursing as inappropriate. Additionally, during perineal care, the CNA used a contaminated gloved hand to obtain more wipes from the container after cleaning feces from the resident's rectal area. This action further demonstrated a failure to adhere to infection control protocols. The facility's failure to ensure that the catheter drainage bag was positioned correctly and to maintain proper hygiene during personal care was identified as a deficiency in infection prevention practices.
Inadequate Kitchen Staffing Leads to Meal Service Deficiencies
Penalty
Summary
The facility failed to ensure adequate staffing in the main kitchen, leading to multiple grievances from residents regarding the quality and timeliness of meals. Observations and interviews revealed that meals were consistently served late, often cold, and not in accordance with the scheduled meal times. Residents reported that breakfast was always cold, meals were overcooked or not flavorful, and dinner service was delayed. Additionally, there were instances where the facility ran out of necessary food items during meal service, resulting in substitutions that were not satisfactory to the residents. Several residents expressed dissatisfaction with the quality of the food, noting that it was often dry, tough, or improperly cooked. One resident, who required a high-protein diet for wound healing, reported that the food was too tough to chew and had to resort to ordering fast food and protein shakes to meet dietary needs. Another resident mentioned that the facility's response to dining concerns was inadequate, attributing the issues to a lack of staff and difficulty in hiring new personnel. Interviews with the facility's administrator and dietary manager confirmed that the dietary department had experienced significant staff turnover and was still in the process of training new staff. The facility had recently changed food providers, which required meals to be made from scratch, further complicating the situation. The dietary department was also short-staffed due to two members being off for a traumatic event, and there were three additional staff openings. Despite having a performance improvement plan, it had not been fully implemented at the time of the survey.
Unresolved Grievances in Food Service and Palatability
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to food service and palatability, as evidenced by multiple unresolved complaints from residents. A grievance form dated 1/9/24 indicated that a resident's daughter was upset about the resident receiving a small amount of soup, and although the registered dietitian confirmed the meal was appropriately served, the resident left the facility against medical advice. Another grievance dated 3/12/24 reported cold breakfast and issues with meal timing for a resident returning from dialysis, but the grievance was not marked as resolved. Further grievances highlighted ongoing issues with meal quality and service. On 3/21/24, a resident expressed dissatisfaction with a dinner meal, stating they would prefer to eat outside food due to management's inadequacies. Another resident on the same day reported a meal as inedible, but later could not recall the grievance. On 4/2/24, multiple residents complained about overcooked chicken and slow service, and on 4/7/24, a resident received the wrong sandwich order. Observations on 4/10/24 and 4/11/24 showed significant delays in meal service, with residents waiting up to an hour for lunch, and issues with food quality and availability. Interviews with residents and staff revealed systemic issues in the dietary department, including staff turnover, a change in food providers, and inadequate staffing levels. Residents reported meals being consistently late, improperly cooked, and not following the menu. The facility's administrator and dietary manager acknowledged ongoing food service issues, attributing them to staff shortages and a recent traumatic event affecting dietary staff. Despite a performance improvement plan being developed, it had not been fully implemented, and meal-related grievances remained unresolved.
Failure to Provide Showers as Per Resident Preferences
Penalty
Summary
The facility failed to ensure that bathing was performed according to the plan of care for residents on two care units. Multiple residents reported not receiving showers as per their preferences, with some residents only receiving bed baths instead. For instance, one resident reported only receiving two showers during their stay, despite their care plan indicating a preference for twice-weekly showers. Another resident was documented as having received only six showers over several months, with numerous bed baths recorded instead. Observations and interviews revealed that some residents had noticeable body odors, indicating inadequate hygiene care. One resident expressed a preference for showers but was routinely given bed baths due to issues with water temperature. Another resident, who was in isolation, was not provided a shower despite being on the shower list, and instead, only a bed bath was offered, which the resident declined. Interviews with staff, including the social services director and the DON, confirmed that there were misunderstandings among staff regarding showering protocols, particularly for residents on COVID precautions. Staff education was conducted due to a high number of resident refusals and documented bed baths, as bed baths were not as thorough as showers in cleaning residents.
Deficiencies in Food Service Quality and Delivery
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Multiple grievances were filed by residents regarding the quality and temperature of the food served. Residents reported issues such as dry and chewy tortillas, cold breakfast meals, overcooked chicken, and meals not being flavorful. Additionally, there were complaints about incorrect meal orders, such as a resident receiving ham instead of a turkey sandwich, and burnt grilled cheese sandwiches. Observations confirmed that meal services were delayed, resulting in cold food being served to residents. Interviews with residents revealed consistent dissatisfaction with the food service, citing slow service, cold and tasteless meals, and small portions. Some residents resorted to ordering fast food or supplementing their meals with protein shakes due to the inadequacy of the facility's food service. The facility's inability to provide meals that met residents' dietary needs and preferences was evident, with reports of meals being served late and not following the menu. Residents also expressed concerns about the lack of alternatives offered and the facility's failure to address their dining concerns. The facility experienced significant staffing issues within the dietary department, with reports of staff turnover and recent changes in food providers. The new menu required meals to be made from scratch, and the facility was still in the process of training new staff. The dietary department faced challenges due to staff being off work following a traumatic event, contributing to ongoing food service issues. Despite the development of a performance improvement plan, it had not been fully implemented, and the meal issues remained unresolved at the time of the report.
Improper PPE Use for Resident on Precautions
Penalty
Summary
The facility failed to ensure that staff correctly donned personal protective equipment (PPE) before providing care to a resident on transmission-based precautions. During an observation, a staff member was seen entering the room of a resident on droplet/contact precautions with a gown worn incorrectly. The gown was tied at the neck but left open in the front, leaving the staff member unprotected. This improper donning of PPE was confirmed during an interview with the staff member, who expressed no concern about the incorrect use of the gown because the resident was not symptomatic. Further interviews revealed that the staff member required education on the proper way to wear a gown when entering the room of residents in isolation. The facility's policy on standard precautions, dated May 2015, specifies that gowns should be worn to protect skin and prevent soiling of clothing during resident care activities. The nurse manager confirmed that remedial training for donning and doffing PPE was being conducted at the facility.
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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 Cheyenne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Polaris Rehabilitation And Care Center | 0.2 mi | ★★★★★ | 28 | 0 |
| Life Care Center Of Cheyenne | 2.3 mi | ★★★★★ | 20 | 0 |
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