Ganado Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 24 (Residents #27, #29) residents reviewed for Activities in that: 1. Residents #29, and #27 stated the activity schedule was not followed and there was no back up, if the activity director did not work. 2. The facility failed to provide activities as posted. This failure could affect all residents and could result in no Activity program for residents.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure menus reflected the needs of the resident population as well as input received from residents and resident groups for for 4 of 25 (Residents #29, #57, #22, and #17) residents reviewed for breakfast in that: 1. Resident #29 was bored of the same breakfast every morning and wanted variety.2. Resident #57 stated she was served the same breakfast every day and would rather have a variety of options. 3. Resident #22 stated she was served the same breakfast every day and would rather have a variety of options. 4. Resident # 17 stated he was served the same breakfast every day and would rather have a variety of options. This deficient practice could affect residents who consume breakfast and could result in psychosocial harm and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Residents #6, #23, #37 and #48) reviewed for infection control, in that: 1. On 02/24/2026, the facility failed to ensure CNA B and CNA C sanitized between their fingers while providing incontinent care for Resident #6 2. On 02/24/2026, the facility failed to ensure CNA D changed gloves between soiled and clean brief, while providing incontinent care for Resident #23. 3. On 02/24/2026, the facility failed to ensure CNA A sanitized her hands between change of gloves and after touching the resident's environment, while providing incontinent care for Resident #37. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure the resident environment remains as free of accident hazards as is possible for residents for 1 of 4 shower rooms reviewed, in that: The shower room at the end of 300 hall contained an unlocked cabinet in which were approximately eight razors for shaving and a container of germicidal wipes labeled not a skin or baby wipe and keep out of reach of children. This deficient practice could result in residents living in an environment that is not safe, clean, and comfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #37) reviewed for incontinent care and catheter care, in that: The facility failed to ensure that, while providing incontinent care for Resident #37, CNA A used a front to back motion to clean Resident #37. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary medication without adequate indication for its use, for 1 (Resident #11) of 15 residents reviewed for unnecessary medication, in that: Resident #11's prescription for Depakote did not have an associated diagnoses. This deficient practice could affect all residents who receive prescription medication.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the food and drink that is palatable, attractive, and at a safe and appetizing temperature for 3 of 25 (#17, #25, and #57) residents reviewed for food temperature in that: 1. Resident #17 stated food temperature was cold. 2. Resident #25 stated food temperature was cold. 3. Resident #57 stated her meals were always served cold. This deficient practice could affect all residents who consume meals and/or snacks from the facility and could result in psychosocial harm and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: A jar of marmalade, labeled refrigerate after opening was stored in a non-refrigerated dry goods pantry after being opened. This deficient practice could affect all residents who consume meals and/or snacks provided by the facility and result in food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 who eloped from the facility on 03/30/2025 when he exited through an unlocked sliding door at the end of hallway 200 and was found outside in the driveway. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/30/2025 and ended on 04/28/25. The facility had corrected the non-compliance before the survey began on 05/13/2025. This deficient practice could place residents at risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 1 narcotics refrigerator in main medication room, and for 1 of 2 medication carts (Hall 200 Medication Cart) reviewed for storage, in that: 1. During medication administration for Resident #34, MA- A left Hall 200 Medication cart unlocked outside the resident's room, out of sight of MA-A. 2. During medication administration for Resident #20, MA-B left 8 blister packages of medication unattended and unsecured on top of the 200 Hall medication cart. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards and not receiving therapeutic effects. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 3 spa/shower rooms reviewed, in that: The toilet in the spa/shower room on 200 hallway was loosely affixed to the floor and was able to be moved approximately two inches to the side. This deficient practice could place residents, staff, and the public at risk of living, working, and visiting within an environment which was unsafe and not functional.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 14 residents (Resident #30) reviewed for advanced directives, in that: The facility failed to ensure Resident #40's Out-of-Hospital Do Not Resuscitate (OOH DNR) was signed by two witnesses, which made the document invalid. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 residents (Resident #37) reviewed for pharmacy services, in that: The Narcotics refrigerator in the main medication storage room, contained an opened and expired medication, Lorazepam for Resident #37. This failure could affect residents whose medications were stored in the medication storage room and place residents at risk of receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #24) reviewed for infection control, in that: MA A did not sanitize the blood pressure cuffs (wrist and manual) and stethoscope between use with different residents. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for the safe storage, preparation, distribution, and serving of food, in that: The facility failed to discard an expired food item in the facility reach-in refrigerator. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for receiving expired food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (10/15/2024 to 10/16/2024) of 2 days reviewed. The facility did not post the required current nurse staffing information from 10/15/2024 to 10/16/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a storage container of prepared food in the reach-in cooler that was not properly sealed. 2. There was an open container of cottage cheese in the reach-in cooler without a date indicating when it should be used or discarded. 3. There were three open containers of thickened liquids in the reach-in cooler without dates indicating when they should be used or discarded. 4. There was an open 25 lb. sack of whole milk powder in the dry storage room that was rolled down and not placed in a sealed container. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 Residents (Resident #34) whose MDS records were reviewed for accuracy in that: Resident #34's quarterly MDS assessment dated [DATE] incorrectly documented the resident was treated with insulin. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 13.16% percent with 38 medication administration opportunities observed with 5 errors for 2 of 3 residents (Residents #6 and #35) and 1 of 2 (Medication Aide A) reviewed for medication administration, in that: Medication Aide A administered an expired medication to Resident #6 and administered medications to Resident #35 outside parameters as ordered by the physician. These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order.