Granada Post Acute

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the low-temperature dishwashing machine reached the required sanitizing water temperature of 120 degrees Fahrenheit (F, unit of temperature) prior to washing soiled dishes, and ensure dietary staff adhered to proper food safety practices when a cook was observed performing meal preparation without a beard net. These failures had the potential to result in improperly sanitized dishware and food contamination, which could increase the risk of foodborne illness, cross-contamination, and the transmission of infectious organisms potentially affecting all residents receiving meals and food services from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure repositioning and turning documentation was completed timely and accurately for five out of five sampled residents (Resident 32, Resident 7, Resident 95, Resident 4, and Resident 64). These failures resulted in documentation that could not be relied upon to verify care and services provided for Residents 32, 7, 95, 4, and 64. Cross reference F686.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavior episodes and the number of hours of sleep were monitored for two of five sampled residents (Resident 2 and Resident 11) receiving psychotropic medication (any drug that changes brain function resulting in alteration to mood, thoughts, feelings or behavior). These failures had the potential to place Resident 2 and 11 at risk for unnecessary psychotropic medication use and unidentified and unaddressed changes in behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS]- a resident assessment tool) for a significant change status was completed for one of two sampled residents (Resident 3) after the resident experienced a fall resulting in a fracture (a broken bone) on 1/28/2026. This failure resulted in delayed assessment and delayed transmission of Resident 3's significant change in condition to the Centers for Medicare and Medicaid Services (CMS, a federal agency within the U.S. Department of Health and Human Services (HHS) that administers major healthcare programs) and had the potential to negatively affect the resident's care planning, and delivery of necessary care and services related to the fall and fracture. Cross reference F657Findings: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set (MDS- a resident assessment tool) was accurately completed for one of one sampled residents (Resident 1), when Resident 1's MDS did not include his active diagnosis of dementia (a progressive state of decline in mental abilities). This failure had the potential to place Resident 1 at risk of not receiving comprehensive care that addressed his diagnosis of dementia.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care and referred to special services as needed) Level 2 evaluation was completed for one of one sampled residents (Resident 1). This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of two sampled residents (Resident 3) after the resident experienced a fall on 1/28/2026, which resulted in a fracture (a broken bone). This failure had the potential to result in ineffective care, treatment, and services for Resident 3, and placed the resident at increased risk for additional falls, injury, and unmet care needs. Cross reference F637Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), fracture of the right fibula (calf bone), and muscle weakness (loss of muscle strength). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four staff-dependent sampled residents' (Resident 25 and Resident 39) fingernails were trimmed and maintained in a clean manner. This failure had the potential to result in a negative impact on Resident 25 and Resident 39's quality of life and self-esteem and had the potential to result in sustaining an injury from scratching and developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer (PU- localized damage to the skin and/or underlying tissue usually over a bony prominence) prevention interventions were implemented for two of two sampled residents (Residents 32 and 52), by failing to: 1. Ensure Resident 32 received timely repositioning. 2. Ensure Resident 52's low air mattress (LAM- a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) was set according to the resident's weight. These failures had the potential to place Residents 32 and 52 at risk for pressure ulcer development and/or worsening skin integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow physician orders for orthostatic blood pressure (the measurement of blood pressure changes that occur from a sitting or lying position to a standing position) monitoring and recording for one of three sampled residents (Residents 24). This failure had the potential to place Resident 24 at risk for undetected orthostatic hypotension, dizziness, syncope (fainting), falls, injury, delayed medical intervention, and adverse cardiovascular complications related to changes in blood pressure upon position changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Urologist (medical doctor who specializes in treating diseases of the urinary tract in both men and women, as well as the male reproductive system) was consulted in a timely manner as ordered on 1/19/2026, and upon readmission to the facility on 2/20/2026 for one of one sampled residents (Resident 5) with an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine). This failure had the potential to place Resident 5 at risk for indwelling catheter related complications such as urinary tract infections (UTI- an infection in the bladder/urinary tract) and sepsis (a life-threatening blood infection).

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication, to the physician) recommendation was reviewed, addressed, and followed up with the physician for pain management therapy and non-pharmacological interventions for one of two sampled residents (Resident 3). This failure had the potential to affect Resident 3's pain management, comfort, and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and standardized recipes for one of four sampled residents (Resident 31). This failure had the potential for affecting Resident 31's meal satisfaction. FindingsDuring a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 3/13/2026 with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness (loss of muscles strength), and hypertension (HTN-high blood pressure). During a review of Resident 31's History of Physical (H&P), dated 3/16/2026, the H&P indicated Resident 31 could make needs known but cannot make medical decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely develop a comprehensive care plan for one out of three sampled residents (Resident 1), who refused to wear a hearing aid (a small electronic device worn in or behind the ear to amplify [increase] sounds, designed to help people with hearing loss). This failure had the potential for miscommunication and Resident 1's needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2), received proper treatment and assistive devices to maintain hearing abilities by failing to:Assist Resident 1 when the resident reported her hearing aids did not work properlyAssist Resident 2 when the resident reported he had concerns with hearing and ensure Resident 2 was assessed by the Otolaryngologist ([ENT doctor] specializing in the care for ear, nose and throat conditions) routinely. These failures had the potential for Residents 1 and 2 not being able to hear adequately during conversations with staff and other residents and could lead to misunderstanding or miscommunication between the residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of three sampled residents (Resident 1) who had a diagnosis of osteopenia (a decrease in bone mineral density and causes bones to get weaker). This deficient practice had the potential for staff not to properly care for Resident 1 and placed the resident at risk for further injuries and fractures (broken bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for three of 19 sampled residents (Residents 23, 19, and 24) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 23, 19, and 24's health status. This deficient practice also created the potential for Residents 23, 19, and 24 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR, a screening tool that helps identify possible serious mental illness [SMI], and if the resident requires specialized services) was submitted for one of four sampled residents (Resident 74). This deficient practice placed Resident 74 at risk of not receiving recommended or required treatments for diagnosed SMIs, or appropriate placement in a facility to meet Resident 74's needs.

Inspectors wrote2. During an observation on 3/24/2025 at 10:05 a.m., in Resident 191's room, observed Resident 191 lying in bed receiving supplemental oxygen via a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at three liters per minute. Observed Resident 191's room did not have an oxygen sign posted outside of the room's doorway. During a review of Resident 191's admission Record, the admission record indicated Resident 191 was initially admitted on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent the development or worsening of pressure ulcers (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for four of seven sampled residents (Residents 288, 74, 23, and 191) when: 1. Low-air-loss-mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings were incorrect for Residents 288, 74, and 191. 2. Resident 23 was not provided with a LALM as ordered by the resident's physician. 3. Resident 191's LALM was labeled with the wrong resident's name and weight settings. These deficient practices placed Residents 288, 74, 23, and 191 at risk for the development or worsening condition of existing pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety was maintained for one of two sampled residents (Resident 288) by failing to pad Resident 288's siderails. This deficient practice placed Resident 288 at risk for harm and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place oxygen signage at the room door entrance indicating oxygen was in use for one of six sampled residents (Resident 191) receiving oxygen therapy. This deficient practice had the potential to place all residents' and staff's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five percent (%) when Licensed Vocational Nurse (LVN) 1 failed to administer one of four randomly selected residents' (Resident 4) medications timely and as ordered by Resident 4's physician. The outcome was six medication errors out of 32 opportunities for errors, with resulted in a Medication Administration Error Rate of 18.75%, based on the following: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a daily menu and offer alternative menu options for one of eight sampled residents (Resident 3). This deficient practice had the potential to impact Resident 3's nutritional status, quality of life and result in food dissatisfaction leading to insufficient food intake.

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff were knowledgeable of the facility's process on how to handle unlabeled resident clothes found in the laundry area and failed to complete a resident belonging list upon readmission for one of seven sampled resident's (Resident 1), to protect the resident's property from loss or theft. This failure had the potential to violate Resident 1's right to a safe and home like environment.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Comprehensive Care Planning, and Falls by a Resident, for one of seven residents (Resident 2) who had a fall on 2/19/2025, by failing to: 1. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting with Resident 2 and the family representative, to discuss and revise (change) the plan of care after Resident 2's fall on 2/19/2025. 2. Reassess and revise care plan interventions to ensure Resident 2's safety and to prevent recurrent fall. These failures placed Resident 2 at risk for recurrent falls and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection prevention and control measures for five out of seven residents (Residents 1, 2, 3, 6, and 7) by failing to: a. Ensure Residents 1 and 3 were not cohorted (grouped together) with a resident (Resident 2) who had orders for contact isolation (a set of precautions used to prevent the spread of germs that can be transmitted by direct or indirect contact with a patient or their environment). b. Ensure clear signage was posted to inform staff and visitors the Enhanced Barrier Precautions ([EBP] use of gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms ([MDROs] bacteria or other microorganism resistant to multiple classes of antibiotics)) that were to be implemented when providing care for Residents 6 and 7. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up and ensure all required documents were sent to the General Acute Care Hospital (GACH) Rehabilitation (Rehab) Center for evaluation, to address one of three sampled residents (Resident 1), requested transfer. This deficient practice resulted to the delay in transfer and physical therapies in a GACH Rehab and had the potential to affect in maintaining Resident 1 ' s highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the Administrator failed to demonstrate or provide evidence of sufficient oversight over the activities of the facility's Medical Doctor (MD 1), who also served as the facility's Medical Director. This deficient practice had the potential to affect all 90 facility residents as the Medical Director was responsible for providing adequate oversight to ensure care and services provided for the 90 in-house residents in the facility met professional standards of quality. Cross Reference:

Inspectors wroteBased on interview and record review, Medical Doctor (MD) 1, who also served as the facility's Medical Director, failed to follow the facility's policies and procedure outlining the responsibilities of the Medical Director. This deficient practice had the potential to affect all 90 facility residents due to a lack of facility staff oversight, and the potential for unidentified resident care concerns. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain informed consent, per its policy and procedure, prior to the initiation and administration of psychotropics (medications that affect the mind, emotions, and behavior) for four of 17 sampled residents (Residents 75, 40, 82, and 20). 2. Ensure that facility staff were aware of the facility policy and procedure for obtaining informed consent prior to the initiation and administration of psychotherapeutic medications (psychotropics). These deficient practices placed Residents 75, 40, 82, and 20 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use. The above failures also removed the residents' rights to make decisions about the care and treatments they received in the facility. Cross Reference: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the care provided met professional standards for nine of 17 sampled residents (Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60) when the following occurred: 1. Informed consents were not obtained per the facility's policy and procedure prior to the initiation of psychotropic medications for Residents 75, 40, 82, and 20. 2. Psychiatric care provided to Residents 75, 82, 200, 94, 40, 20, 3, 13, and 60 under Medical Doctor (MD) 2 (facility psychiatrist) and Nurse Practitioner (NP) 1 was not regularly overseen or monitored by the facility Medical Director (MD 1) for potential concerns or compliance with facility policies and procedures. 3. Performance of MD 1, serving as the facility's Medical Director, was not overseen by the facility Administrator (ADM). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff initiated the administration of psychotherapeutic (also called psychotropics, medications that affect the mind, emotions, and behavior) for eight of 17 sampled residents (Residents 75, 82, 200, 94, 40, 3, 13, and 60) without behavioral justification to warrant the necessity of the medications. This deficient practice placed Residents 75, 82, 200, 94, 40, 3, 13, and 60 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotherapeutic medication use. Findings 1. During a review of Resident 75's admission Record, the record indicated Resident 75 was admitted to the facility on [DATE] with admitting diagnoses that included transient cerebral ischemic attack (a brief blockage of blood flow to the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date food items for 89 out of 95 residents. This deficient practice had the potential to cause food borne illnesses (food poisoning, any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 89 out of the 95 residents receiving food items from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the call light was within reach for one of 20 sampled residents (Resident 94). This deficient practice had the potential to cause avoidable harm to Resident 94 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference F-tag F656.

Inspectors wroteBased on interview and record review, facility staff failed to implement or develop a resident-specific care plan for three of 20 sampled residents (Resident 40, Resident 94, and Resident 30) when the following occurred: 1. Resident 40's care plan did not indicate the level of assistance he required for eating and drinking. 2. Resident 94's care plans indicated his call light needed to be within reach, and Resident 94's call light was observed hanging behind his bed and not within reach. 3. Resident 30's care plan did not indicate a physician ordered medical appointment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were aware of the level of assistance required by one of two sampled residents (Resident 40) for completion of activities of daily living (ADLs, activities related to personal care, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). This deficient practice placed Resident 40 at risk of not receiving his required level of assistance while eating and drinking, creating the potential for Resident 40 to experience avoidable weight loss and dehydration, or complications such as aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the nutritional status of one out of four residents (Resident 29) by not ensuring the registered dietitian (RD, health professional who has special training in diet and nutrition) recommendations were implemented for Resident 29. This deficient practice had the potential to cause further avoidable weight loss and malnutrition (lack of sufficient nutrients in the body) for Resident 29.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately and thoroughly completed Resident 7's Intake and Output Weekly Assessments. This deficient practice placed Resident 7 at risk for avoidable fluid balance problems, such as dehydration or hypervolemia (a condition in which the liquid portion of the blood [plasma] is too high).

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer artificial tears drops (for dry eyes) on time for one out of three residents (Resident 79) according to their policies and procedures. This deficient practice had the potential to result in Resident 79's discomfort and worsening of dry eyes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not expired in the dialysis (treatment that helps your body remove extra fluid and waste products from the blood) emergency kit (E-kit, a small supply of medications to quickly treat symptoms in an emergency). This deficient practice had the potential to cause contamination and loss of efficacy of the medications in the dialysis E-kit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross-contamination when placing soiled linens on top of a shared resident surface. This deficient practice had the potential to spread infectious microorganisms to staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that influenza (flu - a very contagious viral infection that affects the nose, throat, and lungs) and pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae) vaccinations (a method used to protect against harmful germs), were offered as required to one of five sampled residents (Resident 83). This deficient practice placed Resident 83 at a higher risk of acquiring the flu and pneumonia (an infection of the lungs caused by bacteria, viruses, or fungi), which could increase the resident's risk of developing serious complications. This deficient practice also had the potential to increase the risk of flu and pneumonia transmission to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Treatment Nurse (TN) 3 had the specific competencies and skill sets necessary to safely perform a nephrostomy tube (small tube that helped drain urine from kidney) dressing change for one of one sampled resident (Resident 1). This failure resulted in Resident 1 ' s nephrostomy tube being cut, requiring transfer to a general acute care hospital (GACH) and increased the risk for infection and medical complications for the resident.