Ganado Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ganado Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 15, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF679Feb 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF803Feb 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880Feb 25, 2026

  Based 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. […]