Granite Creek Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Granite Creek Health & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628Jan 7, 2026

  Based on closed record review, staff interviews, and review of facility documentation and policy, the facility failed to ensure that the Ombudsman was notified of the transfer/discharge for 3 of 4 sampled residents (#115, #118, & 110). The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided. Findings include: -Resident #110 was admitted to the facility on [DATE] with diagnoses that included encounter for other orthopedic aftercare of right hip fracture, hemiplegia of the right dominant hand, failure to thrive, dementia, and type 2 diabetes mellitus. The care plan initiated on October 4, 2025, revealed a focus on failure to thrive, diabetes, high blood pressure, seizure, urinary tract infection, dementia, and anorexia. […]

• No harm, potential for more than minimal, patternF804Jan 7, 2026

  Based on observation, resident and staff interviews, facility documentation, and policy review, the facility failed to ensure that food items were palatable, and at a safe and appetizing temperature. The deficient practice could decrease residents' desire to eat which could impact their nutrition status and lead to slower recovery from illnesses or injury. Findings include:Review of the facility's 2025 Grievance log revealed the following food related grievances for the following months:January: general dietary/food concernsAugust: dietary concerns regarding temperatureOctober: food preference issues (2 different residents)November: general dietary/food concernReview of the 2025 Resident Council Meeting Minutes documented the following food related issues brought up by attendees during the… […]

• No harm, potential for more than minimal, patternF584Oct 2, 2024

  Based on observation, interview, and review of the facility's policies, the facility failed to ensure that 7 of 7 sampled residents (#65, #344, #38, #13, #19, #58, and #33) were provided a comfortable and homelike environment. The deficient practice could have a negative psychosocial impact on residents. -Regarding Residents #65 and #344: An observation was conducted on September 30, 2024 at 10:43 AM of room [ROOM NUMBER] belonging to Resident #65 who was not in the room at that time. From the doorway, observation of the wall revealed that paint had been scraped off of behind and surrounding the headboards of both A and B beds. An additional observation was conducted of the wall in room [ROOM NUMBER] later that day on September 30, 2024 at 2:25 PM. […]

• No harm, potential for more than minimal, patternF600Oct 2, 2024

  Based on observations, staff and resident interviews, clinical record and policy review, the facility failed to protect the rights of three residents (#22, #54, #89) to be free from abuse. The deficient practice may result in further resident to resident abuse. Findings include: -Resident #22 was admitted on [DATE] with diagnoses of a Crohn's disease, acute kidney failure, anxiety disorder, bipolar disorder, and depression. The care plan dated January 6, 2022 revealed that resident was taking antidepressant medication related to depression for episodes of crying. […]

• No harm, potential for more than minimal, patternF689Oct 2, 2024

  Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision for one resident (#60). The deficient practice resulted in resident wandering into other resident rooms uninvited. Finding includes: Resident #60 was admitted on [DATE] with diagnoses of unspecified cataract, hypertension, benign prostatic hyperplasia and chest pain. The initial admission record dated August 12, 2024 included that the resident was alert and oriented to time, place and person, was able to follow simple commands, had no behavior problems, was ambulatory or self-mobile in the wheelchair. The elopement/wandering evaluation dated August 12, 2024 revealed a score of 5 indicating the resident was low risk for elopement/wandering. […]