Granite Mesa Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 27, 2025

  Based on interview and record review, the facility failed to ensure all residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to keep Resident #1 safe from being yelled at, humiliated, and being denied care by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/24/2025 at 5:42 PM . While the IJ was removed on 01/25/2025 at 2:45 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was no immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury and psychosocial harm. […]

• Actual harm, isolatedF689Jul 11, 2026

  Based on record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for transfers in that:CNA A failed to provide adequate supervision and transfer assistance on 06/21/26 for Resident #1 in her room during a bed to chair transfer requiring x2 person assistance per the plan of care. CNA A completed a transfer alone resulting in Resident #1 having a right tibia(inner and larger of the two bones between the knee and ankle)and fibula (outer and usually smaller of the two bones between the knee and the ankle) fracture and pain requiring hospitalization. The noncompliance was identified as PNC. […]

• No harm, potential for more than minimal, widespreadF727Oct 2, 2024

  Based on interviews, observations, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 19 of 94 days reviewed for RN coverage. The facility failed to ensure they had an RN scheduled on duty for 19 days (07/04/2024, 07/08/2024, 07/09/2024, 07/14/2024, 07/22/2024, 08/05/2024, 08/19/2024, 08/30/2024, 09/03/2024, 09/04/2024, 09/10/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/24/2024, 09/25/2024, 09/26/2024, 10/01/2024, and 10/02/2024) and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. […]

• No harm, potential for more than minimal, patternF558Dec 31, 2025

  Based on observation, interview, and record review, the facility failed to be ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relays relayed the call directly to a staff member or a centralized staff work area from each resident's bedside for 5 of 10 residents (Residents # 13, # 31, # 47, # 48 and # 67) reviewed for call lights.The facility failed to ensure Residents # 13, # 31, # 47, # 48 and # 67's call lights were within reach of the residents. These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life.Findings included:1. […]

• No harm, potential for more than minimal, patternF641Dec 31, 2025

  Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 3 residents (Resident #1, Resident #26 and Resident #70) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #1's admission MDS, dated [DATE], accurately reflected his smoking status.2. The facility failed to ensure Resident #26's admission MDS, dated [DATE], accurately reflected her smoking status. 3. The facility failed to ensure Resident #70's admission MDS, dated [DATE], accurately reflected her smoking status.These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings include:1. […]