Granite Rehabilitation and Wellness

In the surveyor’s words

From the most serious findings on record at Granite Rehabilitation and Wellness, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 26, 2026

  Based on observation, medical record review, resident, resident representative, and staff interview, facility incident review, and policy and procedure review, the facility failed to ensure residents' environment was free of accident hazards on 3 of 4 resident care units (1st floor, 2nd floor, 3rd floor) reviewed for safe water temperatures and for 2 of 3 sample residents (#5, #97) reviewed for falls. The facility implemented a plan of correction regarding the fall during van transport for resident #5, prior to the survey, and verified during the survey. The facility was determined to be in compliance for the fall during van transport on 3/11/26. The findings were: Related to resident falls: 1. […]

• Actual harm, isolatedF692Mar 26, 2026

  Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure adequate interventions and monitoring were provided to prevent significant weight loss and resulting harm for 2 of 8 sample residents (#2, #10) reviewed for nutrition, and offer sufficient fluid intake for 1 of 4 units (secure unit) reviewed for hydration. The findings were: Related to adequate nutrition interventions and monitoring 1. Review of the admission MDS dated [DATE] showed resident #2 had a BIMS score of 8 out of 15 which indicated moderate cognitive impairment, diagnoses which included cerebrovascular accident (CVA) and malnutrition, and required partial to moderate assistance with eating once the meal was placed before the resident. […]

• Actual harm, isolatedF740Jun 24, 2025

  Based on medical record review and staff interview, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (#1) reviewed for behavioral and emotional needs. This failure resulted in actual harm to resident #1 who was arrested for aggravated assault and taken to jail. The findings were: 1. Review of the 1/25/25 admission MDS assessment showed resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and an unspecified injury of the head. […]

• Actual harm, isolatedF600Nov 23, 2022

  Based on observation, medical record review, resident, guardian and staff interview, facility-reported incident review, and policy and procedure review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (#2) reviewed for resident-to-resident altercations. This failure resulted in harm to resident #2 who experienced sexual abuse a reasonable person would have found humiliating, intimidating, demeaning, and degrading. The findings were: Review of the 10/28/22 quarterly minimum data set (MDS) assessment showed resident #2 had a brief interview for mental status (BIMS) score of 9 of 15, indicating moderate cognitive impairment. Further review showed the resident had diagnoses which included multiple sclerosis and non-Alzheimer's dementia. […]

• Actual harm, isolatedF689Jul 14, 2022

  Based on observation, medical record review, resident and staff interview, facility incident investigation review, performance improvement plan review, and staff education and monitoring documentation review, the facility failed to ensure residents were transferred in a safe manner for 1 of 3 (#1) residents reviewed for appropriate transfer assistance. This failure resulted in harm to resident #1, who was transferred inappropriately and sustained a fracture. Corrective measures were implemented by the facility prior to survey, and and compliance was determined to be met on 3/29/22. The findings were: Review of the 6/11/22 quarterly MDS assessment showed resident #1 had diagnoses which included diabetes mellitus type II, other fracture, and [CONDITION(S)]. […]