Inspection Reports for Granger Nursing and Rehabilitation Center
2001 Kennedy Street, IA, 501099746
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 24, 2025
Visit Reason
A complaint investigation for complaints #1634953 and #2674439 was conducted on November 20, 2025 and November 24, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaints #1634953 and #2674439; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2025
Visit Reason
A complaint investigation for facility reported incident #2643702-I was conducted on October 20, 2025 to October 21, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation related to incident #2643702-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2025
Visit Reason
A complaint investigation for complaint #126720-C was conducted on March 06, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #126720-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 14, 2025
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance with health requirements.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective February 14, 2025.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 7
Jan 9, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey from January 6, 2025 to January 9, 2025.
Findings
The facility was found deficient in multiple areas including resident rights related to dignity and respect, failure to provide proper Notice of Medicare Non Coverage, unsafe and unmaintained heating elements, incomplete and inaccurate care plans, medication errors exceeding 5%, lack of qualified dietary staff, and improper food handling practices.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to speak to residents with dignity and respect for 3 of 3 residents reviewed, including rude behavior by a night shift CNA and slow response to call lights. | SS=D |
| Facility failed to provide appropriate Notice of Medicare Non Coverage (NOMNC) to 2 of 3 residents reviewed for Beneficiary Notification. | SS=D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment due to broken and missing baseboard heater safety grates exposing heating elements. | SS=E |
| Facility failed to revise comprehensive care plans to accurately reflect resident status and preferences for 2 of 16 residents reviewed. | SS=D |
| Medication error rate exceeded 5% with errors including crushing extended release medication, incorrect dosage, and improper insulin administration. | SS=D |
| Facility failed to employ a clinically qualified nutrition professional meeting certification requirements; Dietary Manager not yet certified and Registered Dietitian only on site one day per week. | SS=F |
| Facility failed to store, prepare, distribute and serve food in accordance with professional food service safety standards; staff made direct contact with food and serving utensils without proper hand hygiene or gloves. | SS=E |
Report Facts
Medication error rate: 16
Residents reviewed for care plans: 16
Residents reviewed for Medicare Non Coverage: 3
Residents reviewed for dignity and respect: 3
Facility census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Dunlap | Administrator | Named as responsible party for multiple corrective actions including dignity and respect, Medicare Non Coverage, heating elements, dietary operations |
| Walter Kosgei | Director of Nursing | Responsible party for medication administration corrective actions |
| Staff A | Certified Nurse's Aide (CNA) | Named in multiple resident complaints for rude behavior and slow response |
| Staff B | Certified Medication Aide (CMA) | Interviewed regarding proper resident care and medication administration |
| Staff C | Registered Nurse (RN) | Interviewed regarding resident dignity and respect |
| Staff D | Certified Nurse Aide | Interviewed regarding resident positioning and fall prevention |
| Staff E | Registered Nurse (RN) | Interviewed regarding resident positioning and fall prevention |
| Dietary Manager | Dietary Manager | Not yet certified, responsible for dietary operations |
| Director of Maintenance | Director of Maintenance | Interviewed regarding maintenance of baseboard heaters |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding staff expectations and facility conditions |
| Social Services Director | Director of Social Services | Interviewed regarding grievances and Medicare Non Coverage forms |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2024
Visit Reason
An investigation for Complaint #124241-C was conducted on October 23, 2024 to October 24, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was complaint-related for Complaint #124241-C; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 18, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective March 15, 2024.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 9
Feb 12, 2024
Visit Reason
The inspection was an annual recertification survey combined with an investigation of multiple complaints and a facility-reported incident conducted from February 12 to February 15, 2024.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to provide appropriate Medicare Non-Coverage notices, inadequate maintenance of the environment, incomplete background checks for employees, failure to notify the Long-Term Care Ombudsman of resident discharges, incomplete assessments after significant changes, failure to maintain a safe environment, medication errors, and infection prevention and control issues.
Complaint Details
Complaints #116440-C, #116810-C, #117139-C, #117526-C, #117917-C were investigated. Complaints #116440-C, #116810-C, #117526-C, and #117917-C were substantiated. Facility reported incident #117613-I was substantiated. Complaint #117139-C was unsubstantiated.
Deficiencies (9)
| Description |
|---|
| Facility failed to treat each resident with dignity for 3 of 6 residents reviewed. |
| Facility failed to provide appropriate Medicare Non-Coverage notices to residents. |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment; multiple maintenance issues observed. |
| Facility failed to assure all employees had completed Iowa criminal background and abuse registry checks prior to working. |
| Facility failed to notify the Long-Term Care Ombudsman of resident discharges/transfers as required. |
| Facility failed to complete significant change assessments within required timeframes. |
| Facility failed to maintain a safe environment by securing smoking supplies and educating residents and staff on smoking policy. |
| Facility failed to ensure medication error rate was less than 5%; medication pass observations revealed errors. |
| Facility failed to ensure infection prevention and control techniques were properly utilized during incontinence and catheter care. |
Report Facts
Residents reviewed for dignity deficiency: 6
Census: 49
Medication error rate: 5
Residents reviewed for Medicare Non-Coverage notice deficiency: 3
Employees sampled for background check deficiency: 7
Residents reviewed for Ombudsman notification deficiency: 4
Residents reviewed for significant change assessment deficiency: 1
Residents reviewed for medication pass observation: 49
Residents reviewed for infection control deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant | Named in background check deficiency; lacked completed Iowa criminal background check and DHS approval. |
| Staff A | Certified Medication Aide | Named in medication error findings; failed to lock medication cart and administered medications with errors. |
| Staff C | Certified Medication Aide | Named in dignity deficiency; failed to respond to resident calls for pain medication and did not assist resident to smoking area. |
| Director of Nursing | Director of Nursing | Provided statements regarding resident care expectations and medication error education. |
| Staff J | Registered Nurse | Interviewed regarding resident transfer and care needs. |
| Staff F | Certified Nursing Assistant | Named in infection control deficiency; failed to change gloves and sanitize equipment properly. |
| Staff E | Licensed Practical Nurse | Observed performing catheter care and infection control procedures. |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Aug 10, 2023
Visit Reason
The inspection was conducted following a complaint investigation for multiple complaints (#113367, #114059, #113818, #114104, #113989-C, #114188-C) from July 31, 2023 to August 10, 2023, along with a COVID-19 Focused Infection Control Survey.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation involved multiple complaints and the facility was found to be in substantial compliance.
Report Facts
Complaints investigated: 6
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 24, 2023
Visit Reason
A revisit of the survey ending on February 3, 2023 with intakes #110716-I, #111501-C, #111334-I, and #111769-C was conducted from March 15, 2023 to March 24, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, effective February 28, 2023. Complaints #111501 and #111769 and Facility Reported Incidents #110716 and #111334 were not substantiated.
Complaint Details
Complaints #111501 and #111769 were not substantiated.
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 16
Feb 3, 2023
Visit Reason
Recertification and Complaint Survey regarding complaint #110595-C and other regulatory compliance issues including infection control, resident rights, personal funds management, abuse prevention, restraints, transfer/discharge notices, activities, dietary staffing, food safety, administration, and antibiotic stewardship.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to sanitize glucometers between residents causing immediate jeopardy, failure to provide written transfer/discharge and bed hold notices, failure to ensure resident self-determination regarding vending machine access, failure to manage resident trust funds access after hours, failure to prevent resident-to-resident abuse, failure to assess and document use of physical restraints, failure to provide individualized activities, failure to employ a certified activity director and qualified dietary manager, failure to maintain food safety standards, failure to conduct nurse aide performance reviews and in-service training, failure to discontinue unnecessary psychotropic medication, failure to implement infection control and antibiotic stewardship programs, and failure to maintain adequate staff training.
Complaint Details
Complaint #110595-C was substantiated related to infection control and resident rights issues.
Severity Breakdown
E: 3
D: 6
F: 4
K: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to protect residents' rights related to choices by restricting access to vending machines for three residents. | E |
| Facility failed to ensure residents had access to their personal funds held in trust accounts on weekends and after business hours for three residents. | E |
| Facility failed to ensure residents were free from abuse for two residents involved in resident-to-resident altercations. | D |
| Facility failed to assess a tilting wheelchair as a restraint, failed to obtain physician's order, and failed to provide medical symptom for restraint use for one resident. | D |
| Facility failed to ensure residents/representatives received written transfer/discharge notices with required information for two residents. | D |
| Facility failed to provide written bed hold notices with required information for two residents transferred to hospital. | D |
| Facility failed to provide individualized activities for one resident. | D |
| Facility failed to have a certified activity director to direct activities for all residents. | F |
| Facility failed to ensure residents and/or representatives received information on risks, benefits, consent, alternatives, and quarterly assessments related to bed rail use for two residents. | D |
| Facility failed to ensure nurse aides received annual performance reviews and required in-service training for two of three nursing staff reviewed. | D |
| Facility failed to discontinue an antidepressant medication for one resident despite resident's request and no new orders obtained. | D |
| Facility failed to employ a qualified dietary manager with required certification and skills. | E |
| Facility failed to ensure food items in kitchen and bistro refrigerators and storage areas were labeled, unexpired, and stored properly; failed to maintain clean work areas and ice machine. | F |
| Facility failed to administer fingerstick blood sugar tests using sanitized glucometers between residents, failed to perform hand hygiene during medication administration, incontinent care, and tracheostomy care, resulting in immediate jeopardy for infection control. | K |
| Facility failed to implement infection control and prevention portion of their Quality Assurance and Performance Improvement (QAPI) program including infection tracking, antibiotic usage monitoring, and reporting. | F |
| Facility failed to implement and maintain an effective training program for all nursing staff, including required in-service education and orientation documentation. | F |
Report Facts
Survey Census: 49
Sample Size: 19
Supplemental Residents: 10
Deficiencies cited: 15
BIMS Scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA2 | Certified Medication Aide | Named in infection control deficiency related to failure to sanitize glucometers |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including infection control, antibiotic stewardship, and training |
| Administrator | Administrator | Named in infection control and training deficiencies |
| Activity Director | Activity Director | Named in activities and certification deficiencies |
| Dietary Manager | Dietary Manager | Named in dietary staffing and food safety deficiencies |
| Human Resources Director | Human Resources Director | Named in training deficiencies |
| Director of Infection Control and Staff Development | Director of Infection Control and Staff Development | Named in infection control and QAPI deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 1, 2022
Visit Reason
A complaint investigation of intakes #108822-C and #108880-C was conducted from November 30, 2022 to December 1, 2022.
Findings
The facility was found to be in substantial compliance. Complaints #108822 and #108880 were not substantiated.
Complaint Details
Complaints #108822 and #108880 were investigated and found not substantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
A revisit of the survey ending on September 29, 2022 was conducted from November 22, 2022 to November 29, 2022 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 16, 2022. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 6
Sep 29, 2022
Visit Reason
The inspection was conducted following complaints and grievances related to missing personal property, allegations of abuse, and concerns about dentures and nutritional status for several residents.
Findings
The facility failed to properly investigate and report allegations of abuse, including a staff member placing a hand over a resident's mouth and injuries of unknown origin. The facility also failed to timely report and address missing dentures for a resident, resulting in nutritional decline and distress. Additionally, the facility did not ensure call lights were within reach or responded to timely, and a significant medication error occurred when an antibiotic order was not processed promptly.
Complaint Details
The complaint investigation was triggered by multiple grievances and reports regarding missing personal property, alleged abuse including a staff member placing a hand over a resident's mouth, missing dentures, and concerns about nutritional decline and medication errors.
Severity Breakdown
SS=D: 5
SS=G: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to report allegations of abuse to the Iowa Department of Inspections and Appeals within required timeframes. | SS=D |
| Failure to conduct and document thorough investigations of abuse allegations. | SS=D |
| Failure to prevent resident weight loss and overall health decline related to missing dentures and inadequate nutritional care. | SS=G |
| Failure to ensure sufficient nursing staff to meet residents' needs, including call light placement and timely response. | SS=D |
| Failure to ensure residents are free of significant medication errors; specifically, failure to initiate physician antibiotic order timely. | SS=D |
| Failure to assist resident in obtaining routine and emergency dental care in a timely manner, including arranging dental services for missing dentures. | SS=D |
Report Facts
Resident census: 53
Weight loss percentage: 3.75
Weight loss percentage: 6.98
Medication doses missed: 4
Call light response time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Social Worker | Named in investigation of missing personal property and grievance process |
| Staff R | Administrator | Named in investigation and reporting of abuse allegations |
| Staff S | Administrator | Named in oversight of abuse reporting and investigations |
| Staff Q | Interim Director of Nursing | Named in investigation and reporting of abuse allegations |
| Staff C | Licensed Practical Nurse | Named in investigation of missing dentures and medication order processing |
| Staff N | Certified Nursing Assistant | Named in investigation of abuse and missing dentures |
| Staff K | Certified Medication Aide | Named in investigation of missing dentures and abuse |
| Staff J | Certified Nursing Assistant | Named in investigation of bruising and abuse |
| Staff L | Registered Nurse | Named in investigation of bruising and abuse |
| Staff P | Registered Nurse / Director of Nursing | Named in investigation of abuse and bruising |
| Staff U | Speech Therapist | Named in evaluation of resident oral function and diet |
Inspection Report
Inspection Report
Census: 43
Deficiencies: 11
Oct 19, 2021
Visit Reason
A recertification health survey and investigation of multiple complaints and facility reported incidents were conducted from 10/4/21 to 10/19/21.
Findings
The facility was found deficient in multiple areas including failure to provide regular resident council meetings, failure to ensure residents were free from abuse and neglect, failure to complete required staff abuse training, failure to provide bed hold notifications, failure to develop comprehensive care plans, quality of care issues including inadequate assessments and treatments, failure to prevent accidents and falls, inadequate incontinence care, pain management deficiencies, lack of full-time dietary manager, and unsafe bed control cords.
Severity Breakdown
SS=D: 8
SS=E: 2
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide resident council meetings on a regular basis. | SS=D |
| Failure to ensure residents were free from physical and verbal abuse, including an incident where a nurse aide slapped a resident. | SS=D |
| Failure to ensure 3 of 9 staff members completed required Dependent Adult Abuse training within 6 months of hire. | SS=D |
| Failure to provide bed hold notification to residents upon hospital admission. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans for 3 of 20 residents reviewed. | SS=E |
| Failure to provide adequate assessments and interventions for 4 of 15 residents reviewed, including failure to intervene timely for poor intake and dehydration, failure to detect lung fluid, failure to address antibiotic allergies, and failure to administer treatments as ordered. | SS=E |
| Failure to ensure adequate nursing supervision for a resident with a history of falls, resulting in a fall with fracture. | SS=G |
| Failure to provide complete incontinence care and minimize risk of cross-contamination for 2 of 4 residents observed. | SS=D |
| Failure to ensure pain was managed consistent with professional standards and resident preferences for 1 of 15 residents; resident lacked narcotics for pain control for several hours. | SS=D |
| Failure to employ a full-time qualified dietary service manager. | SS=D |
| Failure to maintain bed control cords in safe operating condition; exposed wires were observed on a resident's bed control cord. | SS=D |
Report Facts
Residents: 43
Deficiencies cited: 11
Resident #48 meals with 0 intake: 15
Resident #48 meals refused: 2
Resident #48 meals 26-50% intake: 7
Resident #45 sacrum wound size: 10
Resident #45 sacrum wound size: 4.5
Resident #19 fall risk score: 11
Resident #19 fall risk score: 19
Resident #43 Braden scale score: 21
Resident #47 BIMS score: 12
Resident #43 BIMS score: 14
Resident #39 BIMS score: 15
Resident #1 BIMS score: 3
Resident #19 BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in abuse incident involving Resident #49 |
| Staff D | Certified Nursing Assistant | Witnessed abuse incident involving Resident #49 |
| Staff CC | Licensed Practical Nurse | Nurse on duty during abuse incident with Resident #49 |
| Staff J | Registered Nurse, MDS Coordinator | Responsible for care plans and identified care plan deficiencies |
| Staff M | Licensed Practical Nurse | Involved in medication and wound care deficiencies |
| Staff DD | Licensed Practical Nurse | Involved in medication and fall incident |
| Staff B | Certified Nursing Assistant | Involved in fall incident with Resident #19 |
| Staff GG | Registered Nurse | Involved in fall incident with Resident #19 |
| Staff HH | Agency Certified Nursing Assistant | Involved in fall incident with Resident #19 |
| Staff Y | Certified Nursing Assistant | Reported documenting resident behaviors and use of Stop and Watch |
| Staff F | Pharmacist | Reported pharmacy errors and medication reorder issues |
| Staff L | Licensed Practical Nurse | Entered incorrect medication orders for Resident #47 |
| Staff Z | Certified Medication Aide | Reported holding blood pressure medication based on parameters |
| Staff C | Dietary Staff Member | Reported no dietary manager employed |
| Staff H | Certified Nursing Assistant | Observed with unsafe bed control cord and incontinence care |
| Staff I | Certified Nursing Assistant | Observed with unsafe bed control cord and incontinence care |
Inspection Report
Routine
Census: 44
Deficiencies: 0
Oct 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 49
Deficiencies: 0
Sep 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Jul 16, 2020
Visit Reason
The inspection was conducted as a complaint survey exiting on 7/16/2020, including investigation of Facility Reported Incident #91788-I and Complaints #87585-C, #89982-C, #90188-C, and #90419-C.
Findings
The facility was found not in compliance due to a medication error involving incorrect transcription of an anticoagulant medication order for one resident. The facility failed to transcribe all admission orders correctly, leading to a medication error. The facility reported a census of 39 residents and was found to be out of compliance with the requirement that residents be free of significant medication errors.
Complaint Details
Facility Reported Incident #91788-I was substantiated. Complaints #87585-C, #89982-C, #90188-C, and #90419-C were not substantiated.
Deficiencies (1)
| Description |
|---|
| The facility failed to transcribe all admission orders correctly, resulting in a medication error with anticoagulant medication for one resident. |
Report Facts
Total residents: 39
Medication doses: 7
Medication administration days: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN)/Admissions Director/Clinical Liaison | Named in medication transcription error and education provided |
| Director of Clinical Services | Provided re-education to Staff A on order transcription accuracy | |
| Corporate Nurse | Re-educated nurse completing transcription error | |
| Assistant Director of Nursing (ADON) | Reported process for entering admission orders and responsible for ongoing compliance |
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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