Inspection Reports for
Grants Wellness & Rehabilitation LLC
840 LOBO CANYON ROAD, GRANTS, NM, 87020
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: Jan 22, 2026
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, environment, and assessment accuracy, including temperature control, bed linens provision, Minimum Data Set (MDS) accuracy, and diabetic foot care.
Findings
The facility failed to maintain a homelike environment due to inadequate temperature control and failure to provide bed linens for a resident. The Minimum Data Set (MDS) assessments for one resident were incomplete and inaccurate. Additionally, physician-ordered diabetic foot care was not provided for one resident, risking foot complications.
Deficiencies (4)
Failure to maintain comfortable and safe temperature levels in resident rooms, resulting in cold conditions on the 300-unit.
Resident lying on mattress without linens, failure to provide bed linens promptly.
Inaccurate and incomplete Minimum Data Set (MDS) assessments for one resident, with multiple sections unanswered or dashed.
Failure to provide physician-ordered diabetic foot care for one resident, risking foot-related complications.
Report Facts
Residents reviewed for temperature issue: 5
Dates diabetic foot care not completed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Reported residents were cold and bed linens were not provided promptly |
| RN #1 | Registered Nurse | Confirmed complaints about cold temperatures and bed linens issues |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged thermostat issues and resident complaints about cold temperatures |
| Director of Nursing | Director of Nursing | Confirmed resident complaints about cold rooms, expectation for bed linens to be provided promptly, and diabetic foot care to be followed |
| MDS Coordinator | MDS Coordinator | Responsible for completion of MDS assessments and confirmed expectation for fully completed assessments |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication management, care planning, infection control, and residents' rights.
Findings
The facility was found deficient in multiple areas including failure to promote care with dignity for a resident with an active bleeding wound, failure to obtain informed consent for certain medications, failure to develop baseline care plans within 48 hours of admission, incomplete comprehensive care plans, and inadequate Legionnaires' disease water management program.
Deficiencies (5)
Failure to promote care with dignity and respect for a resident with an active bleeding wound in the dining room.
Failure to ensure residents or their guardians were informed of the medications they received including reasons, risks, and benefits.
Failure to develop and implement an adequate baseline care plan within 48 hours of admission for residents.
Failure to develop and implement a complete comprehensive care plan that meets all resident needs with measurable timetables and actions.
Failure to provide and implement an adequate infection prevention and control program, specifically an inadequate Legionnaires Water Management Program.
Report Facts
Residents reviewed for unnecessary medications: 3
Residents affected by medication consent deficiency: 2
Residents reviewed for baseline care plans: 3
Residents affected by baseline care plan deficiency: 2
Residents reviewed for care plan accuracy: 3
Residents affected by incomplete comprehensive care plan: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including care with dignity, medication consent, baseline care plans, and care plan completeness |
| Administrator | Facility Administrator | Interviewed regarding Legionnaires Water Management Program inadequacies |
| Corporate Nurse | Corporate Nurse | Interviewed regarding Legionnaires Water Management Program inadequacies |
| Corporate Maintenance Director | Corporate Maintenance Director | Interviewed regarding Legionnaires Water Management Program inadequacies |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding Legionnaires Water Management Program inadequacies |
Inspection Report
Routine
Census: 33
Deficiencies: 5
Date: Jul 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accommodations, environment, infection control, and equipment safety at Grants Wellness & Rehabilitation LLC.
Findings
The facility was found deficient in multiple areas including failure to respect residents' privacy by not knocking before entering rooms, inadequate accommodation of resident needs such as call light placement and signage, presence of mice droppings in multiple areas, improper catheter care with catheter bags resting on the floor, and unsafe kitchen equipment with a broken light cover over the stove.
Deficiencies (5)
Failure to treat residents with respect and dignity by not knocking before entering resident rooms.
Failure to reasonably accommodate resident needs by not ensuring call light was within reach and lack of signage in preferred language (Navajo-Dine).
Failure to provide a safe, clean, comfortable, and homelike environment due to presence of mice droppings in multiple facility areas.
Failure to maintain infection prevention and control practices by allowing catheter bag to rest on the floor.
Failure to keep essential equipment working safely by not replacing broken plastic light cover over stove.
Report Facts
Residents affected: 33
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Named in privacy and catheter care findings | |
| Certified Medical Assistant (CMA) #1 | Named in privacy and call light/signage findings | |
| Administrator | Provided census and commented on mice issue | |
| Housekeeper | Commented on mice droppings and cleaning practices | |
| Dietary Manager | Commented on broken light cover in kitchen | |
| Social Services | Confirmed signage should be on 400 hall |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report a resident elopement incident and failure to adequately supervise a resident at risk for elopement, which resulted in actual harm.
Complaint Details
The complaint investigation substantiated that the facility failed to timely report the elopement and failed to provide adequate supervision to prevent the resident from eloping, resulting in actual harm.
Findings
The facility failed to submit a Facility Initiated Report within 24 hours of a resident elopement on 01/17/24 and failed to adequately supervise the resident, who eloped through an unmonitored exit, resulting in injuries including frostbite and skin tears. Staff did not check on the resident hourly as required, and the resident was found outside after several hours.
Deficiencies (2)
Failed to provide a Facility Initiated Report within 24 hours of a resident elopement incident.
Failed to protect a resident from elopement and accidents, resulting in actual harm including frostbite and injuries.
Report Facts
Residents reviewed for incidents: 3
Residents affected: 1
Date of elopement incident: Jan 17, 2024
Date of survey completion: Jan 24, 2024
Number of staff on duty during elopement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Responsible for the hall where resident eloped; provided a written statement about the incident |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding the incident and supervision policies |
Inspection Report
Routine
Deficiencies: 14
Date: Mar 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans for behavioral health needs, inadequate monitoring and documentation of medication refusals, failure to document changes in condition such as oxygen needs, improper wound care documentation, medication administration errors, failure to maintain infection control practices, and lack of a comprehensive antibiotic stewardship program.
Deficiencies (14)
Failure to update a resident's care plan related to behaviors of refusing care and depression.
Failure to meet professional standards for resident preferences related to self-treatment.
Failure to provide appropriate treatment and care according to orders, including monitoring oxygen saturation and ensuring oxygen delivery.
Failure to measure, stage, and document appearance of pressure ulcers for residents reviewed.
Failure to maintain oxygen equipment according to professional standards, including failure to date tubing and use humidifier bottles properly.
Failure to document physician's decisions about resident's course of treatment and lack of progress notes for residents reviewed.
Failure to provide necessary behavioral health care and services, including lack of evaluation and treatment for depression and inappropriate use of antipsychotic medications.
Failure to monitor resident behavior after prescribing psychotropic medications to determine effectiveness.
Medication administration errors observed during inhaler use and failure to instruct residents properly.
Failure to discard refrigerated food after 7-day shelf life, failure to date refrigerated food, and failure to discard dented cans.
Failure to document a resident's change in condition related to oxygen needs and failure to complete Change in Condition assessment.
Failure to follow infection control practices including improper glove removal, failure to wash or sanitize hands between residents, and lack of a comprehensive surveillance plan.
Failure to have a qualified, trained, or certified Infection Preventionist responsible for the infection prevention and control program.
Failure to implement a comprehensive antibiotic stewardship program to monitor antibiotic use.
Report Facts
Medication refusals: 40
Medication refusals: 43
Medication refusals: 45
Medication refusals: 52
Medication refusals: 90
Weight change percentage: 11.34
Weight change percentage: 31.2
Weight change percentage: -21.88
Oxygen saturation: 77
Medication error rate: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #2 | Interviewed about resident R #18's needs and compliance with care | |
| Registered Nurse (RN) #2 | Interviewed about resident R #18's needs and medication refusals | |
| Registered Nurse (RN) #4 | Interviewed about resident R #18's medication refusals and oxygen needs | |
| Certified Nurse Assistant (CNA) #1 | Interviewed about resident R #18's assistance needs during meals | |
| Director of Nursing (DON) | Interviewed about resident care, medication refusals, infection control, and antibiotic stewardship | |
| Director of Therapy | Interviewed about resident R #18's decline and therapy participation | |
| Certified Medical Assistant (CMA) #2 | Interviewed about oxygen equipment maintenance | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about oxygen needs and notification of physician | |
| Dietary Manager | Interviewed about food storage and handling practices |
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