Federal inspectors found that licensed nurses weren't compressing the accordion-shaped collection bulbs on Jackson Pratt drainage systems, a critical step needed to create the negative pressure that draws fluid from surgical wounds. Without proper compression, the drains essentially stop working.
The facility's own physician consultant, identified as Physician 4 in the inspection report, explained the problem directly to inspectors. The doctor described how Resident 1's drain collection bag contained an accordion bellow that "needed to be compressed to promote negative pressure to draw out the fluid." The physician clarified that the system "would not work if the drains were not being flushed."
Jackson Pratt drains are commonly used after surgeries to remove excess fluid and blood that can accumulate around surgical sites. When they malfunction due to improper maintenance, patients face increased risks of infection, delayed healing, and other complications that can extend recovery times significantly.
Granada's own policies outlined exactly what nurses should have been doing. A facility procedure dated September 19, 2019, specifically instructed staff to "fully compress the collection reservoir with one hand, then replace the spout plug with the other hand." The policy continued: "Compress the reservoir by squeezing bulb flat, replacing plug while compressed."
The instructions were explicit about what should happen next: "The collection reservoir should remain compressed, if not; repeat procedure and notify physician."
But nurses weren't following these basic steps.
The facility had promoted its sophisticated care capabilities in internal assessments. Granada's Facility Assessment from August 2025 through July 2026 boasted that "licensed nurses provide skilled services including wound care" and emphasized how "our team of caregivers provides personalized, highly sophisticated health care."
The same document outlined the facility's admission process, stating they would "do some research into the diagnosis or condition to see if we can meet the person's needs" and consider "staff competency and/or ability to train competency."
Yet when it came to basic drain maintenance, staff competency appeared lacking.
Manufacturer instructions for the drainage systems, included in an undated patient information guide, reinforced what Granada's own policies required. The guide specified that users should "compress the bellows" to "re-activate the system," explaining that "the fluid in the bellows will be discharged into the bag and the suction will be re-established."
The instructions also noted that "dual anti-reflux valves prevent liquids and air from backing up into the catheter or wound drain" — but only when the system functions properly.
Granada's policies required nurses to document several critical aspects of drain care: "Appearance of site. Appearance of drainage. Output. Physician notified of any problems." The documentation requirements suggest the facility understood the importance of monitoring these systems closely.
The manufacturer's guide even provided specific positioning instructions, noting that staff should "attach the bag to the patient gown or bedding below the level of the drainage site" to "ensure continuous flow."
Despite having detailed policies and manufacturer guidelines, the facility failed to ensure nurses performed the fundamental step of maintaining proper suction in the drainage systems.
Federal inspectors determined the violations caused "actual harm" to residents, though they noted only "few" patients were affected. The facility is disputing the citation.
Granada had emphasized teamwork in its facility assessment, stating that "another core competency is to work together cooperatively, recognizing that the power of our combined efforts exceeds what we can accomplish individually." But the drain care failures suggest coordination problems between nursing staff and the medical oversight needed to ensure proper wound management.
The inspection revealed a gap between Granada's stated capabilities in providing "highly sophisticated health care" and the basic nursing care actually delivered to surgical patients who needed reliable drain maintenance for proper healing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Granada Rehabilitation & Wellness Center, Lp from 2025-11-25 including all violations, facility responses, and corrective action plans.
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