Grand River Health Care Center

In the surveyor’s words

From the most serious findings on record at Grand River Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 30, 2026

  Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#6) of four residents reviewed for accidents out of 28 sample residents. Specifically, the facility failed to ensure swallowing precautions were implemented for Resident #6, who had a diagnosis of dysphagia (difficulty swallowing). Resident #6 was identified as being at risk for choking upon admission. On 9/16/25, the resident experienced a choking episode in the dining room. The Heimlich Maneuver was not needed; however, the nurse had to reposition the resident forward and to the side in order for him to successfully expel chunks of food with liquid from his throat.On 9/29/25 Resident #6 experienced another choking episode after drinking water. […]

• No harm, potential for more than minimal, patternF730Jan 30, 2026

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews.Specifically, the facility failed to complete a performance review of certified nurse aide (CNA) at least once every 12 months.Findings include:I. Facility Policy and ProcedureThe policy and procedure for annual performance evaluations was requested from the nursing home administrator (NHA) and the director of nursing (DON) on 1/15/26 at 12:37 p.m. […]

• No harm, potential for more than minimal, patternF565Feb 8, 2024

  Based on observations, interviews and record review, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure effective interventions were implemented and sustained in response to staff speaking Spanish to each other in resident areas; and, -Ensure interventions were in place to ensure residents were able to communicate needs/requests to staff providing resident services. Findings include: I. […]

• No harm, potential for more than minimal, patternF812Feb 8, 2024

  Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner for two out of four kitchens. Specifically, the facility failed to ensure: -Staff used adequate hand hygiene while serving meals and touched ready-to-eat food appropriately; and, -Residents were offered and encouraged hand hygiene prior to meals. Findings include I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/27/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices… […]

• No harm, potential for more than minimal, isolatedF572Jan 30, 2026

  Based on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one (#50) of three residents reviewed out of 28 sample residents.Specifically, the facility failed to provide Resident #50 with a written copy of the facility's room change/move policy and procedure upon the resident's request.Findings include:I. Facility policy and procedureThe Patient Rights and Responsibilities policy and procedure, reviewed 6/4/25, was provided by the nursing home administrator (NHA) on 1/15/26 at 5:19 p.m. […]