Grandview Healthcare Center

In the surveyor’s words

From the most serious findings on record at Grandview Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 10, 2022

  Based on clinical record review, observations, physician, staff, and resident interviews, the facility failed to assure that each resident was free from a significant medication administration error for 1 of 4 residents reviewed (Resident #1). On 1/7/22, Staff A, Licensed Practical Nurse (LPN), gave Resident #1, Resident #4's medications that included three diuretics, or a medication that is used to decrease excess fluid that can decrease blood pressure, and one blood pressure medication used to decrease the resident's blood pressure. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF658Dec 4, 2025

  Based on clinical record review, policy review and staff interview the facility failed to follow physician orders by not giving medications within 1 hour before to 1 hour after the ordered time for 5 of 5 residents (Residents #1, #2, #3, #4, #5) reviewed. The facility reported a census of 58 residents. Findings include: Resident #1's admission Record documented an admission date of 4/7/25. The Order Summary Report included medications to be given up to 4 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 15 out of 15 days reviewed. Resident #2's admission Record documented an admission date of 2/12/25. […]

• No harm, potential for more than minimal, isolatedF658Aug 17, 2026

  Based on clinical record review, staff and resident interviews, and facility policy review the facility failed to administer medication as ordered for one of four residents reviewed (Resident #1). The facility reported a census of 61 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. Per the assessment, Resident #1 required total assistance from staff for transfers from one surface to another, dressing, and hygiene. The resident's Care Plan included the following focus dated 1/24/2025: Tube feeding related to Spinal Muscular Scoliosis, Dysphagia (difficulty with swallowing), and Gastroparesis (stomach empties foods slowly). […]

• No harm, potential for more than minimal, isolatedF552Apr 15, 2026

  Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure that 1 out of 5 residents reviewed for unnecessary medications was provided with education regarding the risks and benefits of psychotropic medications (Resident #33). Additionally, the facility failed to offer alternative treatment options prior to the administration of the medications. The facility reported a census of 59 residents. Findings include: The admission Minimum Data Set (MDS) Assessment for Resident #33, dated 3/9/26, documented diagnoses that included late onset Alzheimer's Disease. The MDS recorded the resident's admission date to the facility was 3/2/26. […]

• No harm, potential for more than minimal, isolatedF656Apr 15, 2026

  Based on clinical record review, staff interview, guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and facility policy review, the facility failed to develop and implement a timely, comprehensive care plan for one of fifteen residents (Resident #33) reviewed. The facility reported a census of 59 residents. Findings include: The admission Minimum Data Set (MDS) Assessment of Resident #33, dated 3/9/26, documented an admission date to the facility of 3/2/26. The MDS triggered nine Care Area Assessment (CAA) categories. […]