Grandview Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Grandview Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF678Feb 12, 2024

  Based on a review of clinical records, select facility incident reports and policies, and American Heart Association guidelines and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident (Resident CR1) out of three residents sampled. This failure placed 93 facility residents, desiring cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to their advanced directive, out of the 169 resident census in the facility, in immediate jeopardy to their health and safety with the potential for death as a result of a similar occurrence. […]

• Immediate jeopardy, isolatedF689Oct 4, 2025

  Based on observation, staff interviews, review of facility policies, manufacturer instructions for use (IFU), clinical record reviews, and facility investigative documentation, it was determined that the facility failed to ensure residents were protected from potential hazards in the environment by failing to implement safe and sanitary food handling practices in the facility kitchen. Specifically, the facility failed to ensure that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used in accordance with manufacturer instructions and facility policy. […]

• Immediate jeopardy, isolatedF689Oct 18, 2023

  Based on a review of clinical records, select facility policies, and information submitted by the facility, observation, and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident, with a known history of exit seeking behavior, and conduct planned monitoring of the resident's whereabouts to promptly identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to his health and safety for one resident out of four residents sampled (Resident 146 ). […]

• Actual harm, isolatedF684Oct 4, 2025

  Based on a review of select facility policies, clinical records, investigative reports, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care according to professional standards of practice, which included a failure to implement necessary interventions after a fall, such as close supervision and neurological assessments for one of two residents reviewed for falls resulting in actual harm with a subdural hematoma (brain bleed). […]

• Actual harm, isolatedF600Jul 18, 2025

  Based on a review of clinical records, select facility policy, and facility provided investigative documentation, the facility displayed past non-compliance by failing to protect one of 32 sampled residents (Resident 25) from neglect by not implementing the individualized care plan intervention for transfers, resulting in actual harm in the form of a left tibial periprosthetic fracture.Findings include: A review of the facility policy titled “Abuse Prevention Program,” last reviewed by the facility in January 2025, revealed it is the facility’s policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. […]