Grandview Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Oct 28, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #212) reviewed for pressure ulcers, the facility failed to ensure the resident was free from neglect with resulting physical harm when necessary care and services were not provided including skin assessments, RN assessments of wounds, and notification to the physician and dietitian of changes in skin condition. Further, the facility failed to complete treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Subsequent to these failures, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. […]

• Immediate jeopardy, patternF686Oct 28, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #212, 213 and 95) reviewed for pressure ulcers, the facility did not provide necessary care and services including skin assessments, RN assessments of wounds, and notification to the physician and dietitian of changes in skin condition. Further, the facility failed to complete treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Subsequent to these failures, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. The Findings include: 1. […]

• Immediate jeopardy, isolatedF760Aug 4, 2026

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the six (6) rights of medication administration. The facility failed to ensure the correct methadone bottle and dose were verified prior to administration, resulting in Resident #1 being given another resident's methadone dose of 120 milligrams (mg) instead of 10 mg ordered for Resident #1. This incident represented the second such occurrence in a six month period and placed Resident #1 at risk for significant adverse effects including respiratory depression, decreased level of consciousness, and cardiovascular compromise. […]

• Immediate jeopardy, isolatedF760Mar 3, 2026

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled resident reviewed for medication administration the facility failed to ensure Resident #1, who was prescribed a controlled substance (Methadone) for substance use disorder (SUD) was administered Methadone per physician's order when the licensed nurse removed two (2) residents Methadone from the lock box at the same time, stored the Methadone on the top of the medication cart and then administered Resident #1 another resident's Methadone which was a 1100 percent (%) higher dose than prescribed subsequently leading to a significant medication error which required hospitalization. […]

• Immediate jeopardy, isolatedF600Oct 12, 2022

  Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #14) who was reviewed for sexual abuse, was not able to make decisions for himself/herself and had a Conservator of Person, the facility failed to ensure the resident was free from inappropriate sexual conduct by another resident and failed to communicate and follow through to ensure new interventions were implemented to prevent future incidences with Resident #14 and other residents on the dementia unit after the resident had an incident of physical contact with Resident #14. The failures resulted in a finding of Immediate Jeopardy. […]