Grandvue Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Grandvue Medical Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 21, 2026

  This deficient practice pertains to Intake 2711152.Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for one Resident (#1) of three residents reviewed for abuse and neglect. This deficient practice resulted in psychosocial harm and mental anguish for Resident #1 based on the reasonable personal concept.Findings Include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including dementia, aphasia (a language disorder that impairs a person's ability to communicate, affecting speaking and understanding), overactive bladder, urinary incontinence, and need for assistance for personal care. […]

• Actual harm, isolatedF692Dec 17, 2025

  Based on observation, interview, and record review, the facility failed to monitor and record accurate weights per standard practice of care for one Resident (R1) of three residents reviewed for weight loss. This deficient practice resulted in R1 having a significant weight loss with no interventions. Findings include: This citation pertains to intake 2690422Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 9/25/25 with diagnoses including Alzheimer's disease. R1's Care Plan revealed R1 was independent with cueing and supervision as needed. R1 received a 3/15 on the Brief Interview for Mental Status (BIMS) in September 2025, indicating severe cognitive impairment. […]

• Actual harm, isolatedF684Mar 20, 2025

  Based on interview and record review, the facility failed to follow physician orders for readmission to the facility in two Residents (#25 and #15) of three residents reviewed for quality of care following hospitalization . This deficient practice resulted in rehospitalization for excessive clotting times following a history of GI bleed for R25 and rehospitalization with worsening urosepsis for R15. Findings include: Resident #25 (R25) A nursing progress note in the Electronic Medical Record (EMR) dated [DATE] at 3:06 PM documented R25 had hypoxia (low oxygen level), a gray color to the skin, increased confusion, and a blood pressure of ,d+[DATE]. […]

• Actual harm, isolatedF689Jan 20, 2021

  Based on observation, interview, and record review, the facility failed to prevent falls with major injuries for two Residents (#1 and #3) of six residents reviewed for falls, and failed to properly assess four residents for the use of power lift recline chair remote controls (#1, #4, #5, #6). This deficient practice resulted in harm for Resident #1 (subarachnoid hemorrhages, pain and marked overall decline) and Resident #3 (left [CONDITION(S)], pain, and a functional decline), and the potential for other residents to sustain injuries from falls from remote control chairs. Findings include: Resident #1: Review of Resident #1's Minimum Data Set (MDS) assessment, reference date 12/04/20, revealed diagnoses including dementia, heart failure, stroke, kidney disease, depression, and anxiety. […]

• No harm, potential for more than minimal, widespreadF812Apr 22, 2026

  Based on observation and interview, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 4/20/2026 at 11:42 AM observed Certified Nursing Assistant (CNA) P use a probe thermometer to take temperatures of a food item they were reheating in the microwave. The probe thermometer was observed to not have a protective sheath covering on it as it was being pulled from storage in the drawer. CNA P wiped the thermometer with an alcohol wipe prior to inserting it in the food product. […]