Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grandview Healthcare Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition, seizures, metastatic brain tumor, chronic pain, and migraines returned from a neurology visit with medication changes for anticonvulsant and migraine treatment, but the facility did not initiate Briviact or Nurtec and did not clarify missing or incomplete orders. Staff transcribed changes from an unsigned order summary provided by the family, the MAR did not reflect the new medications, and the pharmacy confirmed it never received the orders. The record also lacked follow-up on a Tramadol order that was later documented as needing clarification for better pain control.
Failure to provide safe and appropriate respiratory care occurred when a resident with severe cognitive impairment and chronic respiratory conditions had oxygen tubing and a humidifier bottle left unchanged beyond the ordered schedule. The resident was on continuous O2 via NC, with orders for weekly tubing changes and facility policy directing humidifier changes when empty, every 72 hours, or per policy/manufacturer guidance. On observation, the tubing and humidifier were dated well past the expected change intervals, and the DON confirmed the outdated equipment and that the TAR lacked direction for humidifier changes.
A resident with intact cognition, dependence for transfers and toileting hygiene, and diagnoses including anemia, HF, HTN, and a seizure disorder had constipation monitoring documented on the bowel audit form, but the MAR and clinical record did not reflect all bowel interventions. The audit showed prune juice, milk of magnesia, and a suppository were given for several days without a BM, yet the MAR lacked documentation for the laxative and suppository, and there was no documented follow-up on PRN effectiveness; an ADON reported he gave the suppository and assessed bowel sounds but did not document it.
Improper Infection Control During Wound Care: An LPN performed wound care for a resident with a stage 4 pressure ulcer while failing to maintain proper hand hygiene and barrier precautions. Supplies and loose gloves were placed on a dresser without a barrier, then moved to a tray table that had not been disinfected after a urinal was handled. The contaminated gloves touched wound care supplies, and the LPN used a gloved finger to apply cream to the peri-ulcer skin. The DON and Infection Preventionist stated the gloves should have been placed on a barrier and the tray table disinfected before use.
The facility failed to date opened food items in storage, as observed during a kitchen tour. Several items, including frozen rolls, peas, and chicken strips, were found without dates. A cook was later seen dating these items based on recent usage. The Certified Dietary Manager confirmed the expectation to date items, but the facility's policy lacked this requirement.
Failure to Follow Physician Medication Orders
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for one resident with severely impaired cognition, cancer, anemia, arthritis, a seizure disorder, metastatic brain tumor, chronic pain, and migraine headaches. The resident’s care plan directed staff to administer anticonvulsant and pain medications as ordered, and the November and December MARs showed Tramadol 50 mg every 8 hours for pain. After a neurology appointment, the resident returned with documented medication changes that included discontinuing Keppra, increasing Vimpat to 100 mg twice daily, and starting Nurtec for migraines, with a separate note also documenting Briviact 100 mg twice daily for focal epilepsy. The clinical record showed the facility did not initiate Briviact or Nurtec, and there was no documentation of clarification or follow-up for the neurology note or the physician progress note that identified the missing medications. A physician progress note documented the DNP reviewed the neurology orders and noted Briviact was not on the MAR and Nurtec had not been given. The record also lacked documentation of clarification or follow-up for the Tramadol order after another physician note stated the Tramadol should be used every 6 hours for better pain control. Staff and pharmacy interviews showed the medication changes were not properly verified or communicated. Staff B reported the resident’s family handed her an order summary form when the resident returned from the appointment, and she transcribed the changes to the MAR and faxed the summary to the pharmacy without calling the neurology office to clarify the orders. The order summary lacked a physician signature, lacked directions for Nurtec, and did not address Briviact. The DON stated the pharmacy had not received orders for Briviact or Nurtec, and the pharmacist confirmed no orders were received for those medications. The facility policy stated medications shall be administered in a safe and timely manner and as prescribed.
Failure to Change Oxygen Tubing and Humidifier as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when Resident #4’s oxygen tubing and water humidifier were not changed as ordered. Resident #4 had severe impaired cognition with a BIMS score of 3 and diagnoses including hypertension, pulmonary fibrosis, respiratory failure, and other lung disorders. A physician order dated 7/7/25 directed oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation above 88% every shift for hypoxia related to chronic respiratory failure, and another order dated 11/8/22 directed staff to change the oxygen tubing every week on Sunday. The care plan revised 9/15/25 documented continuous oxygen use and directed staff to change the oxygen tubing and humidifier per facility policy. On 12/9/25, the oxygen tubing was observed dated 11/23/25 and the water humidifier was dated 10/26/25. The DON acknowledged the dates, removed the oxygen tubing, and stated it would be replaced. Review of the November and December 2025 TAR showed the oxygen tubing was signed off as changed on 11/23/25, 11/30/25, and 12/7/25, but the TAR did not include direction on how often to change the water humidifier. The DON stated staff were expected to change the oxygen tubing weekly per the physician order. The facility policy titled Oxygen Administration dated 2/1/25 directed staff to change oxygen tubing and mask/cannula weekly and as needed if soiled or contaminated, and to change the humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer.
Incomplete Documentation of Bowel Management Interventions
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for one resident. Resident #2’s MDS identified intact cognition with a BIMS score of 13, dependence on staff for transfers and toileting hygiene, always incontinent bowel status, and diagnoses including anemia, heart failure, hypertension, and a seizure disorder. The care plan directed staff to observe for side effects of narcotic analgesic medication, including constipation and decreased bowel sounds. The resident’s bowel records showed a large BM on 10/12/25, followed by no BM from 10/13/25 through 10/16/25. The Daily BM Management Audit documented prune juice on day 2 without a BM, milk of magnesia on day 3 without a BM, and a suppository on day 4 without a BM, with check marks indicating these interventions were given. However, the MAR lacked documentation of milk of magnesia administration and lacked documentation of a physician order for, or administration of, a suppository. The clinical record also lacked documentation of bowel medication administration and follow-up on the effectiveness of PRN medication. The ADON reported he gave the resident a suppository on the morning of 10/16/25 and listened to bowel sounds, but did not document either action. The DON stated staff were expected to document bowel management interventions and assessments in the medical record and to document PRN effectiveness.
Improper Infection Control During Wound Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections during wound care for one resident with a stage 4 pressure ulcer to the right buttocks. The resident’s MDS identified a BIMS score of 12, indicating moderately impaired cognition, and substantial/maximal assistance was required for transfers and toileting. During observation, an LPN gathered wound care supplies at the medication cart and carried them into the room on a blue towel along with loose gloves. The towel with supplies was placed on the dresser in front of the TV, and the loose gloves were placed directly on the dresser without a barrier. The LPN closed the room door and, without completing hand hygiene, put on a gown and gloves. She emptied the resident’s urinal, rinsed it with soap and water, and then removed her gloves and washed her hands. She then moved the towel with supplies to the tray table where the urinal had been without disinfecting the area first, placed the loose gloves on the towel with the other supplies, and left the room to retrieve hand sanitizer from the medication cart. After returning, she put on gloves from the towel and proceeded with wound care without hand hygiene. The contaminated gloves touched the wound cleanser bottle, gauze pads, silver alginate rope, and Mepilex dressing, and the LPN used a gloved finger to apply Baza cream to the peri-ulcer skin. The LPN acknowledged she should not have placed the gloves on the dresser because it was a dirty surface. The DON and Infection Preventionist stated the nurse should have placed the gloves on a barrier and disinfected the tray table before use.
Failure to Date Opened Food Items in Storage
Penalty
Summary
The facility failed to date items in the refrigerator, freezer, and dry food storage after opening, as observed during an initial tour of the kitchen. The surveyor noted several opened items without dates, including frozen rolls, peas, garlic bread, sausage patties, fish, chicken strips, potato chips, bread crumbs, shredded cheese, and lettuce. During a subsequent observation, a cook was seen dating these items based on recent usage rather than the actual opening date. The Certified Dietary Manager confirmed that staff were expected to date food items after opening them. However, the facility's policy, dated June 2015, did not include information regarding the requirement to date food items after opening.
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.