Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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.
Failure to obtain consent and provide psychotropic medication education: A resident with late onset Alzheimer’s Disease was started on multiple psychotropic meds, including an antidepressant, antipsychotic, antianxiety med, and another antidepressant, but the EHR did not show consent before initial administration. There were also no progress notes or assessments documenting education on side effects, risks vs benefits, or offering alternative treatments before the meds were given, despite facility policy requiring informed consent and discussion of nonpharmacological approaches and medication alternatives.
Incomplete Comprehensive Care Plan Development: A resident’s admission MDS triggered multiple CAA areas, but only one of the identified care areas was documented on the comprehensive care plan by the required timeframe. The MDS Coordinator said the resident was missed on the team schedule, and the interim DON stated baseline care plans were expected within 48 hours and comprehensive care plans within 7 days of the admission MDS completion.
Multiple residents did not receive their medications within the required 1-hour window before or after the scheduled dosing time, as confirmed by medication administration audits and staff interviews. Facility policy and DON expectations were not followed, resulting in repeated late or early medication administration for several residents.
A resident with quadriplegia and contractures did not consistently receive prescribed passive range of motion exercises or have hand splints and palm protectors applied as recommended by therapy. Observations showed splints were often not in use, documentation was inconsistent, and staff were unclear about program frequency and responsibilities. The care plan lacked clear instructions, and there was no facility policy for restorative nursing, resulting in failure to provide and document the required restorative care.
A nurse failed to prime an insulin pen and did not hold it at the injection site for the recommended duration while administering insulin to a resident with diabetes. Other nursing staff and facility policy confirmed that the expected procedure is to prime the pen and hold it in place to ensure proper medication delivery.
A resident with chronic wounds and an MDRO infection received wound care from an LPN who failed to place a barrier between the resident's foot and the bed linen, allowing the wound to come into direct contact with the linen. Both the LPN and DON acknowledged the omission, and the bed linens were not changed immediately after the procedure, contrary to facility infection control guidelines.
A resident with edema did not receive physician-ordered tubi-grip compression sleeves due to staff unawareness and incorrect documentation of refusals. The facility lacked the correct size in stock, leading to improper treatment. The resident reported not having the sleeves since a therapy company change, and staff confirmed their absence on multiple occasions.
Two residents with significant weight loss were not served the correct puree portion sizes as prescribed. Despite preparation instructions, dietary staff failed to provide the appropriate amount of food, resulting in both residents receiving less than required. Observations showed that the residents consumed all their meals, indicating insufficient portions.
The facility failed to complete SCSA MDS assessments within the required time frame for two residents in hospice care. One resident's MDS was completed 21 days after a significant change, exceeding the 14-day requirement. Another resident's MDS was not finalized by the required date. Staff G confirmed the lack of an MDS policy and misunderstanding of time requirements.
The facility failed to accurately complete the MDS for three residents, leading to deficiencies in documenting anticoagulant medication and PASRR conditions. One resident was incorrectly documented as taking anticoagulant medication, while two residents had inaccurate PASRR documentation regarding their mental health diagnoses. These errors were confirmed by staff, who admitted to not following the RAI manual's guidance.
The facility failed to properly coordinate and submit PASRRs for two residents, leading to deficiencies in their care plans. One resident's PASRR was not resubmitted despite new diagnoses, while another's PASRR omitted significant diagnoses and medications. Staff interviews revealed a lack of awareness and verification of PASRR accuracy.
Failure to Obtain Consent and Provide Psychotropic Medication Education
Penalty
Summary
The facility failed to ensure that Resident #33 was fully informed and understood the resident’s health status, care, and treatments related to psychotropic medications. Resident #33’s admission MDS, dated 3/9/26, documented late onset Alzheimer’s Disease, and the resident was admitted to the facility on 3/2/26. The MAR for March 2026 showed orders for Escitalopram starting 3/3/26, Quetiapine starting 3/2/26, Lorazepam starting 3/4/26, and Trazodone starting 3/25/26. A review of the EHR did not reveal consent obtained for any of these medications before initial administration. The record also did not show progress notes or assessments documenting education about the side effects, risks versus benefits of psychotropic medications, or the offering of alternative treatments before the medications were given. The Interim DON stated staff were to contact the family and discuss side effects before any new psychotropic medication was started, and that for new residents medication education was a priority before the first dose was administered. The facility policy required documentation of nonpharmacological approaches, assessment of benefits, risks, and treatment goals, informed consent before initiating or increasing psychotropic medications, and education about benefits, risks, alternatives, and black box warnings.
Incomplete Comprehensive Care Plan Development
Penalty
Summary
The facility failed to develop and implement a timely, comprehensive care plan for Resident #33 after the admission MDS assessment triggered nine CAA categories. The facility identified six areas to be addressed in the Comprehensive Care Plan: Cognitive Loss/Dementia, Communication, Urinary incontinence, Behavioral Symptoms, Nutritional Status, and Psychotropic Drug Use. The MDS documented a CAA completion date and care plan completion date of 3/13/26, and the RAI manual required the comprehensive care plan to address the triggered CAA findings within 7 days of the CAA completion date. A record review on 4/13/26 found that only one of the six identified CAA areas was documented on the Comprehensive Care Plan. The admission MDS was dated 3/9/26 and documented an admission date of 3/2/26. On 4/15/26, the MDS Coordinator stated the resident was missed on the team’s schedule and that the team was looking into how that happened. The interim DON stated her expectation was for baseline care plans to be completed within 48 hours of admission and comprehensive care plans to include all needed items within 7 days of the admission MDS being completed. The facility policy stated baseline care plans should be in place within 48 hours and person-centered care plans should be completed after the comprehensive assessment.
Failure to Administer Medications Within Prescribed Time Frame
Penalty
Summary
The facility failed to administer medications within the required time frame of 1 hour before to 1 hour after the scheduled dosing time for five residents. Clinical record reviews, policy review, and staff interviews revealed that all five residents had multiple instances over a 15-day period where medications were given outside of this two-hour window. Specifically, each resident had medications scheduled up to four times daily, and the Medication Administration Audit Reports showed consistent deviations from the prescribed administration times for nearly every day reviewed. Facility policy, last revised in May 2023, directs staff to administer medications in accordance with physician orders and within the specified time frame. During an interview, the DON confirmed the expectation that medications should be given within the 1-hour window before or after the scheduled time. Despite this, the audit reports for all five residents demonstrated repeated failures to meet this standard, as medications were not administered as ordered by the physicians.
Failure to Implement and Document Restorative Nursing Program for Resident with Contractures
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care to maintain or improve range of motion (ROM) and mobility for a resident with significant functional impairments. The resident, who was in a persistent vegetative state with quadriplegia and contractures, was dependent on staff for all self-care and mobility needs. Occupational therapy discharge recommendations specified daily passive range of motion (PROM) exercises for both upper and lower extremities, as well as a hand splint program with splints to be worn two hours on and two hours off, with palm protectors used when splints were not in place. Despite these recommendations, observations revealed that the resident was frequently found in bed without hand splints or palm protectors in use, and the splints were often seen lying unused on the window ledge. Documentation in the electronic medical record was inconsistent, with several days lacking any record of the restorative nursing program (RNP) being completed, and some staff reporting that they marked the resident as refusing the program when, in fact, they had not attempted to apply the splints due to lack of training. Interviews with staff indicated confusion about the frequency and responsibility for the RNP, with some staff unaware of the specific therapy recommendations or unsure who was responsible for carrying out the program on days when the primary restorative staff member was not present. The care plan for the resident lacked clear direction regarding the RNP and the use of hand splints, and there was no facility policy or procedure for restorative nursing. The task record and treatment administration record (TAR) did not consistently reflect the use of hand splints or palm protectors, and nursing staff did not always review therapy discharge recommendations when setting up the RNP. Family members also reported never seeing the hand splints in use during visits. These actions and omissions resulted in the facility's failure to implement and document the prescribed restorative care program for the resident as recommended by therapy.
Failure to Follow Insulin Pen Administration Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow manufacturer instructions for administering insulin using an insulin pen for a resident with diabetes mellitus. The nurse removed the resident's Lantus Glargine pen from the medication cart, checked the physician's order, and set the pen to the prescribed dose of 45 units. However, the nurse did not prime the pen with two units of insulin as required by the manufacturer's guidelines. The nurse then injected the insulin into the resident's lower right abdominal quadrant, pushed the button to administer the dose, and withdrew the pen without holding it in place for the recommended 10 seconds. Interviews with other nursing staff revealed that the expected practice is to prime the insulin pen with one or two units until insulin is visible at the needle tip, then administer the prescribed dose and hold the pen at the injection site for several seconds to ensure full delivery. The facility's policy, consistent with manufacturer instructions, directs staff to prime the pen and hold it in place for 6-10 seconds during administration. The Director of Nursing confirmed that staff are expected to follow these procedures. The failure to prime the pen and hold it for the appropriate duration constituted a significant medication error for the resident.
Failure to Use Barrier During Wound Care Results in Infection Control Deficiency
Penalty
Summary
A deficiency occurred when staff failed to place a barrier between a resident's foot and the bed linen during wound care treatment, as observed by surveyors. The resident had a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, and a multi-drug-resistant organism (MDRO), and was being treated for two unstageable pressure ulcers on the left foot, one of which was infected. The treatment orders required cleansing, application of betadine, and covering the wounds with dressings, but did not specify the use of a barrier between the wound and bed linen. During the observed wound care procedure, an LPN donned appropriate personal protective equipment and prepared the treatment supplies on a barrier on the treatment cart. However, while performing the wound care, the LPN allowed the resident's left foot, which had open wounds and drainage, to rest directly on the bed linen multiple times without placing a barrier underneath. The LPN acknowledged after the procedure that a barrier should have been used to prevent cross contamination. The DON also confirmed that no barrier was used during the treatment. Additionally, the resident reported that the bed linens were not changed after the wound care procedure, and a CNA confirmed that linens are typically changed once per week, with the resident's linens changed the morning after the observed treatment. Facility policy required the use of standard precautions and enhanced barrier precautions for residents with chronic wounds, and contaminated linen should be bagged at the time of use. The failure to use a barrier and to change potentially contaminated linens was inconsistent with these guidelines.
Failure to Administer Physician-Ordered Treatment
Penalty
Summary
The facility failed to administer a physician-ordered treatment for a resident who required tubi-grip compression sleeves due to edema. The resident, who had no cognitive impairment and required total assistance for transfers, was observed without the prescribed tubi-grip sleeves on multiple occasions. The resident's care plan and physician order specified the use of size D tubi-grip from fingers to elbow and size J from elbow to shoulder, to be worn during the day and removed at night. However, the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented frequent refusals of the treatment, and staff interviews revealed a lack of awareness and adherence to the order. Staff members, including CNAs and CMAs, were either unaware of the order or incorrectly documented the resident's refusal without verifying compliance. The facility also failed to maintain an adequate stock of the required size J tubi-grip, leading to the use of an incorrect size as a temporary measure. The resident reported not having the tubi-grips since a change in therapy companies, and staff confirmed the absence of the sleeves on several occasions. The deficiency was further highlighted by the lack of communication and coordination among staff, as well as the failure to ensure the availability of necessary supplies.
Failure to Serve Correct Puree Portion Sizes
Penalty
Summary
The facility failed to serve the correct puree portion size for two residents, both of whom experienced significant weight loss over the past six months. Resident #26, with severe cognitive loss and a history of non-Alzheimer's dementia, was on a mechanically altered diet due to significant weight loss. The resident's weight dropped from 231.4 pounds to 206.5 pounds over six months, indicating an 11.4% weight loss. Similarly, Resident #19, with moderate cognitive loss and diagnoses of aphasia and paranoid schizophrenia, also required a mechanically altered diet. This resident's weight decreased from 264.5 pounds to 231.1 pounds, reflecting an 11.9% weight loss over the same period. The deficiency occurred when the dietary staff failed to follow the prescribed portion sizes for the pureed diet. During meal preparation, Staff B prepared six servings of a pureed ham and cheese sandwich, using a chart to determine the correct portion size. The chart indicated that each resident should receive two #8 scoops and one #30 scoop of the puree. However, Staff C and Staff D did not adhere to these guidelines. Staff C served only one #8 scoop to Resident #26 and another resident, while Staff D used only the #30 scoop for Resident #19, resulting in both residents receiving less than the required portion. Observations revealed that both residents consumed all of their meals, with Resident #26 continuing to scrape and lick his empty bowl, indicating insufficient food. Staff B confirmed that the correct portion sizes were not served, as the #30 scoop was not used. The facility's procedure for determining portion sizes was not followed, leading to the deficiency in serving the appropriate amount of food to residents on pureed diets.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete Significant Change in Status (SCSA) Minimum Data Set (MDS) assessments within the required time frame for two residents who were reviewed for hospice care. Resident #22 had a physician order for hospice referral dated 4/29/24, but the MDS was not completed until 5/21/24, which was 21 days after the determination of a significant change. According to the Resident Assessment Instrument (RAI) guidelines, the MDS should have been completed no later than 14 days after the determination of a significant change in the resident's status. Staff G, the Resident Care Coordinator, confirmed the dates and acknowledged the lack of an MDS policy, relying solely on the RAI for guidance. Similarly, Resident #29 was admitted into hospice care on 6/11/24, with the family signing the Hospice Election Statement on the same day. However, the MDS assessment reference date was 6/21/24, and the assessment was not completed by the required date of 6/24/24. During an interview, Staff G expressed a lack of understanding regarding the time requirements for completing the significant change assessment as per the RAI manual. This oversight resulted in the MDS not being signed, finalized, and locked within the required time frame.
Inaccurate MDS and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. For one resident, the MDS inaccurately documented the use of anticoagulant medication, while the physician's orders only included clopidogrel, an antiplatelet medication. This discrepancy was confirmed by the Co-Director of Nursing, who acknowledged that clopidogrel should not have been coded as an anticoagulant. The facility lacked a specific MDS policy and relied on the Resident Assessment Instrument (RAI) and an MDS Drug Class Index, which correctly listed clopidogrel as an antiplatelet medication. Additionally, the facility failed to accurately document the Pre-Admission Screening and Resident Reviews (PASRR) for two residents. One resident's PASRR indicated a diagnosis of schizoaffective disorder, bipolar type, but the MDS incorrectly marked the resident as not having a serious mental illness. Another resident's PASRR documented a diagnosis of bipolar I disorder and major depressive disorder, but the MDS failed to reflect the major depression diagnosis. These inaccuracies were confirmed by the staff responsible for completing the MDS, who admitted to not following the RAI manual's guidance for coding PASRR conditions.
Failure to Ensure Accurate PASRR Submission for Residents
Penalty
Summary
The facility failed to ensure proper coordination and submission of Pre-admission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in their care plans. Resident #19 was initially approved for a short-term 60-day stay in 2018, with new diagnoses documented in her medical record. However, the facility did not resubmit her PASRR for review of needed services. During interviews, staff members, including a social worker, an LPN, and the administrator, were unaware of the short-term PASRR requirement for Resident #19. It was only on 7/3/24 that a new PASRR was received for this resident. For Resident #22, the facility failed to accurately complete the PASRR prior to admission, omitting significant diagnoses and medications. The admission MDS documented major depressive disorder and psychotic disorder with delusions, and the resident was prescribed quetiapine, Namenda, and lorazepam upon admission. However, the PASRR Level 1 completed on 8/31/23 did not reflect any known or suspected mental health diagnoses, and only included lorazepam and Namenda as medications. An LPN admitted during an interview that she does not verify PASRRs for accuracy regarding diagnoses and medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oelwein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oelwein Health Care Center | 0.2 mi | ★★★★★ | 9 | 0 |
| Maple Crest Manor | 12.7 mi | ★★★★★ | 0 | 0 |
| Rehabilitation Centers Of Independence West Campus | 13.9 mi | ★★★★★ | 14 | 1 |
| Buchanan County Health Center | 14.1 mi | ★★★★★ | 4 | 0 |
| Hillcrest Home | 16.1 mi | ★★★★★ | 0 | 0 |
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