Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Post Acute during CMS and state inspections, most recent first.
The facility failed to ensure timely delivery of a routinely prescribed medication in accordance with its own pharmaceutical services policy requiring medications to be delivered within 24 hours of ordering. A resident with osteomyelitis of the thoracic vertebra and a cognitively intact status, as shown by a BIMS score of 14, had a PRN order for Oxycodone 10/325 mg for pain management. The medication was ordered in the early morning and, due to a pharmacy staff error that placed the order on the next day’s delivery run, was not delivered until approximately 36 hours later, exceeding the 24-hour requirement, as confirmed by pharmacy records, email correspondence, and the DON’s interview.
A resident with multiple chronic conditions, though cognitively intact and needing only minimal to moderate ADL assistance, was discharged home without an orderly and coordinated discharge plan. The facility documented that prescriptions were faxed to the resident’s pharmacy of record, but the fax number was left blank and pharmacy records showed discharge medications were not transmitted until a week later. The resident was referred to a home health agency for PT, OT, and nursing, but the agency was out of network and notified the facility it could not admit the resident; no alternative in-network referral was made and calls were not returned. The SSD did not schedule a follow-up appointment with the primary care provider, relying on the resident to arrange it, and key discharge-planning staff, including those responsible for care coordination, were off duty with no designated backups, leading to missed communications and an ineffective discharge plan.
The facility failed to maintain a clean and homelike environment, with damaged walls observed in 15 resident rooms and a nutrition room. Residents expressed dissatisfaction, noting the damage existed since admission. The Administrator and Maintenance Director confirmed the need for repairs, highlighting a systemic failure in housekeeping and maintenance services.
A resident with moderate cognitive impairment was observed by staff engaging in non-consensual contact with another resident, who expressed discomfort. Despite the facility's zero-tolerance policy for abuse, the incident was not immediately addressed as required. The staff failed to remove the perpetrator and protect the resident, and the incident was not promptly reported to the Abuse Coordinator.
A CNA in an LTC facility misappropriated $350 from a resident's bank card, exploiting the resident's trust. Despite the facility's zero-tolerance policy for abuse, the CNA transferred the funds to her account without consent. The incident was reported to the police, leading to the CNA's arrest and charges of financial exploitation. The facility confirmed the misappropriation but failed to report the CNA to the Abuse Registry.
Failure to Obtain Ordered Pain Medication Within 24 Hours
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to timely medication delivery. Facility policy titled “Choice of Pharmacy and Medicare (Part D) Drug Plans” revised 4/2007 requires the pharmacy service provider to deliver routinely prescribed medications within 24 hours of the order, or sooner if needed. For one resident admitted with osteomyelitis of the thoracic vertebra and management of vascular access, a physician’s order dated 3/19/2026 at 5:10 AM prescribed Oxycodone 10/325 mg every 4 hours as needed for osteomyelitis-related pain. The resident’s quarterly MDS dated 3/7/2026 showed a BIMS score of 14, indicating the resident was cognitively intact. Pain assessments from 3/19/2026–3/20/2026 showed no increase in pain during this period. Pharmacy workflow and delivery documentation showed that the ordered Oxycodone 10/325 mg was not delivered to the facility until 3/20/2026 at 5:30 PM, approximately 36 hours after the medication was ordered, exceeding the 24-hour timeframe required by facility policy. Email correspondence between the DON and the pharmacy’s General Manager confirmed that the order, submitted at 5:10 AM on 3/19/2026, should have been included on the delivery run that same day, but a pharmacy staff member incorrectly placed it on the following day’s run. In an interview, the DON confirmed that the medication was ordered on 3/19 at 5:00 AM and arrived on 3/20 at 5:30 PM, acknowledging that the facility failed to obtain the resident’s Oxycodone 10/325 mg within 24 hours of the order.
Failure to Ensure Safe and Coordinated Discharge Planning and Medication Provision
Penalty
Summary
The deficiency involves the facility’s failure to execute an orderly and effective discharge for one cognitively intact resident who was discharged home. Facility policy on transfer or discharge required that information such as disposition of medications and confirmation that receiving providers’ services were available to meet the resident’s needs be communicated at discharge. The resident had multiple diagnoses, including aphasia following cerebral infarction, type 2 diabetes with neuropathy, unspecified dementia, depression, duodenal ulcer, and fibromyalgia, but was assessed as cognitively intact with no behavioral issues and needing only minimal to moderate assistance with activities of daily living. At discharge, the facility’s discharge summary identified the resident’s pharmacy of record and stated that prescriptions were conveyed to the pharmacy by fax, but the pharmacy fax number line was left blank. Review of pharmacy records showed that discharge medication orders were not actually transmitted to the pharmacy until seven days after discharge, and there was no evidence that prescriptions were sent at the time of discharge as documented. The DON later confirmed the facility could not provide any information showing that prescriptions were faxed on the discharge date and that the electronic transfer of prescriptions occurred a week later, after a family complaint. The facility also failed to ensure appropriate post-discharge services and follow-up medical care were arranged. The resident was referred to a local home health agency for PT, OT, and nursing services, but the agency was out of network for the resident’s insurance and therefore did not admit the resident. The home health service director reported notifying the facility on the day of referral that the resident was not eligible, but the facility did not return the call or make an alternative in-network referral. The SSD, who coordinated the discharge, did not schedule a follow-up appointment with the resident’s primary care physician, stating the resident said she would do it herself, and was unaware that the home health provider was out of network. The DON and Administrator confirmed that multiple staff responsible for discharge planning and care coordination were off duty over the holidays, no backup personnel were designated, and messages from the home health provider were not relayed, resulting in a failure to provide a safe and effective discharge plan for the resident’s wound care, therapy, and medication needs.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by the presence of dirty walls with black vertical marks, vertical scrapes, and holes in the sheet rock in 15 out of 48 observed resident rooms. These deficiencies were noted in various rooms, including those occupied by residents with significant medical conditions such as paraplegia, pressure ulcers, and chronic obstructive pulmonary disease. The observations revealed that the walls behind the headboards in these rooms were damaged, with sheet rock dust present, indicating a lack of timely maintenance and repair. Interviews with residents revealed dissatisfaction with the state of their living environment. For instance, one resident expressed that the wall had been damaged since their admission and would have been repaired if it were their own home. Another resident, who was cognitively intact, also noted that the wall should be fixed. These statements highlight the residents' awareness and concern about the substandard conditions of their rooms, which were not addressed by the facility. The facility's administration and maintenance staff acknowledged the issues during interviews, confirming the presence of black marks, scrapes, and holes in the walls. Both the Administrator and the Maintenance Director agreed that the walls needed to be repaired, yet the deficiencies persisted across multiple rooms and even in a nutrition room. This indicates a systemic failure in the facility's housekeeping and maintenance services to uphold the residents' right to a safe and comfortable environment, as outlined in the facility's policy on resident rights and responsibilities.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. Resident #12, who has moderate cognitive impairment, was observed by staff with his hand inside the shirt of Resident #6, who has no cognitive impairment and uses a wheelchair. Despite the facility's zero-tolerance policy for abuse, the incident was not immediately addressed as required. Dietary Staff M witnessed the inappropriate contact and attempted to intervene by coughing, but the behavior continued. Resident #6 expressed discomfort and attempted to shoo Resident #12 away, indicating non-consensual contact. The facility's policy mandates immediate removal of the perpetrator and protection of the resident, but this was not effectively executed. LPN O was informed of the incident and spoke with Resident #6, who confirmed feeling uncomfortable. However, Resident #12 was not directly supervised following the incident, and the staff did not promptly remove him from the situation. The Director of Nursing later stated that staff are expected to intervene and report such incidents to the Abuse Coordinator, but these actions were not adequately taken in this case.
CNA Misappropriates Resident's Funds
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation and exploitation when a Certified Nursing Assistant (CNA) wrongfully transferred money from a resident's bank card to her personal account. The facility's policy, titled 'Abuse Prohibition Plan,' clearly states a zero-tolerance policy for abuse, including misappropriation of resident property. Despite this policy, the CNA exploited the resident's trust by withdrawing $350.00 from the resident's account without consent. The incident was reported to the police, and an investigation was initiated. The resident, who had moderate cognitive impairment, reported the theft after being informed by her bank. The facility's investigation confirmed the misappropriation, and the CNA was terminated for policy violation. However, the facility did not report the CNA to the Abuse Registry, as confirmed by the former Director of Nursing. Interviews with various staff members, including the Administrator, Housekeeping Supervisor, and Social Worker, corroborated the resident's account of the incident. The police detective confirmed that the CNA was arrested and charged with financial exploitation of an elderly or vulnerable person. The facility's failure to report the CNA to the Abuse Registry highlights a significant oversight in handling the incident.
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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 Cookeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Cookeville | 2.1 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Putnam County | 2.6 mi | ★★★★★ | 0 | 0 |
| Standing Stone Care And Rehab | 11.3 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Sparta | 13.9 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Sparta | 15.7 mi | ★★★★★ | 0 | 0 |
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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.