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 Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's needs.
The facility did not develop or implement comprehensive care plans addressing denture use and oral care for multiple residents, resulting in unmet needs and significant weight loss for at least one resident. Staff were often unaware of residents' denture requirements, and care plans lacked measurable objectives or updates when residents' needs changed. This led to inadequate assistance with dentures, limited dietary options, and ongoing nutritional decline.
A resident with significant weight loss and low albumin levels was not properly assessed or assisted with denture use, despite system alerts and care plan requirements. Staff were unaware of the resident's need for denture assistance, and the care plan was not updated to reflect this need. The resident's food preferences and nutritional needs were not adequately addressed, resulting in continued impaired nutritional status.
The facility did not make survey results or information about their location readily accessible to residents, family members, or staff. Staff were unaware of the survey binder's location, and it was kept hidden behind the nurse's station. The binder was also missing results from previous state visits. Multiple residents reported not knowing how to access survey results or being informed about them, despite facility policy requiring such postings to be accessible.
Surveyors found that food items in the kitchen were not properly labeled or sealed, and that a dietary staff member failed to sanitize equipment and practice proper hand hygiene during meal preparation. Management and staff confirmed that use-by dates were not used and that required sanitation and labeling procedures were not followed, contrary to facility policy.
The facility did not implement its QAPI plan as required, failing to conduct at least one annual performance improvement project (PIP) in high risk or problem-prone areas. Instead, the DON addressed issues informally during morning meetings, and the ADM chose not to initiate formal PIPs, believing the facility was already performing well.
Several residents' MDS assessments failed to accurately document denture use and fall history, despite direct observations, interviews, and progress notes confirming these conditions. Staff and care plans did not consistently reflect the presence of dentures or record a documented fall, resulting in assessments that did not match the residents' actual status.
Several residents were prescribed medications, including antianxiety, antibiotic, and anticoagulant drugs, without proper documentation of diagnoses or monitoring for side effects. For example, a resident received Lorazepam without a documented diagnosis of anxiety, and others on anticoagulants were not monitored for bleeding or bruising as required. Nursing staff and the DON confirmed the lack of formal processes for documenting medication indications and monitoring adverse effects.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Care Plan and Implement Denture-Related Oral and Nutritional Care
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for all residents reviewed, specifically neglecting to address oral care needs related to denture use and associated interventions for oral and nutritional maintenance. This deficiency was identified for 27 residents, including one resident who experienced significant weight loss and impaired nutritional status due to the lack of assistance with denture use, despite system-generated warnings and lab results indicating low protein levels. The care plans for these residents did not include measurable objectives or timeframes to address their medical, nursing, and psychosocial needs, nor did they describe the services required to help residents attain or maintain their highest practicable well-being. Multiple residents who required assistance with dentures were not identified as such in their care plans, and staff were often unaware of residents' denture needs. For example, one resident with a history of cerebral aneurysm, depression, and hypertension, who had no natural teeth and required supervision or touch assistance with oral care, was not provided with the necessary support to use her dentures. Despite repeated expressions of frustration and requests for help, she was left to eat a limited diet of soft foods, resulting in ongoing weight loss and dissatisfaction with her care. Staff interviews revealed a lack of awareness and communication regarding residents' denture status, with CNAs and dietary staff relying on verbal cues or incomplete documentation rather than care plans or shift sheets. The deficiency was further evidenced by the absence of documentation addressing system-generated alerts for significant weight loss, as well as the lack of updates to care plans when residents received dentures after admission. Interviews with staff, including CNAs, nurses, and the MDS coordinator, confirmed that denture use was not consistently included in care plans, and there was confusion about responsibility for updating this information. As a result, residents who required assistance with dentures did not receive appropriate support, placing them at risk for impaired nutritional status and unmet care needs.
Failure to Address Nutritional Needs and Denture Assistance
Penalty
Summary
A deficiency occurred when the facility failed to recognize, evaluate, and address the nutritional needs of a resident who experienced significant weight loss over a one-year period. Despite system-generated warnings and multiple lab results indicating low albumin levels, which signaled low protein status, there was no documented response or intervention to address the resident's declining weight. The care plan did not reflect the resident's use of dentures, and there was no evidence that the system alert for significant weight loss was addressed in progress notes or during weight meetings. The resident's care plan interventions, such as health shakes and monitoring, were not updated to reflect the ongoing weight loss, and the resident's food preferences and needs were not adequately considered. The resident, who had a history of cerebral aneurysm, vitamin D deficiency, depression, hyperlipidemia, anemia, and hypertension, was cognitively intact and required assistance with oral hygiene and denture care. Observations and interviews revealed that the resident was not wearing her dentures during meals and was not assisted by staff in using them, despite expressing a desire to eat a greater variety of foods. Staff members, including CNAs and dietary staff, were either unaware of the resident's need for dentures or assumed she did not have them. The resident repeatedly stated she wanted to use her dentures to eat different foods but did not receive the necessary assistance, leading her to stop asking for help. The facility's policies required monitoring of undesirable weight changes, individualized care planning, and provision of denture care, but these were not followed in this case. Staff interviews confirmed a lack of awareness regarding the resident's denture needs, and the care plan was not updated to include this information. The resident's meal tickets did not reflect her preferences or needs, and the dietary manager was unaware of her denture status. The failure to provide assistance with dentures and to address the resident's nutritional needs resulted in continued impaired nutritional status and significant weight loss.
Failure to Make Survey Results Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that residents were aware of where to locate the State Agency (SA) survey inspection results, including surveys, certifications, and complaint/incident investigations. During observations and interviews, it was found that there were no survey results posted in the lobby or common areas, nor was there any signage indicating where these results could be found. Staff members, including an LVN, were unaware of the location of the survey binder, and the administrator retrieved the binder from a hidden location behind the nurse's station, stating she was not aware it needed to be publicly accessible. The binder itself was incomplete, missing results from previous state visits. Additionally, interviews with eight residents revealed that none of them knew where or how to access survey results within the facility, nor had they ever been informed about the outcomes of any SA visits. Several residents expressed a desire to have access to this information. The facility's policy required that such postings be accessible to all staff and residents, but this was not being followed at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation practices. During a tour, it was found that food items stored in two reach-in refrigerators and a walk-in freezer were not properly labeled or dated with a use-by date. Items such as potato salad, pea salad, oatmeal, pureed eggs, and pureed sausage were only marked with a preparation date and lacked identification or use-by dates. Additionally, a vacuum-sealed ground beef package and a bag of beef and bean burritos in the freezer were not properly sealed or labeled, with the burritos also being exposed to air-borne contamination. Further observations revealed improper sanitation and hand hygiene practices during meal preparation. A dietary staff member (DC K) was seen preparing pureed meals without sanitizing the blender between uses, only rinsing it with water in a soiled sink without soap or sanitizer. The staff member also failed to change gloves or wash hands after touching potentially contaminated surfaces, such as the sink, before returning to food preparation. These actions were contrary to the facility's own policies, which require thorough cleaning and sanitizing of equipment and proper hand hygiene to prevent cross-contamination. Interviews with dietary staff and management confirmed that use-by dates were not being used, as staff were trained to discard items after three days rather than label them. Management acknowledged that items should be labeled with preparation and use-by dates, and that all food should be properly sealed to prevent contamination. Policies reviewed by surveyors outlined clear requirements for handwashing, equipment sanitation, and date marking, all of which were not followed as observed during the survey.
Failure to Implement QAPI Program and Conduct Required PIPs
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan and program as required. Specifically, the facility did not conduct at least one performance improvement project (PIP) annually, which is a requirement outlined in their QAPI plan. During an interview, the DON stated that issues are identified and addressed during morning meetings, typically through in-services or CNA check-offs, rather than through formal PIPs. The ADM, who is responsible for the QAPI program, acknowledged understanding what a PIP is but indicated that no changes were made to the system upon her arrival because she believed the facility was performing well. A review of the facility's QAPI plan confirmed that the facility is expected to conduct PIPs in high risk or problem-prone areas at least annually, based on data collection and analysis. However, the facility did not follow this process, as no PIPs were conducted during the review period. This lack of formalized quality improvement activities was identified through both interviews and record review.
Inaccurate Resident Assessments for Oral/Dental Status and Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the oral/dental status and fall history for several residents. Specifically, multiple Minimum Data Set (MDS) assessments for five residents did not correctly indicate the presence of dentures or the absence of natural teeth, despite direct observations, interviews, and progress notes confirming denture use. For example, one resident was observed wearing ill-fitted upper dentures, and both the resident's family member and facility staff confirmed the use of dentures, yet the MDS assessments marked 'none of the above' for oral/dental status. Similar discrepancies were found for other residents, where care plans and MDS assessments did not document denture use, even though progress notes and resident interviews confirmed it. Additionally, the facility failed to accurately code a fall for another resident on the MDS assessment. Nursing progress notes documented an incident where the resident slid from a chair to the floor, resulting in a hematoma, but the corresponding MDS assessment did not reflect a fall during the look-back period. Interviews with the MDS Coordinator, DON, and nursing staff confirmed that such an event should have been coded as a fall and included in the assessment. Staff acknowledged the importance of accurate documentation for care planning and funding, and recognized that the omission was inconsistent with facility policy and regulatory requirements. Facility policy and federal regulations require that assessments accurately reflect the resident's status, including direct observation and communication with residents and staff. The findings showed that qualified staff did not consistently document medical and functional problems, such as denture use and falls, in the MDS and care plans. This resulted in assessments that did not accurately represent the residents' conditions at the time of assessment, as required by both facility policy and federal guidelines.
Failure to Monitor and Document Medication Indications and Side Effects
Penalty
Summary
The facility failed to ensure that residents' drug regimens were adequately monitored and free from unnecessary drugs for several residents. For one resident, there was no diagnosis provided for the use of an antianxiety medication, Lorazepam, despite multiple as-needed orders for varying dosages. The resident's care plan and medication administration records did not indicate a diagnosis of anxiety or agitation, nor was there documentation in the Minimum Data Set (MDS) to support the use of an antianxiety medication. Another resident was prescribed Doxycycline, an antibiotic, without a related diagnosis such as MRSA being documented in the physician's order or medication administration record. Although the resident had a chronic wound with a history of MRSA, the specific indication for the antibiotic was not included in the order. Additionally, this resident, along with two others, was receiving anticoagulant therapy, but there was no evidence of monitoring for side effects such as abnormal bleeding or bruising in their treatment administration records. Interviews with nursing staff and the Director of Nursing (DON) confirmed that there was no specific process or documentation in place for monitoring side effects of anticoagulant medications. Staff stated that while they visually observed residents for signs of bleeding or bruising, there was no formal order or designated area in the records for documenting such monitoring. Facility policy required that each resident's medication regimen be managed and monitored for indications, clinical need, and adverse consequences, but these requirements were not met for the residents reviewed.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grandview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Itasca | 8.1 mi | ★★★★★ | 5 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 9.6 mi | ★★★★★ | 4 | 0 |
| Town Hall Estates Keene, Inc. | 12.1 mi | ★★★★★ | 0 | 0 |
| Heritage Trails Nursing And Rehabilitation Center | 14.1 mi | ★★★★★ | 4 | 0 |
| Colonial Manor Nursing Center | 14.5 mi | ★★★★★ | 3 | 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.