Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Grand View Care Ctr during CMS and state inspections, most recent first.
The facility failed to prevent and manage pressure injuries for two residents, leading to the development and worsening of PIs. One resident developed a stage 4 PI due to inadequate interventions and lack of timely assessments, while another resident's refusal to reposition led to multiple PIs, including an unstageable PI. The facility did not adhere to professional standards for PI prevention and management, resulting in harm to the residents.
A resident with a history of falls and severe cognitive impairment experienced a fall resulting in a head injury requiring staples due to the facility's failure to ensure non-skid footwear was worn, as per the care plan. The incident occurred at the nurse's station, where the resident was found barefoot, indicating a lack of adherence to fall prevention measures.
The facility did not provide mandatory QAPI training to staff, as required by their QAPI plan. A review of orientation and annual education records showed no evidence of such training. The NHA confirmed the absence of QAPI education in staff training programs.
A resident with moderate cognitive impairment alleged physical abuse by a CNA, claiming their head was banged against the wall. The incident was reported internally within two hours, but the facility failed to report it to the state agency within the required timeframe. The NHA later determined the incident was not intentional abuse, but this conclusion was not reached within the initial two-hour period.
The facility did not establish a compliance and ethics program to prevent and detect violations and promote quality care, potentially affecting all 43 residents. The facility assessment lacked ethics and compliance training, and the NHA admitted the program was not implemented due to other priorities.
The facility did not implement an effective ethics and compliance training program, affecting all 43 residents. The facility assessment lacked this training, and records showed that three CNAs and two licensed staff, including an RN and an LPN, did not receive training. The NHA acknowledged the need for a program but deprioritized it due to other issues, leading to no training being conducted.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and manage pressure injuries (PIs) for two residents, R1 and R2, leading to the development and worsening of PIs. R1 was admitted without a PI but was at risk for developing one. The facility did not implement adequate interventions, failed to conduct weekly comprehensive assessments, and did not update the care plan timely. As a result, R1 developed a facility-acquired PI that progressed to a stage 4. The facility's inaction included not staging the PI, not offering alternative repositioning schedules, and not educating R1 on the importance of repositioning. R2 was also admitted without a PI but was at risk due to severe cognitive impairment and other medical conditions. The facility did not complete comprehensive assessments or offer alternative interventions when R2 refused repositioning. Consequently, R2 developed two deep tissue injuries that worsened into multiple PIs, including an unstageable PI with undermining. The facility failed to stage the wounds when first noted and did not provide adequate interventions to prevent further deterioration. The deficiencies were identified through observations, interviews, and record reviews, revealing that the facility did not adhere to professional standards for PI prevention and management. The lack of timely assessments, staging, and care plan updates contributed to the worsening of the residents' conditions, indicating a failure to provide appropriate care and services to prevent harm.
Removal Plan
- Full facility skin assessment sweep completed by facility nursing leadership.
- Wound Care Consultant rounded for residents with areas of wound concerns.
- Full facility Braden Scale Sweep completed by nursing leadership.
- Interventions put in place based on Braden scale score.
- All care plans for residents with any skin concerns reviewed for appropriate interventions and updated.
- Review each resident's nutrition, appetites, weights, blood sugar, hydration by nursing leadership to ensure appropriate interventions are in place.
- Inventory of all mattresses and cushions that residents utilize and identify the stages for each.
- Order an Alternating Air Mattress that supports up to a Stage IV wound.
- Obtain mattress and cushion information from manufacturer or supplier to ensure they meet the correct needs of the residents.
- Hydration assessments on residents identified for Pressure Ulcers.
- Training for RNs and LPNs initiated.
- Implement weekly Wound Rounds to be completed on Tuesday Mornings.
- Update Admission and Re-admission checklist to clarify expectations upon admission for the Skin assessment, Braden scale, and interventions implemented in the baseline care plan.
- Implement checklist for nursing to use when a new skin concern is identified.
- Implement new documentation for meals, fluids, and snacks.
- Implement provider and resident representative being updated weekly after wound rounds with current wound measurements and wound assessment.
- Update policy and procedures related to skin, wounds, Braden scales, and repositioning.
- Conduct audits daily for residents with pressure injuries.
- QAPI will review all residents with wounds monthly.
- QA will review all residents with wounds quarterly and review/update skin care policies as needed.
- Facility Assessment will be updated related to any wound resident care requirements.
Failure to Implement Fall Prevention Measures Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as R7. R7, who has a history of falls and severe cognitive impairment due to end-stage Alzheimer's disease, experienced a fall resulting in a head injury that required staples. The incident occurred because the care plan intervention of ensuring R7 wore non-skid footwear was not followed, leading to the resident being barefoot at the time of the fall. R7 had a documented history of multiple falls since admission, with eight falls recorded. The facility's fall protocol required staff to implement specific interventions to prevent falls, including ensuring that R7 wore non-skid footwear. Despite this, on the day of the incident, R7 was found barefoot, which was a direct violation of the care plan. The fall occurred at the nurse's station, where R7 was seen sleeping in a recliner chair shortly before the fall, suggesting a lack of adequate supervision. Interviews with facility staff, including the Director of Nursing, Certified Nursing Assistants, and a Registered Nurse, confirmed that the care plan was not followed. The staff acknowledged that R7 was barefoot at the time of the fall, and the Director of Nursing admitted that the care plan was not adhered to. This failure to implement the care plan interventions directly contributed to the fall and subsequent injury, highlighting a deficiency in the facility's fall prevention measures.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program, as required by their own QAPI plan dated January 2024. This plan mandates that all staff participate in ongoing annual QAPI training and that new employees receive QAPI education during orientation. However, upon review of the facility's new orientation and annual education records, the surveyor found no evidence of QAPI training being provided. During an interview, the Nursing Home Administrator confirmed that QAPI education was not included in the orientation or annual education for employees, acknowledging it as a missing component of staff education.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse within the required timeframe. A resident, who has moderate cognitive impairment, alleged that a CNA physically abused them by banging their head against the wall during care. This incident was reported to an LPN by the resident, who then assessed the resident and found no visible injuries or pain. The LPN reported the incident to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) within two hours, and the CNA involved was sent home pending investigation. However, the facility did not report the incident to the state agency until more than two days later, which is beyond the required two-hour reporting window for allegations involving abuse. The NHA determined that the incident was not a willful or intentional act of abuse by the CNA, partly based on the resident's history of making derogatory statements about minority staff and the lack of injuries. The NHA concluded that the resident may have accidentally hit their head on the wall during a roll, but this determination was not made within the initial two-hour period after the allegation was reported. Consequently, the facility did not comply with the regulatory requirement to report the alleged abuse to the state agency within the specified timeframe.
Lack of Compliance and Ethics Program
Penalty
Summary
The facility failed to develop a compliance and ethics program that is reasonably designed, implemented, and enforced to effectively prevent and detect violations and promote quality of care. This deficiency has the potential to affect all 43 residents in the facility. During the survey, it was found that the facility assessment, revised on 02/20/24, did not include ethics and compliance training. When interviewed, the Nursing Home Administrator (NHA) acknowledged the need for such a program but admitted that it was not implemented due to other priorities taking precedence.
Lack of Ethics and Compliance Training
Penalty
Summary
The facility failed to implement an effective ethics and compliance training program, which has the potential to affect all 43 residents. The facility assessment, revised on 02/20/24, did not include ethics and compliance training. Upon review of training records, it was found that three Certified Nursing Assistants (CNAs) and two licensed staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), did not receive any ethics and compliance training. During an interview, the Nursing Home Administrator (NHA) admitted awareness of the need for such a program but stated that it was deprioritized due to other issues, resulting in the absence of training.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blair
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trempealeau Cty Hcc Imd | 6.6 mi | ★★★★★ | 2 | 0 |
| Pigeon Falls Hcc | 9.2 mi | ★★★★★ | 0 | 0 |
| Marinuka Manor | 14.7 mi | ★★★★★ | 2 | 0 |
| Meadowbrook At Black River Falls | 18.4 mi | ★★★★★ | 14 | 0 |
| Pine View Care Center | 18.6 mi | ★★★★★ | 27 | 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.