Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
Surveyors found that staff failed to review and revise care plans when residents’ needs changed. Several residents experienced significant weight loss with physician orders for special diets, supplements, and increased weight monitoring, but these changes were not added to their care plans, and CNAs reported they were unaware of the weight loss. Other residents used bed rails or assist bars observed in daily care, yet their care plans contained no directions for this equipment. A resident with Alzheimer’s disease had the diagnosis documented in the MDS but not in the care plan, and no cognitive interventions were listed. The MDS nurse, who was inexperienced with MDS and care planning, was identified as responsible for updates, while the DON and Administrator stated they expected individualized care plans to reflect weight changes, nutritional interventions, cognitive status, assistive devices, and required assistance levels.
Staff failed to follow abuse and misappropriation protocols when a cognitively intact resident experienced multiple fraudulent charges on their credit card over an extended period, allegedly involving a housekeeper who was later observed by law enforcement using the resident’s card at a gas station. Although facility policy required prompt reporting to the state agency and a thorough investigation of alleged exploitation, there was no documentation that an investigation into this misappropriation was completed, and the current administrator was unaware of the incident until surveyors inquired.
Staff failed to provide adequate daily hygiene and clothing changes for three cognitively impaired residents who required assistance with ADLs. One resident had a care plan directing staff to monitor and remove facial hair as needed, yet was repeatedly observed with long facial hair. Another resident, assessed as needing extensive assistance with hygiene, dressing, and bathing and care planned for two-person assistance and clean clothing daily, was observed wearing the same sweatshirt over multiple days with long facial hair. A third resident, care planned to receive supervision and assistance for all ADLs and clean clothing daily, was also observed in the same sweatsuit over several days with long facial hair. An LPN, the DON, and the Administrator stated that aides are responsible for changing clothes and shaving, charge nurses must ensure cares are completed, and residents’ clothes should be changed daily, but they were unaware these cares had not been provided or documented as refused.
Staff failed to consistently monitor and document bowel movements for two residents at risk for constipation, resulting in prolonged periods without documentation or intervention. One resident was hospitalized with fecal impaction, and staff interviews revealed a lack of awareness and adherence to facility policy regarding bowel movement monitoring and administration of as-needed laxatives.
The facility failed to transmit MDS data for ten residents within the required timeframe. The MDS Coordinator completed the assessments, but the DON, responsible for submission, missed deadlines due to vacations and lack of a backup. The administrator was unaware of submission frequency, contributing to the deficiency.
A resident, who is cognitively intact and uses a motorized wheelchair, was restricted from independently visiting a nearby park, a preferred activity that helps manage their depression and anxiety. Despite being assessed as a safe smoker and having no documented safety issues related to this activity, the facility staff cited safety concerns due to incidents of the resident hitting objects with their wheelchair. The decision was made without proper documentation or communication among staff, leading to a failure in respecting the resident's right to self-determination.
Facility staff failed to maintain and label oxygen equipment properly, leading to a deficiency in infection control. Observations showed that oxygen tubing for several residents was not dated, and concentrator filters were unclean. Interviews with staff revealed a lack of adherence to the facility's policy for regular equipment maintenance and labeling, contributing to the risk of infection spread.
Facility staff failed to connect a resident's nasal cannula to the oxygen concentrator and did not turn it on, despite the resident's severe cognitive impairment and medical conditions requiring oxygen therapy. The resident's care plan lacked directions for oxygen therapy, and staff did not notify the physician of the resident's low oxygen saturation.
Failure to Update Care Plans for Weight Loss, Cognitive Status, and Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans when residents’ needs changed, as required by facility policy and federal regulations. The policy states that individualized care plans must be based on thorough assessments, including the MDS, and must be updated with significant changes in condition, at least quarterly, and when changes occur that impact care. Surveyors found that for multiple residents, care plans did not reflect significant weight loss, new or ongoing nutritional interventions, use of bed rails or assist bars, or cognitive diagnoses, despite these being documented elsewhere in the record and observed in practice. For one resident with severe cognitive impairment, stroke, dementia with agitation, anxiety, depression, violent behavior, and stage III chronic kidney disease, the MDS and physician orders showed a soft and bite-sized diet, nutritional supplements (Boost Breeze and Super Cereal), and weekly weights due to weight loss from 155.4 lbs to 140.4 lbs. However, the care plan dated 12/03/25 was not updated to include the recent weight loss, the ordered supplements, or the increased frequency of weights. A CNA reported not knowing the resident had weight loss and stated that if aware, they would have tried to encourage more intake. The MDS Coordinator confirmed that weight loss and related interventions, including supplements and assistance level with eating, should be on the care plan. Another resident with anoxic brain damage, diabetes, stroke, dementia, schizophrenia, gastroparesis, depression, and anxiety experienced a weight decrease from 179.2 lbs to 151.6 lbs over five months. Physician orders included a Level Six soft and bite-sized diet, yogurt twice daily, weekly weights, and a high-calorie supplement. Despite this, the care plan dated 12/15/25 did not document the significant weight loss, the use of nutritional supplements, or the change in weight-monitoring frequency. The CNA who assisted with feeding did not know about the weight loss, and the DON described needing to encourage this resident to eat, while the MDS Coordinator again stated that weight loss and interventions should be reflected in the care plan. A resident assessed as cognitively intact was repeatedly observed in bed with a right grab bar/bed rail in the upright position on multiple days, yet the care plan dated 10/03/25 contained no direction for the use of bed rails. The MDS Coordinator stated that if a resident used bedrails, this should be listed on the care plan. Another resident with severe cognitive impairment, delusions, daily behavioral symptoms, and dependence on staff for eating had a documented weight drop from 129.8 lbs to 103.6 lbs over five months, with physician orders for a regular diet, house supplement, and weekly weights. The care plan dated 12/22/25 did not include the significant weight loss, the nutritional supplement, or the change in weight frequency. The CNA did not know the resident had weight loss and described variable assistance with eating, while the MDS Coordinator reiterated that weight loss and related interventions should be care planned. A further resident with severe cognitive impairment and a diagnosis of Alzheimer’s disease had an admission MDS reflecting this condition, but the care plan dated 11/12/25 did not document the Alzheimer’s diagnosis or include any interventions related to cognitive impairment. The MDS Coordinator stated that the diagnosis should be on the care plan so staff know how to care for the resident. Another resident, cognitively impaired and requiring substantial/maximal assistance for bed mobility and transfers, was repeatedly observed with a left assist bar in the upright position on the bed, yet the care plan dated 10/23/25 did not document direction for use of the assist bar. A CNA stated that bed rails should be listed on care plans and that dementia or Alzheimer’s diagnoses should be included so staff know how to care for residents. Interviews with leadership confirmed expectations that care plans be individualized and updated with changes. The MDS Coordinator reported having worked at the facility for only a couple of months, with no prior experience in MDS or care planning, and acknowledged that care plans should be updated with every change of condition, quarterly, and annually. The DON and Administrator both stated that the MDS nurse is responsible for updating care plans and that they expect care plans to direct resident care and include bed rails, weight loss and interventions, frequency of weight checks, nutritional supplements, cognitive status, and the amount of assistance needed. The Administrator also noted that the facility holds a morning meeting to discuss incidents or changes and expects care plans to be updated when needed based on those discussions.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation into an allegation of misappropriation of a resident’s funds. The facility’s Abuse Prohibition Protocol Manual directed staff to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment, to prevent further incidents while an investigation was in process, and to take appropriate corrective action based on findings. The policy also required the Administrator or designee to report allegations to the state survey agency within two hours. A cognitively intact resident, as documented on a Significant Change MDS dated 04/23/25, had multiple fraudulent charges made on their credit card over an extended period. A detective reported that a housekeeper employed by the facility was caught using the resident’s credit card at a gas pump and then using their own personal card inside the gas station. The facility’s prior abuse and neglect investigation records did not contain documentation that an investigation into this misappropriation allegation had been completed. The former Administrator stated that the facility was not made aware of any incidents involving the resident’s credit card until after the resident had been discharged and that an investigation was started, but they did not know what happened to it or whether it was finished. The former Administrator also reported that when they spoke with the housekeeper, the housekeeper denied making the fraudulent charges. The current Administrator, who began employment after the incident period, reported having no knowledge of the incident or any facility-reported incident until the survey team began the annual survey and stated that a detailed investigation and timely report to the state agency would have been expected if a misappropriation report had been made. The facility had a practice of discouraging residents from keeping valuables in their rooms and maintained a lock box in the business office for residents’ valuables, but there was no documented investigation into whether other residents were affected or into the specific misappropriation allegation involving this resident.
Failure to Provide Daily Hygiene and Clothing Changes for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, grooming, and clothing changes, for three cognitively impaired residents. For one resident, the Quarterly MDS dated 12/02/25 documented severe cognitive impairment, no behaviors or care refusals, and independence with ADLs, with a care plan directive for staff to monitor and remove facial hair as needed. Despite this, repeated observations from 01/11/26 through 01/14/26 showed the resident consistently had long facial hair, indicating that staff did not follow the care plan related to grooming. A second resident’s admission MDS showed severe cognitive impairment, no behaviors or refusals, and a need for extensive assistance with hygiene, dressing, and bathing, with a care plan dated 12/02/25 directing staff to provide assistance from two staff for all ADLs and to provide clean, appropriate clothing daily. Observations over four consecutive days showed this resident wearing the same grey sweatshirt and having long facial hair. A third resident’s Quarterly MDS documented severe cognitive impairment, no behaviors or refusals, independence with dressing, and moderate assistance needed for hygiene and bathing, with a care plan dated 09/26/25 requiring supervision and assistance for all ADLs and clean clothing daily. Observations over multiple days showed this resident wearing the same green sweatsuit and having long facial hair. In interviews, an LPN, the DON, and the Administrator each stated that aides are responsible for assisting residents with changing clothes and shaving, that charge nurses are responsible for ensuring these cares are completed, and that they were not aware these residents’ clothes were not changed and their faces not shaved, despite expectations for daily clothing changes and shaving as needed, particularly with showers and with documentation of any refusals.
Failure to Monitor and Document Bowel Movements Leads to Fecal Impaction
Penalty
Summary
Facility staff failed to monitor and document bowel movements for two residents, both of whom were assessed as being at risk for constipation and dehydration. The facility's policy required staff to determine daily if residents had a bowel movement, document this information, and notify the charge nurse if a resident had not had a bowel movement in three days. For one resident with impaired cognition and a history of opiate use, staff did not document any bowel movements for over a week, nor did they administer prescribed as-needed laxatives. This resident was ultimately sent to the hospital and diagnosed with fecal impaction. For the second resident, who also had a diagnosis of constipation and was prescribed multiple medications with constipating side effects, staff failed to document bowel movements for several extended periods, including gaps of seven, eight, and eleven days. There was no documentation that as-needed laxatives were administered during these times. Interviews with staff revealed a lack of awareness regarding the residents' bowel movement status and inconsistent monitoring and documentation practices. Staff interviews confirmed that CNAs were responsible for documenting bowel movements each shift and notifying licensed staff if a resident had not had a bowel movement in three days. However, both CNAs and licensed staff were unaware of the prolonged periods without bowel movements for the affected residents, and there was no evidence that appropriate interventions were implemented as required by facility policy and physician orders.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit the required Minimum Data Sets (MDS) for ten residents within the mandated timeframe. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, all MDS assessments must be transmitted electronically within 14 days of completion. However, the facility did not meet this requirement for ten residents, including those with quarterly, annual, and Significant Change of Status assessments. The facility's census was 48, and the deficiency was identified through interviews and record reviews. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the MDS, while the Director of Nursing (DON) was responsible for submitting the data. The DON admitted to submitting the data every other week but failed to do so due to taking vacations in June and forgetting to submit upon return. The administrator was unaware of the submission frequency and confirmed that there was no backup person to handle submissions in the DON's absence. This lack of a backup plan contributed to the failure to transmit the MDS data as required.
Failure to Support Resident's Right to Self-Determination
Penalty
Summary
Facility staff failed to respect and promote the rights of a resident to make choices about significant aspects of their life, specifically the choice to independently go outside the facility. The resident, who is cognitively intact and uses a motorized wheelchair, expressed a preference to visit a nearby park independently, which was previously allowed. However, the facility staff recently prohibited this activity, citing safety concerns, despite the resident's ability to operate the wheelchair independently and use a cell phone for assistance if needed. The resident's family member also supported the resident's choice, noting its importance for managing depression and anxiety. The facility's decision was based on an assessment that deemed the resident an unsafe smoker and noted incidents of the resident hitting objects with their wheelchair. Despite these concerns, the resident's medical record did not document any specific safety issues related to the preferred activity of going to the park. Interviews with various staff members, including the Assistant Director of Nursing, MDS coordinator, and Director of Nursing, revealed a consensus on the safety concerns, leading to the restriction of the resident's unsupervised trips. However, there was a lack of communication among staff, as some were unaware of the restriction, highlighting a gap in the implementation of the resident's rights policy.
Deficiency in Oxygen Equipment Maintenance and Infection Control
Penalty
Summary
The facility staff failed to properly manage and maintain oxygen equipment for four residents, leading to a deficiency in infection prevention and control. Observations revealed that oxygen tubing for these residents was not labeled with dates, indicating that it had not been changed as per the facility's policy. Additionally, the oxygen concentrator filters were found to be covered with a white residue, suggesting they were not cleaned regularly. The facility's policy, dated March 2015, requires regular checks and cleaning of oxygen equipment, including changing humidifiers and tubing according to cleaning guidelines. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that oxygen tubing should be changed monthly and labeled with the date of change. However, it was noted that there was no preventative maintenance plan for cleaning oxygen filters. The DON acknowledged the responsibility to ensure tubing changes, while the administrator was uncertain about the frequency of changes, indicating a lack of clarity and adherence to the facility's policy. This lack of compliance with established procedures contributed to the risk of infection spread among residents using oxygen therapy.
Failure to Properly Administer Oxygen Therapy
Penalty
Summary
Facility staff failed to connect a resident's nasal cannula tubing to the oxygen concentrator and did not turn the concentrator on. The resident, who had severe cognitive impairment, was dependent on staff for various activities and had medical conditions including atrial fibrillation, heart failure, and dementia. The resident's care plan did not include directions for oxygen therapy, despite a physician's order for two to five liters of oxygen per minute as needed. On the day of the incident, the resident was found with an oxygen saturation of 55%, and there was no documentation that the physician was notified of this change in condition. Interviews revealed that the CNA working with the resident believed the nasal cannula was connected and the concentrator was on, but later it was found disconnected and off. The LPN confirmed that the resident was too lethargic to have removed the cannula independently. The Director of Nursing and the facility administrator both expected staff to follow physician orders and ensure proper oxygen administration, but this was not done in this case.
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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 Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Health Care Center | 8 mi | — | 0 | 0 |
| Union Nursing | 10.1 mi | — | 2 | 0 |
| New Haven Care Center | 10.8 mi | — | 0 | 0 |
| St Clair Nursing Center | 14.7 mi | — | 1 | 0 |
| Pacific Care Center | 16.5 mi | — | 21 | 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 August 2026) and official state health department websites.