Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Life Care Center Of Grandview during CMS and state inspections, most recent first.
A resident with dementia and a history of falls was startled by a door opening on a locked memory care unit, fell onto the right side, and exhibited pain responses when the right leg was touched. Facility staff notified hospice, and a hospice nurse later assessed the resident, documented no pain complaints and no new orders, and stated they would inform the family. However, facility records contained no documentation that the resident’s responsible party was notified on the day of the fall, and there was no follow-up by facility staff to verify that hospice had contacted the family, despite staff and leadership acknowledging that nurses are responsible for immediately notifying responsible parties of changes in condition and that this notification should occur regardless of hospice involvement.
Multiple incidents of physical aggression occurred between residents, including one resident striking another in the head after a verbal exchange, another resident punching a peer in the face resulting in injuries, and a third incident where hot sauce was poured on a resident's face. These events involved residents with cognitive and behavioral issues and were not prevented due to lack of supervision and failure to address escalating behaviors.
A resident with diabetes and cognitive impairment was sent to a hospital following two altercations and was subsequently issued an Immediate Notice of Involuntary Discharge. Facility staff, including the administrator and DON, determined the facility could not meet the resident's needs and refused readmission after hospital treatment. The resident was not updated on their status and expressed distress about not being allowed to return, while the social services designee sought alternative placements and notified the Ombudsman. The facility's policy lacked guidance on immediate involuntary discharges, and staff acknowledged noncompliance with regulations regarding reevaluation after treatment.
A resident with a history of epilepsy did not receive the correct dosage of Lamotrigine due to pharmacy delivery issues and staff errors in medication administration. The facility failed to administer the prescribed dose on admission and subsequently gave incorrect doses, leading to the resident experiencing seizure-like activity and requiring hospital transfer. Staff interviews revealed a lack of adherence to medication administration policies.
Two residents, both severely cognitively impaired, were involved in an altercation when one attempted to sit on the other's lap in the dining area. The seated resident said 'No', prompting the other to strike them, causing injuries. Staff witnessed the incident but could not intervene in time. The aggressive resident had a history of mood problems and was care planned for potential aggression. The facility's policy failed to prevent this resident-to-resident abuse.
A facility failed to ensure the safe storage and accountability of a resident's narcotic medication, resulting in 30 missing Oxycodone tablets. RN B signed for a delivery without verifying the contents due to being busy, and the narcotic card was not found in any storage locations. The pharmacy's protocol for verifying and signing for medications was not followed.
The facility failed to maintain a comprehensive infection prevention program, ensure proper hand hygiene during wound care, and screen residents for TB according to policy. Staff did not consistently implement Enhanced Barrier Protection, and several residents lacked documented TB tests or screenings.
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with PTSD. The resident's care plan lacked specific interventions related to PTSD, and staff were unaware of the diagnosis and potential triggers. Interviews with staff and review of medical records confirmed the deficiency.
The facility failed to maintain cleanliness and proper food safety standards, with debris in storage areas, dirty kitchen utensils, and infrequent changes of deep fryer oil. A refrigerator also lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage.
The facility failed to provide education and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Interviews revealed that the ADON and DON were responsible for ensuring vaccination processes, but these were not followed for the residents in question.
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents. The ADON and DON confirmed these deficiencies, noting the absence of necessary documentation and forms for indicating consent or refusal.
The facility failed to coordinate PASARR assessments for a resident diagnosed with schizophrenia after admission. The resident's initial screening did not indicate a major mental illness, but a subsequent diagnosis should have triggered a referral for a Level II evaluation, which was not documented. Interviews revealed that staff did not follow the expected protocol for PASARR coordination.
The facility failed to complete a PASARR for a resident with depression, bipolar disorder, and dementia. Staff interviews confirmed that the PASARR was not done as required, and the facility had been without a Social Worker for about a month.
The facility failed to update comprehensive care plans for two residents, one with severe cognitive impairment and another with significant dental issues. Despite documented behaviors and conditions, these were not reflected in the care plans, leading to a lack of continuity in care.
A resident with hemiplegia and contractures did not have a prescribed hand brace applied as required. Despite a physician's order and multiple observations, staff failed to assist the resident in wearing the brace, and documentation was incomplete. Interviews revealed a lack of adherence to the care plan and physician's order.
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls, resulting in multiple incidents without proper documentation of root cause analysis, environmental factors, or fall prevention measures. Staff were unaware of the resident's fall history and specific prevention measures, leading to incomplete and inaccurate incident reports.
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording oral intake and not weighing the resident regularly. Staff interviews revealed a lack of clarity on who was responsible for weighing the resident, leading to inconsistent monitoring of the resident's nutritional status.
The facility failed to maintain sanitary oxygen equipment for three residents, including improper storage, lack of water in humidifiers, and failure to change and date oxygen supplies. Staff interviews revealed inconsistencies and lack of knowledge regarding proper procedures.
The facility failed to address a pharmacy recommendation to discontinue an antipsychotic medication for a resident with Parkinson's Disease and dementia. Staff interviews revealed a lack of clear processes for documenting physician responses to pharmacy recommendations, resulting in the recommendation being missed and not addressed in a timely manner.
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Staff members were unaware of the residents' dental needs, and there was a lack of follow-up and documentation for dental appointments.
A resident's debit card and checks were misappropriated, leading to unauthorized transactions and financial loss. The facility's investigation could not identify the perpetrator, and the resident was offered a lock box for safekeeping of personal items. Staff were re-educated on policies following the incident.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition following a fall. A resident admitted for a respite stay with a history of falling and dementia was on a locked memory care unit when a staff member opened a door, startling the resident, who then fell to the floor onto the right side. The resident was non-verbal but moaned in pain when the right leg was touched, although some range of motion remained. Facility documentation shows that hospice was notified and a hospice nurse assessed the resident later that evening, noting no complaints of pain, the ability to move the leg without complaint, and no new orders. The hospice nurse indicated they would follow up and inform the resident’s family. The facility’s fall investigation and review of the electronic medical record revealed no documentation that the resident’s responsible party was notified of the fall on the day it occurred. The investigation noted that the hospice nurse stated they would notify the family, and there was no follow-up by facility staff to ensure that this notification actually occurred. Interviews with the Administrator, CMT, RN, LPN, and DON confirmed that nurses were responsible for notifying a resident’s responsible party immediately after a change in condition and that the facility remained responsible for notification even if a hospice nurse said they would notify the family. Staff and leadership acknowledged that the resident’s family was not notified by the facility on the day of the fall and that the family was notified later than expected under facility policy and practice.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several incidents of physical aggression between residents. In one case, a resident with hemiplegia and a history of verbal aggression struck another resident in the back of the head after being called a derogatory name. Both residents involved had cognitive impairments and behavioral histories, and the altercation was preceded by verbal exchanges. Staff and administration were aware of prior verbal altercations but did not implement interventions to prevent escalation to physical abuse. Another incident involved two residents in the dining room, where one resident with dementia and a history of psychosocial issues physically assaulted another resident, causing visible injuries including a laceration and bruising. The altercation was triggered by a dispute at the lunch table, with conflicting accounts from residents and staff about the sequence of events. Staff were not present in the dining room at the time of the incident, and the response to the altercation was delayed, resulting in one resident being struck multiple times before staff intervened. A third incident occurred when a resident with a history of aggressive behavior poured hot sauce on the face of another resident with severe cognitive impairment. The event followed a pattern of playful interactions that escalated into aggression, with both residents initially engaging in mutual teasing. Staff observed the aftermath and intervened to separate the residents and provide care. In all cases, the facility's failure to adequately supervise residents, recognize escalating behaviors, and implement preventive interventions contributed to the occurrence of abuse.
Failure to Allow Resident Return After Hospitalization and Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a resident was allowed to return after being sent to a local hospital, resulting in an involuntary discharge that did not meet regulatory requirements. The resident, who had a diagnosis of Diabetes Mellitus Type II and moderately impaired cognition, was involved in two resident-to-resident altercations and was subsequently sent to the hospital. The facility issued an Immediate Notice of Involuntary Discharge, citing endangerment to the safety and health of individuals in the facility, and refused to readmit the resident after hospital treatment. Interviews with facility staff revealed that the administrator and director of nursing did not believe the facility was equipped to care for the resident and made the decision not to allow the resident back. The social services designee sent referrals to other facilities and notified the Ombudsman of the discharge. The resident expressed confusion and distress about not being allowed to return, stating that the facility was their home and they had not been updated on their situation. The facility's policy on transfers and discharges did not address immediate involuntary discharges, and staff acknowledged that regulations were not met by failing to reevaluate the resident after hospital treatment.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Lamotrigine Extended Release (ER) for seizure management. The resident, who had a history of epilepsy and was admitted to the facility from the hospital, did not receive the prescribed dose of Lamotrigine on the day of admission. The medication was not administered because it had not arrived from the pharmacy, and the staff did not utilize the available medication from the Omnicell. On subsequent days, the resident received incorrect doses of the medication. The pharmacy delivered 100 mg tablets instead of the prescribed 200 mg tablets, and the staff failed to administer the correct total dosage of 400 mg at bedtime. This error was compounded by the lack of communication with the physician to clarify the medication order or to address the discrepancy in the dosage provided by the pharmacy. Interviews with the nursing staff and the Director of Nursing revealed a breakdown in the medication administration process, including failure to verify medication orders against the medication administration record (MAR) and the medication cards. The staff did not follow the facility's policy of checking the Omnicell for available medications or notifying the physician when the correct dosage was not available. These actions and inactions led to the resident experiencing seizure-like activity and being transferred to the hospital.
Resident-to-Resident Altercation Due to Cognitive Impairment
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, both of whom were severely cognitively impaired, was involved in an altercation. On the day of the incident, one resident attempted to sit on the lap of another resident who was seated in a wheelchair in the dining area. When the seated resident put up their hands and said 'No', the other resident turned around and struck them in the face, causing a scratch on the lip and a bruise over the left eye. This resulted in the resident sliding out of their wheelchair and being transported to the emergency room for evaluation. The incident was witnessed by several staff members, including CNAs and a CMT, who were unable to intervene in time to prevent the altercation. The staff members reported seeing the resident attempt to sit on the other resident's lap and then strike them when they were told 'No'. The facility's investigation determined that the resident who initiated the aggression had a history of mood problems related to a heightened startled response, which was care planned. The root cause analysis suggested that the resident reacted to being startled by the other resident's verbal refusal. Both residents involved in the incident had diagnoses of dementia and cognitive communication deficits, with the aggressive resident also having a care plan indicating potential for physical aggression. The facility's policy on abuse and neglect emphasizes that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, highlighting a failure to ensure the safety and protection of residents from abuse by peers.
Failure to Verify and Store Narcotic Medication
Penalty
Summary
The facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication, specifically 30 tablets of Oxycodone HCL 10 mg, which were reported missing. The incident involved a failure to verify and sign for the delivery of medications to the East Nurses Station. RN B, who was responsible for receiving the medications, signed for a delivery without verifying the contents, which included the missing narcotic medication for a resident with a history of chronic pain and other significant medical conditions. RN B admitted to signing for a blue bag from the pharmacy without opening it or checking the contents due to being busy. The pharmacy's delivery manifest indicated that two narcotic medications were delivered, but RN B did not check off the medications as received. The pharmacy driver also signed the delivery receipt, but there was no documentation of the time or date of delivery. The facility's investigation revealed that the narcotic card was not found in any of the usual storage locations, and RN B was suspended pending the investigation. Interviews with other staff members highlighted the protocol for receiving and storing narcotic medications, which was not followed in this instance. The pharmacy's General Manager confirmed that controlled substances are typically delivered in a red sealed bag, and the receiving nurse is expected to verify and sign for each medication. However, in this case, the verification process was not completed, leading to the unaccounted narcotic medication.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program, which included the prevention and transmission of water-borne pathogens. The facility's water management program lacked a diagram or flowchart identifying specific potential risk areas, a facility-specific risk assessment, and a completed CDC toolkit with control measures. Additionally, there was no documented infection prevention program or plan to deal with outbreaks of Legionella and other waterborne pathogens, including testing protocols and acceptable ranges for control measures. The Maintenance Supervisor and Administrator acknowledged the deficiencies during interviews, and the in-service sign-in sheets provided lacked educational materials attached. The facility also failed to ensure proper hand hygiene and infection control practices during wound care for two residents. One resident with open wounds on the thighs did not have Enhanced Barrier Protection (EBP) in place, and the wound care nurse did not change gloves or cleanse hands between treating different wounds, leading to potential cross-contamination. Another resident with a suprapubic catheter had the catheter drainage bag touching the floor multiple times, and the nurse did not wear a gown during catheter irrigation, contrary to EBP protocols. Staff interviews confirmed that the facility had recently provided education on EBP, but the implementation was inconsistent. Furthermore, the facility did not ensure that all residents were screened for tuberculosis (TB) according to the facility policy. Several residents did not have documented two-step TB skin tests or chest x-rays upon admission, and there was no annual screening for TB symptoms. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lapses in TB screening and testing, attributing the deficiencies to incomplete orders and documentation by the nursing staff.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess, identify, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's admission record indicated multiple diagnoses, including PTSD, dementia with mood disturbances, major depressive disorder, borderline personality disorder, and hemiplegia. However, the Trauma Informed Care assessment did not include any detailed information about the resident's PTSD, triggers, or events. The care plan also lacked specific interventions related to the PTSD diagnosis, and there was no documentation of psychiatric consultations or further assessments for PTSD in the resident's medical records. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and potential triggers. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) interviewed were unaware of the PTSD diagnosis and any associated triggers. The Director of Social Services and the Director of Nursing (DON) acknowledged that the care plan should have included the PTSD diagnosis, triggers, and interventions, and that staff should have been informed about the resident's PTSD status. The deficiency was identified as a failure to provide trauma-informed care as per the facility's policy.
Failure to Maintain Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen and food storage areas. Observations revealed that the dry storage room and walk-in freezer floors were littered with various debris, including plastic, paper, and food packets. The manual can opener had an unknown residue on its blade, and several cutting boards were excessively scored, posing a risk of cross-contamination. Additionally, the deep fryer oil was not changed frequently enough, resulting in oil that was black and filled with crumbs. A white-handled spatula was found with chipped edges, further indicating poor maintenance of kitchen utensils. During inspections, it was also noted that a refrigerator in the galley between the locked unit dining room and the rehab unit dining room lacked a thermometer, making it difficult to confirm adequate temperature ranges for food storage. Interviews with the Dietary Services Manager (DSM) and the Administrator confirmed these deficiencies, with the DSM acknowledging that the deep fryer oil was changed only every other week and that all refrigerators should have thermometers. Despite these acknowledgments, follow-up inspections showed that the issues persisted, with the deep fryer oil remaining in poor condition and debris still present in the storage areas.
Failure to Provide Pneumococcal Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education to residents or their representatives and obtain signed consent or refusal for the pneumococcal vaccine for four residents. Specifically, two residents had no evidence of being offered or administered the vaccine, nor any signed consent or refusal documented. Another resident had a status of consent refused for the vaccine but lacked a signed refusal form. Additionally, one resident had verbally consented to the vaccine, but there was no evidence of education provided or the vaccine being administered. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the ADON was responsible for ensuring the completion of pneumococcal vaccinations, including reviewing vaccine history on admission and offering the vaccine to residents. The DON confirmed that the ADON was tasked with infection control and ensuring the completion of vaccinations, while the DON was ultimately responsible for ensuring education, obtaining signed consents/refusals, administering the vaccine, and documenting the vaccination status in the medical records. However, these processes were not followed for the residents in question.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education on the COVID-19 vaccine, obtain signed consent or refusal, and document the vaccination status for three residents out of five sampled residents. Specifically, Residents #48, #61, and #166 had no evidence in their medical records of COVID-19 vaccination history, education provided, or signed consent or refusal forms. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed these deficiencies during interviews, noting that the facility did not have a form for residents to sign indicating consent or refusal for the COVID-19 vaccine. The ADON was responsible for ensuring the completion of COVID-19 vaccinations for residents, including reviewing vaccine history on admission and offering the vaccine to residents or their medical representatives. Despite these responsibilities, the facility failed to document the necessary information in the medical records of the affected residents. The DON acknowledged that the ultimate responsibility for ensuring residents received education, signed consents, and proper documentation of vaccination status rested with the facility's administration.
Failure to Coordinate PASARR Assessments for Resident with New Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with a newly diagnosed mental disorder. Specifically, the facility did not refer Resident #48, who was diagnosed with schizophrenia after admission, for a Level II PASARR evaluation. The resident's initial Level One screening did not indicate a major mental illness, but a subsequent diagnosis of schizophrenia was made, which should have triggered a referral to the appropriate state-designated mental health authority for further review. However, there was no documentation of such a referral or evaluation in the resident's medical record. Interviews with the Social Services Director and the Regional Director of Nursing revealed that the facility's staff did not follow the expected protocol for PASARR coordination. The Social Services Director acknowledged that an evaluation should have been completed following the new diagnosis to ensure the resident's needs could be met by the facility. The Regional Director of Nursing confirmed that the facility social worker was responsible for PASARR coordination and should have conducted a follow-up after the new diagnosis of schizophrenia. This oversight resulted in a failure to comply with federal requirements for appropriate placement and care of residents with mental impairments.
Failure to Complete PASARR for Resident
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one resident out of 23 sampled residents. The resident, who had diagnoses of depression, bipolar disorder, and dementia, was admitted to the facility without a Level I PASARR being completed. The facility's policy mandates that a PASARR should be completed prior to admission, but this was not done for the resident in question. The resident's medical record showed no documentation of a Level I PASARR, and interviews with staff confirmed that the PASARR was not completed as required. The Social Service Director and Social Service Assistant both acknowledged that the PASARR for the resident was not done and should have been completed within 72 hours of admission. The Director of Nursing (DON) also confirmed that the PASARR should have been completed at the time of admission and that the Social Worker was responsible for ensuring its completion. The facility had been without a Social Worker for about a month, and the MDS Coordinator was assisting in ensuring all residents had a PASARR. However, this particular resident's PASARR was missed.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to provide continuity of resident care by not reviewing and revising comprehensive care plans for two residents. Resident #114, who was severely cognitively impaired, exhibited multiple instances of refusing care, medication, and food. Despite these behaviors being documented in progress notes, they were not reflected in the resident's care plan. Interviews with staff revealed that behaviors were reported and documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR), but the care plan was not updated accordingly. The Director of Nursing confirmed that these refusals should have been documented in the care plan. Resident #9 had broken teeth and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite the resident's dental issues being noted during an admission assessment and a subsequent dental visit, these issues were not included in the resident's care plan. Interviews with various staff members, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), Registered Nurse (RN), and Social Service Assistant (SSA), revealed a lack of awareness about the resident's dental issues and confirmed that these should have been documented in the care plan. The Director of Nursing acknowledged that both residents' care plans should have been updated to reflect their current needs and issues. The facility's policy required comprehensive care plans to be updated periodically and with each Minimum Data Set (MDS) assessment. The failure to update the care plans resulted in a lack of continuity in resident care, as the care plans did not accurately reflect the residents' current conditions and needs.
Failure to Apply Prescribed Hand Brace
Penalty
Summary
The facility failed to ensure that staff applied a brace to a resident's hand as prescribed. Resident #13, who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and contractures, had a physician's order for a splint/brace to be applied to the left hand for six to eight hours daily. Despite this order, multiple observations over several days showed that the resident was not wearing the brace, and interviews with the resident and staff confirmed that the brace was not being applied as required. The resident reported being unable to put the brace on independently and stated that staff had not assisted despite requests. Interviews with various staff members, including CNAs, RNs, and the Director of Nursing, revealed a lack of awareness and adherence to the physician's order. Staff members admitted they had not seen the resident with the brace on and acknowledged that it should have been applied during morning care. Documentation in the Treatment Administration Record (TAR) was incomplete, with no records indicating that the brace had been applied or removed, only assessments of pain and skin integrity. The Director of Nursing and other staff members confirmed that the responsibility for ensuring the brace was applied fell on the CNAs, RAs, and ultimately the Charge Nurse. However, the failure to document and follow through with the physician's order resulted in the resident not receiving the necessary treatment to manage their condition effectively.
Failure to Complete Comprehensive Fall Investigations
Penalty
Summary
The facility failed to accurately complete comprehensive fall investigations for a resident at risk for falls. The resident, diagnosed with dementia and severe cognitive impairment, experienced multiple falls, including an unwitnessed fall that resulted in a head injury. The facility's documentation lacked details on the root cause analysis, environmental factors, and fall prevention measures in place at the time of the incidents. On one occasion, the resident fell out of bed and was sent to the hospital for evaluation. Upon return, no new preventative fall interventions were documented. Another fall occurred, and the incident report did not include comprehensive details such as the resident's positioning, the bed's position, or the presence of fall mats. Interviews with staff revealed a lack of awareness of the resident's fall history and the specific fall prevention measures required. The facility's fall management policy was not followed, as evidenced by incomplete and inaccurate incident reports and a lack of detailed investigations. The Director of Nursing and other staff members acknowledged the deficiencies in the fall investigation process, including the absence of a detailed root cause analysis and follow-up documentation.
Failure to Ensure Adequate Nutrition and Regular Weighing of Resident
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube and oral intake was receiving adequate nutrition by not recording the amount of food taken orally and not weighing the resident regularly. The resident, who had diagnoses including gastrostomy status, anoxic brain damage, autistic disorder, and dysphagia, was admitted with specific dietary and feeding instructions. However, there was no physician's order or care plan documentation specifying the frequency of weighing the resident, and the last recorded weight was on 4/9/24, despite the resident being on tube feedings and requiring regular monitoring of nutritional status. Interviews with facility staff, including a CNA, CMT, RN, and the DON, revealed a lack of clarity and communication regarding who was responsible for weighing the resident. The staff indicated that the Restorative Aide was typically responsible for weighing residents, but this individual had been sick, and there was no clear protocol for ensuring that other staff members took over this responsibility. The staff also confirmed that the resident should have been weighed weekly, but this was not consistently documented or communicated. The facility's policy required consistent methods for weighing residents and monitoring their nutritional status, but these procedures were not followed for the resident in question. The lack of documentation and clear responsibility led to the resident not being weighed regularly, which could have impacted their nutritional management and overall health status. The deficiency highlights a breakdown in communication and adherence to established protocols within the facility.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to ensure that oxygen equipment for three residents was stored and maintained in a sanitary condition. Resident #5's oxygen humidifier had less than 1/4 inch of water, was not dated, and the oxygen tubing was not dated. The nebulizer mask was left on the bedside tray table without a bag or date. The resident was unaware of when the tubing was last changed, estimating it had been a couple of weeks. Resident #9's oxygen humidifier was empty, and the water container was not dated. The CPAP mask was in a bag dated 4/18/24, and the resident reported that staff did not regularly change the oxygen supplies or assist with the CPAP mask at night. Observations on 5/3/24 confirmed the humidifier was still empty, and the CPAP mask remained in the same dated bag. Resident #51's oxygen tubing was dirty and improperly stored, with the humidifier also lacking water. The tubing was observed on a bloody incontinent pad, and the resident indicated that the tubing was changed infrequently, possibly monthly. The wound care nurse confirmed the improper storage and changed the tubing but did not date the new water container. Interviews with staff revealed a lack of knowledge and consistency in changing and dating oxygen supplies, with the Director of Nursing acknowledging the deficiencies and attributing them to missed responsibilities by the night shift charge nurse.
Failure to Address Pharmacy Recommendation in a Timely Manner
Penalty
Summary
The facility failed to address the pharmacy's recommendation to the physician in a timely manner for one resident. The resident, who had been diagnosed with Parkinson's Disease and dementia, was on three medications for Parkinson's. The pharmacy recommended discontinuing Nuplacid, an antipsychotic medication, but there was no documentation from the physician responding to this recommendation. Interviews with various staff members, including RNs, LPNs, the ADON, and the DON, revealed that there was no clear process for documenting the physician's response to pharmacy recommendations, especially when the physician disagreed with the recommendation. The DON admitted that the recommendation was missed and not addressed in a timely manner. The facility's policy required that the pharmacist's recommendations be addressed by the attending physician, Medical Director, and DON, and that any actions or rejections be documented in the resident's health record. However, in this case, the policy was not followed, and there was no documentation of the physician's decision regarding the pharmacy's recommendation. The staff interviews indicated a lack of clarity and consistency in handling and documenting pharmacy recommendations, leading to the deficiency in addressing the resident's medication regimen review in a timely manner.
Failure to Provide Necessary Dental Services and Consultations
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken or missing teeth and did not provide a dental consultation for another resident who had a physician order for dental extractions. Resident #9 had broken teeth and was at risk for malnutrition. Despite a dental visit recommending extractions and dentures, there was no follow-up appointment scheduled, and the resident expressed frustration about the delay. Staff members were unaware of the resident's dental issues, and there was no documentation of a scheduled appointment for the extractions. Resident #13 had missing teeth and dentures upon admission but lost the dentures while at the facility. The resident expressed a desire for new dentures, but there was no documentation of a dental visit or follow-up. Staff members were unaware of the resident's dental needs, and the Social Services department failed to ensure the resident saw a dentist. The resident's care plan did not address the dental issues, and there was no annual assessment to determine the need for dentures. Resident #27 had multiple missing and broken teeth and a physician order for a referral to an oral surgeon for extractions. Despite the order, there was no progress in scheduling the appointment, and the resident had not received an update. The Social Services department and the Assistant Director of Nursing were both involved in the process but failed to coordinate effectively, resulting in a lack of follow-up and documentation. The Director of Nursing acknowledged the responsibility of the Social Services department to make dental appointments and the need for proper documentation.
Failure to Protect Resident's Belongings
Penalty
Summary
The facility failed to protect a resident's belongings, resulting in the misappropriation of the resident's debit card and checks. The resident, who had a history of memory deficit following a stroke, bilateral hearing loss, and depression, reported the missing items on 10/12/23. The facility's Social Service Assistant (SSA) and Director of Nursing (DON) initiated an investigation and found the checkbook but not the debit card. Unauthorized transactions were identified, including a declined purchase of $11.60, a $60.00 gas bill payment, and two checks cashed for $875.00 and $1000.00, respectively. The resident did not authorize these transactions and was unaware of who took the items. The facility's investigation revealed that the resident's debit card was used without authorization on multiple occasions, and the checks were cashed with forged signatures. The police were notified, and a report was filed on 10/12/23. The SSA assisted the resident in contacting the bank to cancel the debit card and close the compromised account. The bank confirmed the fraudulent transactions and provided copies of the cashed checks, which were not signed by the resident. The facility interviewed relevant staff and the resident but could not identify the perpetrator. The resident was offered a lock box for safekeeping of personal items, and the bank refunded the stolen money. Despite these measures, the facility's failure to protect the resident's belongings led to significant financial loss and distress for the resident. The facility's policies on abuse, neglect, and misappropriation of resident property were reviewed, and staff were re-educated on these policies following 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 Grandview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hilltop At Blue River, The | 3.3 mi | — | 2 | 0 |
| Bridgewood Health Care Center | 3.4 mi | — | 20 | 3 |
| Jeanne Jugan Center | 4.9 mi | — | 0 | 0 |
| Ignite Medical Resort Carondelet Llc | 5 mi | — | 34 | 0 |
| Kingswood Senior Living | 5.3 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 August 2026) and official state health department websites.