Grandvue Medical Care Facility

Inspectors wroteBased on observation and interview, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 4/20/2026 at 11:42 AM observed Certified Nursing Assistant (CNA) P use a probe thermometer to take temperatures of a food item they were reheating in the microwave. The probe thermometer was observed to not have a protective sheath covering on it as it was being pulled from storage in the drawer. CNA P wiped the thermometer with an alcohol wipe prior to inserting it in the food product. Prior to placing the thermometer back into the drawer, CNA P wiped the thermometer again but did not place a protective sheath onto the cleaned thermometer prior to placing it in the drawer. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents' rights to be free from verbal and mental abuse by a resident for two Residents (#4 & #62) of four residents reviewed for resident-to-resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the State Agency (SA) of verbal and physical resident-to-resident altercations for three Residents (#4, #9, & #10) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate resident-to-resident abuse for three Residents (#4, #9, & #62) of four residents reviewed for investigation of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility and ensure pertinent medical records were sent to the receiving provider upon transfer for two Residents (#3 & #6) of two residents reviewed for discharge practices.

Inspectors wroteBased on interview and record review, the facility failed to provide hospice documentation for one Resident (#8) of one resident reviewed for hospice care services. This deficient practice resulted in the potential for uncoordinated care between the provider and the hospice care service.

Inspectors wroteBased on observation, interview, and record review the facility failed to store respiratory equipment in a sanitary manner for two Residents (#35 & #47) of two residents reviewed for respiratory care.

Inspectors wroteThis deficient practice pertains to Intake 2711152. Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for one Resident (#1) of three residents reviewed for abuse and neglect. This deficient practice resulted in psychosocial harm and mental anguish for Resident #1 based on the reasonable personal concept. Findings Include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including dementia, aphasia (a language disorder that impairs a person's ability to communicate, affecting speaking and understanding), overactive bladder, urinary incontinence, and need for assistance for personal care. Review of Section C: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and record accurate weights per standard practice of care for one Resident (R1) of three residents reviewed for weight loss. This deficient practice resulted in R1 having a significant weight loss with no interventions.

Inspectors wroteThis deficient practice pertains to Facility Reported Incident (FRI) MI00153071. Based on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record following an unwitnessed fall for one Resident (#1) of 3 residents reviewed for medical records.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for readmission to the facility in two Residents (#25 and #15) of three residents reviewed for quality of care following hospitalization. This deficient practice resulted in rehospitalization for excessive clotting times following a history of GI bleed for R25 and rehospitalization with worsening urosepsis for R15.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 93 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for four Residents (#15, #25, #87, #34) of four residents reviewed for transfer and/or discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications and dispose of expired or discontinued medications in three medication carts of four medication carts reviewed and one medication room of two medication rooms reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment documentation was accurate for one Resident (#23) of 19 residents reviewed for assessments. This deficient practice resulted in the potential for lack of appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the person-centered care plan for the management and prevention of wounds for one Resident (#53) of one resident reviewed for pressure injuries, resulting in the potential for unmet care needs.

Inspectors wroteF770 Grandvue Based on interview and record review, the facility failed to ensure laboratory services were provided to meet the needs of one Resident (#25) of one resident reviewed for laboratory services.

Inspectors wroteF883 Grandvue Based on interview and record review, the facility failed to administer recommended pneumococcal vaccinations or document the clinical reasons for withholding the pneumococcal vaccinations in three Residents (#36, #75, and #15) of five residents reviewed for immunizations.

Inspectors wroteThis deficiency pertains to Facility-Reported Incident intake #MI00143534 Based on interview and record review, the facility failed to ensure one Resident (#292) of one resident reviewed for significant medication errors received the correct medication as ordered by the physician. This deficient practice resulted in R292 receiving an unprescribed antipsychotic medication.