Inspection Reports for
Grand View Care Center
620 GRANDVIEW AVE, BLAIR, WI, 54616
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, catheter care, pain management, pharmaceutical services, and medication storage at Grand View Care Center.
Findings
The facility was found deficient in ensuring resident safety with mechanical lifts, appropriate catheter care, individualized pain assessments, proper pharmaceutical record keeping, and secure and properly labeled medication storage. Several residents were affected by these deficiencies, but harm was minimal or potential.
Deficiencies (5)
Resident R23 was left unattended while connected to mechanical lift equipment, violating safety protocols.
Resident R28's Foley catheter was changed on a routine schedule without clinical indications, contrary to professional standards.
Resident R28 did not have individualized pain assessments completed to monitor and evaluate pain management efficacy.
Facility did not maintain accurate records and reconciliation of controlled substances, with unsecured controlled medications found in an unlocked metal box.
Drugs and biologicals, including controlled substances, were not stored or labeled according to accepted professional principles; expired medications were found in unlocked refrigerator without proper labeling.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 44
Controlled substance counts: 5
Controlled substance counts: 4
Controlled substance counts: 7
Controlled substance counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Assistant | Mentioned in relation to mechanical lift safety deficiency for resident R23 |
| CNA G | Certified Nurse Assistant | Mentioned in relation to mechanical lift safety deficiency for resident R23 |
| DON B | Director of Nursing | Interviewed regarding mechanical lift safety, Foley catheter care, pain management, and medication storage deficiencies |
| RN F | Registered Nurse | Interviewed regarding medication storage and destruction of expired medications |
| LPN D | Licensed Practical Nurse | Interviewed regarding controlled substance storage and tracking |
| RN E | Registered Nurse | Interviewed regarding reconciliation of controlled medications |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect, pressure injury care, fall prevention, and compliance with ethics and quality assurance programs.
Complaint Details
The complaint investigation was substantiated with findings of failure to timely report abuse, inadequate pressure injury care causing immediate jeopardy, failure to implement fall prevention interventions leading to injury, and lack of compliance and ethics programs and training.
Findings
The facility failed to timely report an alleged abuse incident, did not provide adequate pressure injury prevention and care resulting in immediate jeopardy for one resident, failed to ensure fall prevention interventions were in place leading to a fall with injury, and lacked effective compliance, ethics, and QAPI training programs for staff.
Deficiencies (6)
Failure to timely report suspected abuse involving a resident being physically abused by a CNA.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in immediate jeopardy for two residents.
Failure to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent falls, resulting in actual harm.
Failure to develop and implement a compliance and ethics program.
Failure to conduct mandatory training for all staff on the facility’s Quality Assurance and Performance Improvement Program.
Failure to provide training in compliance and ethics to staff.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 43
Residents affected: 43
Residents affected: 43
Number of falls for R7 since admission: 8
Fall risk assessment score: 18
Fall risk assessment score: 25
Fall risk assessment score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding abuse reporting, pressure injury care, fall prevention, compliance and ethics program, and QAPI training |
| DON B | Director of Nursing | Interviewed regarding abuse reporting, pressure injury care, fall prevention, and staff education |
| LPN K | Licensed Practical Nurse | Assessed resident R10 after alleged abuse incident |
| CNA J | Certified Nursing Assistant | Alleged perpetrator in abuse incident involving resident R10 |
| NP I | Nurse Practitioner | Interviewed regarding wound avoidability and resident condition |
| CNA E | Certified Nursing Assistant | Interviewed about fall care plan adherence for resident R7 |
| CNA D | Certified Nursing Assistant | Interviewed about fall care plan adherence for resident R7 |
| RN C | Registered Nurse | Interviewed about fall care plan adherence for resident R7 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide necessary care and assistance for activities of daily living to a resident (R19) who is unable to perform these independently.
Complaint Details
The complaint investigation found that resident R19 was not repositioned or provided incontinence care for extended periods, including sitting in a chair for 6 hours without care. The Director of Nursing confirmed the expectation for repositioning and incontinence care at least every 2 hours.
Findings
The facility failed to ensure that resident R19 received timely repositioning and incontinence care as required by their care plan, resulting in prolonged periods without care and noted skin redness. Observations showed R19 sitting for hours without repositioning or toileting, and staff confirmed the deficiency.
Deficiencies (1)
Failure to provide care and assistance to perform activities of daily living for resident R19, including repositioning and incontinence care.
Report Facts
Residents affected: 1
Observation times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nursing Assistant | Confirmed noted redness of resident R19's buttocks to Surveyor |
| DON B | Director of Nursing | Interviewed regarding observation of R19 sitting for 6 hours without repositioning and incontinence care |
Inspection Report
Routine
Census: 45
Capacity: 50
Deficiencies: 7
Date: Jan 24, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, staffing, infection control, and facility operations at Grand View Care Center.
Findings
The facility was found deficient in multiple areas including incomplete and inadequate care plans, failure to provide necessary assistance with activities of daily living, medication administration errors, improper catheter care, inaccurate nurse staffing postings, failure to maintain proper food safety logs, and inadequate infection prevention practices related to sanitizing equipment.
Deficiencies (7)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Post nurse staffing information every day.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 45
Residents affected: 3
Census: 45
Total licensed capacity: 50
Days missing refrigerator temperature logs: 10
Days without bowel movement: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding care plan deficiencies, medication administration, catheter care, and infection control expectations |
| Scheduler M | Interviewed regarding nurse staffing postings and census inaccuracies | |
| CNA H | Certified Nursing Assistant | Observed transferring resident R19 and confirming skin condition |
| LPN L | Licensed Practical Nurse | Interviewed about droplet precautions for resident R3 |
| LPN D | Licensed Practical Nurse | Interviewed about refrigerator temperature logging responsibility |
| DA J | Dietary Aide | Interviewed about sanitization testing of chemicals in kitchen |
| DM I | Dietary Manager | Interviewed about sanitization testing and dishwasher temperature logs |
| NHA A | Nursing Home Administrator | Interviewed about refrigerator temperature logging and food safety issues |
| CNA C | Certified Nursing Assistant | Observed and interviewed regarding failure to sanitize mechanical lifts between residents |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate an injury of unknown origin involving Resident R3, who was found with bruising on her breast and hip that was not reported within the required timeframe.
Complaint Details
The complaint investigation found that the facility failed to timely report an injury of unknown origin and did not conduct a thorough investigation into the injury. The Nursing Home Administrator was on vacation during the time the bruises were discovered and assumed they were related to a fall during her absence. The Director of Nursing was tasked to review fall reports but found no relevant falls closer to the bruising date. The only CNA statement was vague and did not specify bruise details. The injury was not reported to the state as required.
Findings
The facility failed to report the injury of unknown origin to the state survey agency and law enforcement within 2 hours as required by policy and did not thoroughly investigate the injury. The bruises were discovered on 10/15/23, but no cause was identified, and the facility attributed the bruises to a fall during the Nursing Home Administrator's vacation without evidence. Documentation and investigation were insufficient.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for an injury of unknown origin.
Did not thoroughly investigate an injury of unknown origin involving bruising on resident's breast and hip.
Report Facts
Bruise size: 10
Bruise size: 11
Bruise size: 4.5
Bruise size: 7
Date of fall with no injury: Sep 25, 2023
Date bruises noted: Oct 15, 2023
Date of survey: Nov 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Provided information about the injury investigation and vacation absence |
| DON B | Director of Nursing | Tasked with reviewing fall reports to investigate bruising cause |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to investigate and resolve a resident grievance about not receiving assistance with peri care.
Complaint Details
The complaint was substantiated as the facility failed to document, investigate, and follow up on a grievance reported by Resident 3 regarding not receiving assistance with peri care. The grievance was not found in the facility's grievance file, and both the Nursing Home Administrator and Director of Nursing confirmed no documentation or follow-up was available.
Findings
The facility did not document, investigate, or follow up on the grievance reported by Resident 3 (R3) concerning lack of assistance with peri care, and the grievance was not found in the facility's grievance records despite policy requirements.
Deficiencies (1)
Facility did not ensure grievances were investigated and resolved in accordance with facility policy for 1 Resident (R3).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) A | Interviewed regarding grievance documentation and follow-up | |
| Director of Nursing (DON) B | Interviewed regarding grievance documentation and follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 14, 2023
Visit Reason
The inspection was conducted due to complaints and incidents involving abuse and neglect of residents, failure to report abuse timely, and failure to provide appropriate care and assessments.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to protect residents from abuse by staff and other residents, failed to report abuse incidents timely to authorities, and failed to provide appropriate care and assessments.
Findings
The facility failed to protect residents from verbal and physical abuse by staff and other residents, did not timely report abuse incidents to authorities, lacked proper policies for abuse reporting and resident assessments, failed to ensure RN coverage for at least 8 hours daily on several days, and did not complete timely performance evaluations for some CNAs.
Deficiencies (6)
Failed to protect residents from verbal and physical abuse by a CNA and from resident-to-resident abuse resulting in injury.
Did not implement abuse policies and procedures properly, including failure to remove abusive staff immediately and failure to report abuse to law enforcement timely.
Did not timely report suspected abuse and resident-to-resident incidents to state authorities and law enforcement.
Failed to provide appropriate treatment and care according to orders and professional standards, including delayed RN assessments after incidents and lack of assessment policies.
Did not have a registered nurse on duty for at least 8 consecutive hours a day on multiple days.
Did not complete performance evaluations for every nurse aide at least once every 12 months for 2 of 5 CNAs reviewed.
Report Facts
Residents affected: 2
Days without RN coverage: 5
Days delayed reporting abuse to state: 2
Days delayed reporting abuse to law enforcement: 23
Days delayed reporting resident-to-resident incident to state: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Witnessed abuse by CNA C and reported incident to LPN. |
| CNA C | Certified Nursing Assistant | Perpetrator of verbal and physical abuse against resident R1. |
| LPN E | Licensed Practical Nurse | Did not immediately report abuse incident or remove CNA C from resident care area. |
| NHA A | Nursing Home Administrator | Interviewed regarding abuse incidents, reporting delays, and facility policies. |
| LPN H | Licensed Practical Nurse | Provided delayed assessment and wound care for resident R2 after fall. |
| DON B | Director of Nursing | Interviewed about fall incident and need for x-ray for resident R2. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 30, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, wound care, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including inadequate wound care and assessment for residents with arterial and pressure ulcers, lack of monitoring and non-pharmacological interventions for residents on psychotropic medications for sleep, and failure to maintain an effective infection prevention and control program, including improper use of PPE and failure to provide hand hygiene to residents before meals.
Deficiencies (4)
Resident with arterial wounds did not receive necessary care and treatment; wound assessments were incomplete and not done weekly as required.
Facility did not implement care planned approaches for a resident with pressure injury; assessments were not conducted weekly and repositioning was inadequate.
Facility administered psychotropic medications for sleep without monitoring effectiveness or implementing non-pharmacological interventions.
Facility failed to maintain an infection prevention and control program; staff did not use proper PPE for residents on droplet precautions and did not offer hand hygiene to residents before meals.
Report Facts
Wound measurement: 3.5
Wound measurement: 3
Wound measurement: 1.5
Wound measurement: 0.2
Wound measurement: 0.1
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 13
Number of residents observed eating without hand hygiene: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding wound care deficiencies, sleep medication monitoring, and infection control issues |
| RN G | Registered Nurse / Infection Preventionist | Interviewed regarding infection prevention program and PPE requirements |
| CNA C | Certified Nursing Assistant | Interviewed about resident repositioning and hand hygiene practices |
| CNA F | Certified Nursing Assistant | Interviewed about PPE use for residents on droplet precautions |
| CNA H | Certified Nursing Assistant | Observed and interviewed regarding PPE use in resident rooms |
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