Grand Avenue Rest Home

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on August 7, 2026.

  CMS has cited this home for F0580 2 times since 2024.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on December 5, 2025.

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• Fire safety citation

  CMS removed citation K0161 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0222 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0225 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0232 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0241 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0291 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0293 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0345 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0711 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0712 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0918 from the fire safety inspection on August 26, 2024.

• Fire safety citation

  CMS removed citation K0920 from the fire safety inspection on August 26, 2024.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 31, 2025.

  CMS has cited this home for F0880 3 times since 2023.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on October 31, 2025.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on October 31, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on October 31, 2025.

  CMS has cited this home for F0657 2 times since 2025.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on October 31, 2025.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on October 31, 2025.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on October 31, 2025.

  CMS has cited this home for F0883 2 times since 2023.

• Citation F0912. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  CMS has cited this home for F0912 3 times since 2023.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0657. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on February 21, 2025.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on February 21, 2025.

  CMS has cited this home for F0727 3 times since 2023.

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• CMS abuse icon

  CMS removed its abuse icon from this home.

CMS lists this as a standard inspection.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on October 11, 2024.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on October 11, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 11, 2024.

• Citation F0881. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for F0881 2 times since 2023.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for F0758 2 times since 2023.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on October 11, 2024.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for F0583 2 times since 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for F0609 2 times since 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 11, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for F0684 2 times since 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 11, 2024.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on October 11, 2024.

• Citation F0912. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  CMS lists it as corrected on October 11, 2024.

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CMS lists this as a standard inspection.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for E0009 2 times since 2023.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on October 11, 2024.

  CMS has cited this home for E0029 2 times since 2023.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on October 11, 2024.

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• Staffing

  Total nurse staffing reported to CMS went from 2.0 to 1.7 hours per resident per day.

CMS lists this as a complaint inspection.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 31, 2024.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0568. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  CMS lists it as corrected on May 4, 2024.

  CMS has cited this home for F0568 2 times since 2024.

• Citation F0570. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on April 17, 2024.

  CMS has cited this home for F0570 2 times since 2023.

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CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on April 27, 2024.

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CMS lists this as a complaint inspection.

• Citation F0567. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to manage his or her financial affairs.

  CMS lists it as corrected on March 18, 2024.

• Citation F0568. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  CMS lists it as corrected on March 18, 2024.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 8, 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 8, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 8, 2023.

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CMS lists this as a standard inspection.

• Citation F0570. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on October 31, 2023.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on October 31, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 31, 2023.

• Citation F0881. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on October 31, 2023.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on October 31, 2023.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on October 31, 2023.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on October 31, 2023.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on October 31, 2023.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on October 31, 2023.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on October 31, 2023.

• Citation F0583. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on October 31, 2023.

• Citation F0584. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on October 31, 2023.

• Citation F0912. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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CMS lists this as a standard inspection.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on October 31, 2023.

• Citation E0023. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on October 31, 2023.

• Citation E0026. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on October 31, 2023.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on October 31, 2023.

• Citation E0036. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on October 31, 2023.

• Citation E0041. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement emergency and standby power systems.

  CMS lists it as corrected on October 31, 2023.

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