Cycle 1
Health 2025-05-04 · Fire 2025-05-04
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Grandview, TX
Grandview Nursing And Rehabilitation Center
3-star overall rating with 2-star inspections with $21,125 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
301 W Criner St, Grandview, TX
(817) 866-3367
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-06-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
4.03
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
675
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0197
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.49
Baseline 21.64% · Performance 17.03% · Measure score 9.49 · Achievement 9.49 · Improvement 9
Healthcare-associated infections
5.69
Baseline 6.20% · Performance 6.13% · Measure score 5.69 · Achievement 5.69 · Improvement 0.07
Total nurse turnover
7.31
Baseline 16.67% · Performance 33.78% · Measure score 7.31 · Achievement 7.31 · Improvement 0
Adjusted total nurse staffing
3.72
Baseline 4.14 hours · Performance 4.14 hours · Measure score 3.72 · Achievement 3.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 8.05% · Lower 95% interval 6.91% |
| Discharge to community | 59.53% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 58.46% · Lower 95% interval 46.58% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 47.73% |
53.69%
6 pts worse
|
Numerator 21 · Denominator 44 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 18 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.13% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 1.89% · Lower 95% interval 2.63% |
| Staff COVID-19 vaccination coverage | 5.77% |
8.2%
2.4 pts worse
|
Numerator 6 · Denominator 104 |
| Staff flu vaccination coverage | 34.72% |
42%
7.3 pts worse
|
Numerator 50 · Denominator 144 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 22 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 2 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
2.7%
2 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.0% · Q3 5.1% · Q4 5.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
3.3%
2.8 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
18.9%
3.3 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.8% · Q3 10.0% · Q4 13.5% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
10.8%
7.6 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.1% · Q3 2.1% · Q4 2.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.8% |
15.4%
17.4 pts worse
|
16.3%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 27.6% · Q3 35.4% · 4Q avg 32.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
16.1%
6.2 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 24.1% · Q3 22.9% · Q4 10.4% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.5%
1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.5% · Q3 2.7% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
15.0%
7.1 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 26.5% · Q3 18.1% · Q4 23.8% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.2%
2.6 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 1.7% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
89.7%
5 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 92.2% · Q3 93.2% · Q4 94.7% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
12.0%
6.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.7% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
88.0%
7.3 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
25.9%
7.4 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 16.7% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-01-24 · Fire 2023-01-24
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-16
E · Potential for more than minimal harm
2025-05-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-09
F · Potential for more than minimal harm
2024-03-13
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-19
F · Potential for more than minimal harm
2024-03-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-01
F · Potential for more than minimal harm
2024-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
E · Potential for more than minimal harm
2024-03-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-01
F · Potential for more than minimal harm
2023-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-30
E · Potential for more than minimal harm
2023-01-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-01-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-16
H · Actual harm
2025-05-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-18
H · Actual harm
2025-05-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-05-04
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-05-27
F · Potential for more than minimal harm
2025-05-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-16
F · Potential for more than minimal harm
2025-05-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-27
E · Potential for more than minimal harm
2025-05-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-15
D · Potential for more than minimal harm
2024-02-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-25
F · Potential for more than minimal harm
2023-01-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-21
F · Potential for more than minimal harm
2023-01-24
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-14
E · Potential for more than minimal harm
2023-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-01-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-13
Penalties and ownership
What sits behind the stars
$21,125
2025-05-04
Fine
Fine · fine $21,125
Fine
$0
2025-05-04
Payment Denial
Payment Denial · denial start 2025-06-12 · 6 days
6 day denial
Ownership
Anderson, Donna
Operational/Managerial Control · Individual
Basham, Kirby
Corporate Officer · Individual
Basham, Mitchell B
Corporate Director · Individual
Fry, Aaron F
Corporate Director · Individual
Holloway, Julie
Corporate Director · Individual
Pickering, Clayton
Operational/Managerial Control · Individual
Quisenberry, David
Corporate Director · Individual
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