Grandview Healthcare Center
800 Fifth Street SE, Oelwein, IA 50662 · Fayette County · 72 certified beds · avg 60 residents/day · certified since Aug 1, 1997
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (12)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 15, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 4, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 3, 2024 | B · Minimal risk, repeated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jul 3, 2024 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 3, 2024 | B · Minimal risk, repeated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Nov 8, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (3 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 5 | 0 | D |
| 2025 | 4 | 0 | E |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.75 | 4.37 | 3.95 | bottom 21% in Iowa; bottom 49% in the U.S. |
| Registered Nurse hours | 0.45 | 0.85 | 0.69 | bottom 8% in Iowa; bottom 30% in the U.S. |
| Weekend total nurse staffing | 3.17 | 3.86 | 3.50 | bottom 14% in Iowa; bottom 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.51 | 0.48 | bottom 17% in Iowa; bottom 32% in the U.S. |
| Total nursing staff turnover (%) | 27.0 | 44.0 | 45.8 | top 9% in Iowa; top 9% in the U.S. |
| RN turnover (%) | 60.0 | 42.1 | 42.9 | bottom 26% in Iowa; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.15, RN 0.50, weekend 3.51. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gorgona Sub Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 08/15/2024 |
| Allen, Craig | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Allen, Craig | Individual | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Beasley, Karla | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Behounek, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Borcherding, Jenny | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Burken, Sheri | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cascade Capital Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| CCG Gorgona LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Cook, Cassandra | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Deford, Colin | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/18/2025 |
| Deford, Colin | Individual | ADP of the SNF | NOT APPLICABLE | 08/18/2025 |
| Friedenberg, Laura | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Friedman, Brian | Individual | Trustee of the SNF | NOT APPLICABLE | 01/03/2012 |
| Gorgona Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Propco Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Gorgona Sub Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/15/2024 |
| Hedberg, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
| Heying, Larina | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/15/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you explain health changes and treatment options to residents and their families?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Oelwein Health Care Center | 0.2 mi | Oelwein, IA | ★★★☆☆ | 3/5 | |
| Maple Crest Manor | 12.7 mi | Fayette, IA | ★★★★☆ | 4/5 | |
| Rehabilitation Centers of Independence West Campus | 13.9 mi | Independence, IA | ★★★☆☆ | 2/5 | |
| Buchanan County Health Center | 14.1 mi | Independence, IA | ★★★★★ | 4/5 | |
| Hillcrest Home | 16.1 mi | Sumner, IA | ★★★★☆ | 3/5 | |
| Strawberry Point Lutheran Home | 18.8 mi | Strawberry Point, IA | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165340.