Grand View Care Ctr

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the Memory Care Unit (MCU) were maintained with the proper temperatures, and food items are dated and labeled to prevent the potential for food-borne illness. The facility did not ensure the snack/nourishment refrigerators on the [NAME] Wing Lobby (WWL) were maintained with food items dated and labeled to prevent the potential for food-borne illness. This has the potential to affect all 45 residents in the facility. According to the US Food and Drug Administration (FDA) Food Code 2022: Annex 3-123 .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. [...]

Inspectors wroteBased on record review and interview, the facility did not notify the Ombudsman of a resident who was transferred from the facility to a hospital on 2 occasions for 1 of 1 resident (R) (R1). R1 transferred to an emergency department on 03/27/26 due to a change in condition and the Ombudsman was not notified of emergency transfer. R1 transferred to an emergency department on 05/06/26 due to a change in condition and the Ombudsman was not notified of emergency transfer. The facility policy titled Notice of a Transfer and/or Discharge updated 2011, does not address the requirements of notifying the Ombudsman. R1 was admitted to the facility on [DATE] and required on 2 occasions (03/27/26 and 05/06/26) due to a change in condition, transfer to an emergency department; wherein, the facility did not notify the Ombudsman via the facility's monthly email process. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline for 1 of 1 resident (R) reviewed (R6).-The facility did not complete an accurate assessment upon admission related to R6's post-traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and record review the facility did not ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 1 resident (R) reviewed (R6).-R6 has a diagnosis of post-traumatic stress disorder (PTSD). The facility did not complete an assessment to determine the cause and triggers.-The facility did not establish a trauma-informed care plan.-No education was provided to staff related to PTSD and trauma-informed care.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 4 residents (R) (R30 and R10) observed for medication administration. The facility had 38 opportunities and 4 medication errors resulting in a 10.53% error rate. R30's divalproex delayed release (DR) tablet (an anticonvulsant and mood stabilizer), omeprazole delayed release capsule (a proton pump inhibitor for gastric acid) and tamsulosin capsule (an alpha blocker to relax muscle in prostate) were opened, crushed and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released. R10's omeprazole delayed release capsule was opened and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents are free of significant medication errors for 2 of 4 residents (R) reviewed for medication administration (R30 and R10). R30's divalproex delayed release tablet (an anticonvulsant and mood stabilizer), omeprazole delayed release capsule (a proton pump inhibitor for gastric acid) and tamsulosin capsule (an alpha blocker to relax muscle in prostate) were opened, crushed and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released. R10's omeprazole delayed release capsule was opened and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released. This is evidenced by:Facility policy titled, Crushing Medications, dated 2012, states: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R23) reviewed. R23 was left unattended while connected to mechanical lift equipment. This is evidenced by: The Food and Drug Administration (FDA) Safety Information guidance provided in Kwik points Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. Facility policy titled, Lifting Machine, using a Portable, dated 2024, states in part: .#3. To transfer a resident from a bed to a chair, you should: v. Remain with the resident until he or she is comfortable and free of any adverse effects from the transfer . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 2 residents (R28) reviewed with a Foley catheter. R28's Foley catheter was changed on a routine schedule without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part: E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 12 residents (R28) reviewed for pain management. R28 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management. This is evidenced by: Facility policy titled, Pain Assessment and Management, dated 2019, states in part: The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Facility did not determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This has the potential to affect all 44 residents in the facility.

Inspectors wroteBased on observation and interview, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, for 4 of 5 residents (R) reviewed (R1, R24, R27, R7). -Facility did not have open date labels on controlled medications that had been opened and were located in the medication storage room refrigerator for 3 of 4 residents (R) reviewed. (R1, R24, and R27) -Observation of R7's Lorazepam, which expired on [DATE], still located in medication storage room in unlocked refrigerator.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing and promote healing for 2 of 2 residents (R1 and R2) reviewed for PIs. R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. The facility failed to implement robust interventions to prevent PI development, did not assess or stage the PI weekly and did not update care plan interventions timely. R1 developed a facility acquired PI that worsened to a stage 4. The facility's failure to complete weekly comprehensive PI assessments, offer alternate repositioning schedules, update the care plan and implement interventions for R1 created a finding of immediate jeopardy that began on 01/09/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 3 residents (R7) reviewed for accidents. R7 has a history of falls and has had 8 falls since admission. On 01/27/25, the facility failed to ensure that R7's fall interventions were in place resulting in R7 having a fall with injury requiring staples to the head, as well as a skin tear. This is cited at actual harm.

Inspectors wroteBased on interview and record review, the facility did not ensure staff received Quality Assurance Performance Improvement (QAPI) program training. This practice had the potential to affect all 43 residents in the facility. The facility did not provide any staff with required training on the facility's QAPI plan. This is evidenced by: The facility's Quality Assurance & Performance Improvement Plan, dated 01/2024, states in part: Staff Training and Orientation In order for caregivers to become and remain proficient with quality improvement tools and techniques, QAPI principles and staff responsibilities related to QAPI, and ongoing quality improvement will also be included in orientation for all new employees. In order to become and remain proficient with quality improvement tools and techniques all staff will participate in ongoing annual QAPI training . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 incidents reviewed. R10 alleged being physically abused by Certified Nursing Assistant (CNA) J on 02/09/25 at 11:00 PM. [...]

Inspectors wroteBased on interview and record review, the facility did not develop a compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and promote quality of care. This has the potential to affect all 43 residents.

Inspectors wroteBased on interview and record review, the facility did not set forth an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program. This has the potential to affect all 43 residents.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. Sanitization testing was not recorded, dishwashing temperatures were not recorded, and refrigerator temperature logs were not recorded. This has the potential to affect all 45 residents who reside in the facility. This is evidenced by: The facility policy, entitled Dishwashing Machine Use, states: .A dietary personal will check the dishwashing machine for proper concentrations of sanitizer after filling the dishwashing machine and every day to reach 160 degrees F using Chem Strips .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 12 (R3) residents reviewed for comprehensive care plans had a developed care plan specific to the resident. This is evidenced by: The facility policy, entitled Care Plans - Comprehensive, states: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . On 1/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes and colitis due to Clostridioides difficile (C-diff). [...]

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 4 sampled residents, (R) R19, who are unable to carry out activities of daily living, receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This is evidenced by: The facility policy entitled: Repositioning, states in part .1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. R19 was admitted to the facility on [DATE] and placed on hospice for end-of-life care on 08/29/23 related to decline in status related to a diagnosis of atherosclerotic heart disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 2 sampled residents (R) R39 received treatment and care in accordance with standards of practice when R39 was not given medication as ordered. This is evidenced by: The facility policy, entitled Physician Medication Orders states: Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state. On 01/05/24, R39 was seen by urologist related to bladder urgency. The urologist ordered a laxative Polyethylene glycol 17 grams/dose powder oral in am. If not 1 bowel movement (BM) per day give additional 17grams at night related to findings of constipation and enlarged prostate. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 1 of 1 residents (R) reviewed with a suprapubic catheters (R3) received appropriate treatment and services for the catheter. This is evidenced by: On 1/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses included, but not limited to benign prostatic hyperplasia, supra pubic catheter, prostate abscess, and urinary retention. Review of R3's Minimum Data Set (MDS) assessment, dated 12/13/23, included indwelling catheter. Review of R3's care plan indicated .I have a supra pubic catheter .I need my nurses to care for my catheter and change catheter . R3 had a suprapubic catheter placed on 7/10/23 due to retention and prostate abscess. Review of R3's urology note dated 8/16/23 stated, Under the order and the supervision of the Urologist. [...]

Inspectors wroteBased on observation and interview, staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between 3 of 3 residents (R) (R11, R20, R21). This is evidenced by: The facility policy entitled: Cleaning and Disinfection of Environmental surfaces states in part .8. Equipment (EZ stand, lifts, etc.) used for multiple residents will be disinfected between residents. On 01/24/24 at 8:32 AM, Surveyor observed Certified Nursing Assistant (CNA) C remove the EZ stand lift out of R21's room after transferring R21 to a wheelchair. CNA C then took the lift to R20's room to transfer R20 to the wheelchair. CNA C then placed the EZ stand lift into the hallway cubby. Sanitizing of the lift before, between residents or after use was not observed by Surveyor. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff postings did not accurately reflect the census, or the actual hours worked by licensed and unlicensed staff on a daily basis. This has the potential to affect all 45 residents that reside in the facility. This is evidenced by: On entrance to the facility, Surveyor requested staff posting information. Review of staff postings from 12/21/23- 01/21/23 noted the census number listed on all sheets read 50. Surveyor was told the census was 45 during the entrance conference. Observation of the staff posting on 01/21/23, the day of entrance, revealed the posting indicated the census was 50. On 01/22/24 at 10:45 AM, Surveyor interviewed Scheduler M who completes the postings. Surveyor asked how Scheduler M completes the postings. Scheduler M relayed the following process. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an injury of unknown source, was not reported immediately but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 injury of unknown origin reviewed. (Resident R3) R3 was found to have an injury of unknown origin, bruising on her breast and hip. This was not reported to the state survey agency or law enforcement within 2 hours. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not thoroughly investigate an injury of unknown origin for 1 of 1 injury of unknown origin reviewed. R3 was found to have an injury of unknown origin, bruising on her breast and hip. This was not thoroughly investigated. This is evidenced by: The facility policy entitled Abuse, Neglect and Misappropriation dated 04/02/23, states in part; all alleged violations including . injuries of unknown source .will be investigated. Injuries of Unknown Source: The source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of: i. The extent of the injury, or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). The facility policy entitled, Bruises dated 2011, states in part; C.N.A. [...]