Grandview Center

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who are appealing a discharge from the facility remain or return to the facility pending their appeal for 1 of 1 resident reviewed, Resident ID #2.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for medication refusals, Resident ID #5.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic, for 3 of 4 residents reviewed for antibiotic use, Resident ID #s 20, 22, and 36.

Inspectors wroteBased on record review, surveyor observation, and staff interview it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 of 2 residents observed for wound care, Resident ID #55.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for Lovenox (an anticoagulant; a blood thinning medication), Resident ID #19.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality, relative to the use of borrowed medications and inaccurately documenting in the narcotic count book for 2 of 2 residents reviewed, Resident ID #s 2 and 3.

Inspectors wroteBased on surveyor observation, record review, staff and resident interviews, it has been determined that the facility failed to treat each resident with respect and dignity and relative to providing assistance to residents who require supervision and/or one-to-one assistance with eating for 3 of 4 residents reviewed, Residents ID #s 16, 54 and 60.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to monitor and assess as outlined by the comprehensive care plan to meet professional standards of quality related to anticoagulant therapy (blood thinner) for 4 of 6 residents reviewed, Resident ID #s 9, 10, 41, and 373.

Inspectors wroteBased on surveyor observation, record review, staff and resident representative interviews, it has been determined that the facility failed to ensure that a resident receives proper treatment to maintain hearing abilities for 1 of 1 resident reviewed for hearing concerns, Resident ID #10.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 3 residents reviewed for oxygen use, Resident ID #s 5 and 10.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed relative to medication administration with parameters, Resident ID #20.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility has failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions to ensure that improvements are realized and sustained relative to changing and dating oxygen tubing.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an ongoing program to support a resident in their choice of activities designed to meet the interests of and support the well-being of each resident, based on the comprehensive assessment, care plan and preferences for 1 of 1 resident reviewed for activities who is non English speaking, Resident ID #27.

Inspectors wroteBased on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to provide adequate supervision to prevent an accident hazard for 1 of 1 resident reviewed who requires the assistance of two staff for transfers with a gait belt, Resident ID #9.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive trauma informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences for 1 of 1 resident reviewed with post-traumatic stress disorder (PTSD, a health condition triggered by a terrifying event causing flashbacks and nightmares), Resident ID #54.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide special adaptive eating equipment and utensils for a resident who requires a divided lip plate, Resident ID #9.

Inspectors wroteBased on record review, surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served, in accordance with professional standards for food service safety, relative to the lunch meal service.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission, for identified communication concerns and instructions needed to provide effective and person-centered care, for 1 of 1 residents reviewed for baseline care plans, Resident ID #62.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to physician's orders for 1 of 4 residents reviewed for supplemental oxygen use, Resident ID #12.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 1 of 1 residents reviewed for an orthopedic follow up, Resident ID #62.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 7 residents reviewed relative to pressure ulcers, Resident ID #59.