Grandview Healthcare Center

Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use and use food in a first-in first out manner. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to maintain kitchen equipment and surfaces in a clean and sanitary manner and ensure staff personal items were stored away from food storage and preparation areas. Facility staff failed to properly wash, sanitize and air-dry mechanically washed dishes to prevent cross-contamination and the growth of foodborne pathogens. Facility staff also failed to maintain a chemical sanitizer test kit to ensure the chemical sanitizer used in the mechanical dishwasher maintained the appropriate concentration. [...]

Inspectors wroteBased on record review and interview, facility staff failed to maintain an Antibiotic Stewardship Program (the monitoring for appropriate antibiotic use and effectiveness to improve outcomes and prevent development of antibiotic resistance). The facility census was 52. 1. Review of the facility's policy titled, Antibiotic Stewardship Champion Program, undated, showed:-The community will select an Antibiotic Stewardship Champion (ASC) who will be responsible for implementing and maintaining the Antibiotic Stewardship Champion Program;-Antibiotic usage will be reviewed during morning meeting, the resident's name, antibiotic, start date and location/type of infection will be listed on the white board for follow up until antibiotic is complete or repeat culture results are received;-Seventy-two hours after the start of antibiotics, a Time Out will be conducted: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for six residents (Resident #2, #6, #7, #17, #22, and #27) out of 21 sampled residents. The facility census was 52. Review of the facility's policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited:71. Review of the facility policy titled Event Investigation, undated, showed complete a Report of Event form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident. Examples of when a form should be completed include fall or person found on the floor. The charge nurse is responsible for completing the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. When completing the form be certain to complete the form in full, leaving no blanks. [...]

Inspectors wroteBased on observation, interview, and record reviews, facility staff failed to ensure the residents' environment remained safe from hazards when staff failed to safely propel four residents (Resident #2, #15, #37, and #52) out of 21 sampled residents while in wheelchairs. Facility staff failed to store medication in a safe and effective manner when medication carts were left unlocked and unattended, and medication was left on top of the cart with residents close by. The facility census was 52. 1. Review of the facility's policy titled Wheelchair, Use of, undated, showed the policy did not address the use of foot pedals while propelling residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails and complete bed rails assessments for six residents (Resident #3, #7, #8, #27, #38, and #50) out of 21 sampled residents. The facility census was 52. 1. Review of the facility's policy titled Bed Rails, undated, showed:-Educate the resident/legal representative on the benefits and risks of bed rail use;-Once the bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative;-After the review is completed the resident and/or resident representative will sign the consent ling and the nurse will sign as well, once it is signed it will be uploaded into the resident's medical record.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove and discard discontinued medication and improperly labeled medication from one of three medication carts and two of two medication rooms. The facility census was 52.1. Review of the facility's policy titled Injectables and Irrigating Solutions, undated, showed all multiple dose vials shall be dated and initialed upon opening. Once the seal is broken and punctured on Insulin, it shall be discarded after 28 days. Review of the facility's policy titled Medications, Storage of, undated showed all medications must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or a locked mobile medication cart. No discontinued or outdated biologicals may be retained for use.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate hand hygiene to prevent the spread of bacteria for two residents (Resident #14 and #13) out of two sampled residents. Facility Staff failed to use enhanced barrier precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE), gowns, gloves, and/or eye protection), and/or failed to have EBP signs posted for two residents (Resident #13 and #51) out of five sampled residents. Facility staff failed to ensure sanitary conditions for a urinary drainage bag (a container to hold urine) when staff failed to keep the container off the floor for one resident (Resident #16) out of two sampled residents. The Facility census was 52. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for six residents (Resident #3, #7, #8, #27, #38, and #50) who used bed rails out of 21 sampled residents. The facility census was 52. 1. Review of the facility's policy titled Bed Rails, undated, showed when installing or maintaining bed rails, staff should follow manufacture's recommendations and specifications for applicable bed rails, mattresses, and bed frames. Staff will conduct regular inspections of all bedframes, mattress, and bed rails, to identify possible entrapment.2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff assessed the resident as cognitively intact and restraints not used. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to initiate and complete a thorough investigation of misappropriation of resident funds which affected one resident (Resident #64) of five sampled. The facility census was 52.1. Review of the facility's policy titled Abuse Prohibition Protocol Manual, undated, showed staff were directed to:-Resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Administrator or designee must report to the state survey agency no later than two hours after an allegation is made;-The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation, or mistreatment from occurring while the investigation is in process; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care, to maintain personal hygiene and grooming for three residents (Resident #5, #16, and #46) out of 21 sampled. The facility census was 52.1. Review of the facility's policy titled Daily Care Needs, undated showed assist a resident to do as much of his/her care needs as possible. Encourage self-care when possible. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/02/25, showed staff assessed the resident with severe cognitive impairment, did not have behaviors or refuse care, and independent with all Activities of Daily Living (ADL's). Review of the resident's care plan, revised 05/21/25, showed staff were directed to monitor facial hair and remove as needed. Observation on 01/11/26 at 11:53 A.M., showed the resident with long facial hair. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide professional standards of care for two residents (Residents #1 and #2) out of eight sampled residents, when staff failed to monitor and document residents' bowel movements, which resulted in Resident #1 being admitted to the hospital with a diagnosis of fecal impaction (a condition where a hard, dry mass of stool becomes stuck in the rectum or colon). The facility census was 48. The administrator was notified on 09/09/25 of past Non-Compliance which occurred on 08/15/25 when the administrator implemented new policies and procedures to ensure aides documented residents' bowel movements each shift, and licensed staff monitored residents' bowel movements daily. Staff were in-serviced on 8/15/25 regarding documentation and monitoring of residents' bowel movements. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to transmit the required Minimum Data Sets (MDS), a federally mandated resident assessment completed by facility staff, for ten residents (Resident #2, #6, #11, #13, #18, #26, #32, #42, #44 and #53) of sixteen sampled residents. The facility census was 48. 1. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, showed: -The CMS Long-Term Care Facility RAI User's Manual is the primary source of information for completing an MDS assessment; - All Medicare and/or Medicaid-certified nursing homes must transmit MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for one (Resident #12) of five sampled residents when staff failed to promote the resident's self determination through support of resident choices when staff failed to allow the resident the choice of independently going outside the facility. The facility census was 48. 1. Review of the facility's Nursing Home Residents' Rights policy, undated, showed the resident had the right to self determination including the choice of activities, the reasonable accommodation of needs and preferences, and participation in developing and implementing a person-centered plan of care incorporates personal and cultural preferences. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to change and store oxygen tubing and/or clean oxygen concentrator filters in a manner to decrease the risk of the spread of infection for four (Resident #8, #25, #36, and #42) out of four sampled residents. The facility census was 48. 1. Review of the facility's Oxygen Administration policy, dated March 2015, showed: -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -Change humidifier and tubing per cleaning guidelines; -At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and access resident's respiration to determine further need for oxygen therapy. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/24 showed staff assessed the resident as: -Severely cognitively impaired; [...]

Inspectors wroteBased on interview and record review, facility staff failed to connect one resident's (Resident #1) nasal cannula tubing to the residents oxygen concentrator and failed to turn the oxygen concentrator on. The facility census was 53. 1. Review of the facility's oxygen administration policy, dated March 2015, showed when administering oxygen staff are directed to attach a face mask or cannula tubing to the humidifier and set the flow meter to the rate ordered by the physician. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/23, showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Dependent on staff to roll right or left in bed; -Dependent on staff to move from sitting to a lying position; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 61. 1. Review of the Dining Services Manager policy, dated April 2011, showed the dining services manager is delegated the administrative authority, responsibility and accountability necessary for carrying out the assigned duties which included supervision of personnel in the dietary department; planning, preparing and serving regular and modified diets to the residents; documenting in resident records for items such as care plans, progress notes, weight committee reports and minimum data set (MDS) assessments; and budget management. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. 1. Review of the facility's Menus policy, dated May 2015, showed: -Menus will be dated and posted on the bulletin board in the kitchen; -Standardized recipes are available in the dietary department for foods on the menu; -A food substitute should be consistent with the usual and ordinary food item provided by the facility. All substitutes provide equal nutritional value; -When substitutions are made, changes are posted on the menu or substitution sheet. If an entire meal is substituted, for instance for a special function, the meal should be posted on the menu. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff also failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 61. 1. Review of the facility's Receiving and Storage of Food policy, dated May 2015, showed The Dining Services Manager is responsible for receiving and storing food and nonfood items. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed the policy directed: -the dietary department to store dry food and supplies in accordance with facility guidelines and state regulations; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. The facility census was 61. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. Observation on 09/19/23 at 10:00 A.M., showed two of four lids open on the outside dumpster which contained waste. [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to meet professional standards of care when nursing staff did not sign out narcotics as they were given during a medication pass, and did not count narcotics at change of shift when the medication cart changed from one staff member to another. The facility census was 61. 1. Review of the facility's policy titled, Medications, Administration Guidelines, dated March 2015, showed the person administering the drugs must chart medications immediately following the administration. Review of the facility's policy titled, Narcotic Count, dated March 2015, showed staff were directed to do the following: -To complete a physical inventory of narcotics at each shift change to identify discrepancies; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet residents' interest during the weekend, and for six dependent residents (Resident #7, #12, #16, #19, #31, and #264) The facility census was 61. 1. Review of the facility's Activity Programming Policy, dated March 2022 showed staff are instructed to: -Plan, organize and carry out a program of activities to meet individual residents' needs; -Implement an individualized program for residents unable to participate or attend activities; -Program activities to give residents entertainment, communication, exercise, relaxation, and opportunities to express their creative talent; -All staff is to assist residents to activities of their choice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess two sampled residents (Resident #20 and #45) for use of a restraint, failed to provide safe mechanical lift transfers for three residents (Residents #12,#16, and #18) in a manner to prevent accidents, failed to properly propel three residents (Resident #23, #39, #40) in wheelchairs in a manner to prevent accidents and failed to maintain medication safety when staff left a medication in one resident room (Resident #1). Staff failed to supervise short-order grills when heated for cooking. The facility census was 61. 1. Review of the facility's Use of Restraints Policy, dated March 2015, showed: -Restraints shall only be used to treat the resident's medical symptoms and never for the prevention of falls; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage rooms, and two of two medication carts sampled. The facility census was 61. 1. Review of the facility's policy titled, Medication, Storage of, dated March 2015, showed staff were directed to do the following: -All medications for resident's must be stored at or near the nurse's station in a locked cabinet, a locked mediation room, or one or more locked medication carts; -All mobile medication carts must be under the visual control of the staff at all time when not stored safely and securely, carts must be either in a locked room or otherwise made immobile; -The key to the medication cabinet, medication room, and/or medication cart is the responsibility of the person authorized to hand and administer medications; [...]