Grandview Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to revise comprehensive person-centered care plans for three (3) of nine (9) residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans. The facility failed to update the care plans for Residents #1, Resident #2, and Resident #3 to match the dietary orders. This failure could place residents at risk of not having their individualized needs met and communicated to providers in a timely manner and could result in injury and a decline in physical well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 27 of 27 residents (Residents #6, #7, #9, #13, #19, #22, #24, #28, #31, #32, #33, #34, #36, #39, #40, #41, #42, #43, #44, #45, #47, #50, #51, #53, #55, #57, #59) who were reviewed for care plans. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain acceptable parameters of nutritional status in such as usual body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise for 1 of 4 (Resident #55) residents reviewed for weight loss. 1. The facility failed to recognize, evaluate, and address the nutritional needs of Resident #55 despite a system generated warning on 11/15/24 for -7.5% change (comparison weight 08/09/24, 154.2 lbs, -8.0%, 12.4 lbs) and lab results on 09/05/24, 12/06/24, and 03/13/25 which reflected low albumin levels indicating low protein resulting in a 4.9 lbs (-3.62 %) loss in a month, a 12.3 lbs (-8.62 %) loss in 6 months, and 23.9 lbs (-15.49 %) loss in the last year 04/05/24 through 04/15/25. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were aware of where to locate the State Agency (SA) survey inspection results such as (surveys, certifications, and complaint/incident investigations) and post in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 facility in that: 1. The facility failed to make the survey binder readily available and easily identified to all residents. 2. The facility failed to maintain the survey binder; the binder failed to include previous state visit results from 10/04/24 and recently on 02/04/25. This failure placed residents at risk of not being able to fully exercise their rights and at risk of not being aware of the facility's past deficiencies.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods in 2 of 2 reach in refrigerators and 1 of 1 walk in freezer were properly labeled and dated with a use by date. 2. The facility failed to ensure food in 1 of 1 walk-in freezer was properly sealed from air-borne contamination. 3. The facility failed to ensure DC K sanitized the blender in between usage during pureed meal preparation and practiced hand hygiene during handling of pureed and regular texture foods to prevent cross contamination. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was to be gathered and analyzed, and plans of action were to be developed, implemented, and evaluated to address adverse events related to potential deficient practice for 1 of 1 QAPI programs reviewed. The facility failed to conduct at least one performance improvement project (PIP) annually that focused on high risk or problem prone areas identified by the facility, through data collection and analysis. This failure could place residents of the facility at risk of the facility not developing, monitoring and implementing corrective actions for identified areas of improvement.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 5 (Resident #36, #40, #42, #47, #50 and Resident #167) of 15 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #36 and Resident #47's admission and comprehensive MDS assessments accurately reflected their use of dentures and having no natural teeth. The facility failed to ensure Resident #40, #42, and #50's comprehensive MDS assessments accurately reflected their use of dentures and having no natural teeth. The facility failed to accurately code a fall on the MDS Assessment completed for resident #167 on 04/19/2025. This deficient practice could have placed the resident at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident's #61) of 12 residents reviewed for pharmacy services. The facility failed to provide a diagnosis for Resident #61's order for Doxycycline (an antibiotic used to treat types of infections). These failures could place residents at risk of ineffective interventions/treatments related to infections resulting in hospitalizations.

Inspectors wroteBased on interviews and record reviews the facility failed to immediately report allegations that involved abuse neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to the administrator of the facility and to HHSC, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility's staff did not report Resident's #1's unwitnessed fall to the administrator. The facility did not report a fracture of unknown origin to Resident #1's 7th rib and punctured lung until the second day after it was identified. This failure placed residents at risk of not having abuse or neglect identified promptly and thus being subjected to further abuse or neglect.