Grandview Nursing and Rehabilitation

Inspectors wroteBased on a review of the facility assessment, facility-provided training documentation, and staff interviews, it was determined the facility failed to ensure an effective behavioral health care and services training program was provided for employees for 12 out of 12 months reviewed (May 2025 through April 2026).

Inspectors wroteBased on clinical record review, review of Minimum Data Set (MDS) assessments, and staff interview, it was determined the facility failed to ensure the MDS assessments accurately reflected the residents' status for six of eight residents reviewed for MDS accuracy (Residents 2, 4, 6, 7, 14, and 39).

Inspectors wroteBased on a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional status and implement nutritional interventions for 3 of 33 residents reviewed (Residents 146, 84, and 161).

Inspectors wroteBased on a review of clinical records, Medication Administration Records (MARs), facility policy, and staff interview, it was determined the facility failed to ensure pain was managed in accordance with professional standards of practice by not consistently attempting or documenting non-pharmacological (non-medication) interventions prior to the administration of as-needed (PRN) opioid pain medications for two of 33 residents reviewed (Residents 3 and 78).

Inspectors wroteBased on observation, staff interview, manufacturer guidelines, and review of select facility policy, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications and failed to maintain proper refrigeration temperatures for medications used in resident treatment on one of two nursing units (West), involving 10 residents (Residents 2, 4, 6, 22, 39, 56, 87, 90, 93, and 123).

Inspectors wroteBased on a clinical record review and staff interview, it was determined the facility failed to ensure that the required resident information was communicated to the receiving health care provider for three out of 33 residents reviewed (Residents 7, 39, and 108).

Inspectors wroteBased on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure injuries for two of 33 residents reviewed (Residents 7 and 75).

Inspectors wroteBased on clinical review and resident and staff interviews, it was determined the facility failed to ensure a resident with limited mobility received appropriate equipment necessary to maintain or improve mobility with the maximum practicable independence for one of 33 residents reviewed (Resident 4).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined the facility failed to provide care and services in accordance with professional standards and physician orders for the management and monitoring of a Peripherally Inserted Central Catheter (PICC) line and subsequent midline catheters for one resident out of 33 residents reviewed (Resident 75).

Inspectors wroteBased on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to provide food and beverages in accordance with residents' documented allergies, intolerances, and stated food preferences for two residents of 33 residents reviewed (Residents 188 and 167).

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined the facility failed to provide required adaptive dining equipment to maintain the resident's ability to eat independently for one resident out of 33 residents reviewed (Resident 188).

Inspectors wroteBased on clinical record review, staff interviews, and review of facility job descriptions, it was determined the facility failed to ensure staff responsible for participation in the Minimum Data Set (MDS, a federally mandated standardized assessment used to evaluate a resident's condition and guide care planning) assessment process were adequately trained and competent to perform assigned duties in accordance with federal requirements and professional standards of practice which resulted in inaccurate resident assessments for six out of eight residents reviewed (Residents 2, 4, 6, 7, 14, and 39).

Inspectors wroteBased on review of select facility policy, resident grievance forms, and resident and staff interviews, it was determined that the facility failed to make prompt and adequate efforts to resolve ongoing resident complaints regarding delayed call bell response times expressed during interviews, including those voiced by four of four residents interviewed. (Residents 1,3,4 and 5).

Inspectors wroteBased on observation, resident and staff interviews, and review of the facility's meal service schedule, it was determined that the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department. This failure resulted in delayed meal service and meals not served at palatable temperatures for residents on the East unit.

Inspectors wroteBased on observations, resident and staff interview, and test tray results, and food committee minutes, it was determined that the facility failed to serve meals that were palatable, attractive, and at safe and appetizing temperatures for a test tray completed on East Unit during the lunch room tray service.

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to assess and determine a resident's capability to self-administer medications for one of 13 residents reviewed (Resident 1).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify the attending physician of a significant change in condition for one of nine residents reviewed (Resident CR1). This failure resulted in a delay in physician notification following a documented decline in the resident ' s physical and mental condition.

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan that reflected individualized fall-prevention interventions for one of ten sampled residents (Resident 2).

Inspectors wroteBased on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to implement planned interventions and provide necessary treatment and services to prevent the worsening of a pressure ulcer for one resident out of four residents reviewed for pressure ulcer care (Resident CR1).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of twelve sampled residents (Resident CR2).

Inspectors wroteBased on observation, staff interviews, review of facility policies, manufacturer instructions for use (IFU), clinical record reviews, and facility investigative documentation, it was determined that the facility failed to ensure residents were protected from potential hazards in the environment by failing to implement safe and sanitary food handling practices in the facility kitchen. Specifically, the facility failed to ensure that hazardous chemical cleaning and sanitizing solutions were properly labeled, stored, and used in accordance with manufacturer instructions and facility policy. This deficient practice resulted in a corrosive sanitizing chemical being mistaken for a beverage, prepared and served to ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) out of 57 residents who resided on the East unit of the facility. [...]

Inspectors wroteBased on a review of select facility policies, clinical records, investigative reports, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care according to professional standards of practice, which included a failure to implement necessary interventions after a fall, such as close supervision and neurological assessments for one of two residents reviewed for falls resulting in actual harm with a subdural hematoma (brain bleed). Resident CR1.

Inspectors wroteBased on observation of the dietary department, Pavilion unit dining room, and resident pantry areas, review of relevant facility policy, and staff interviews, it was determined the facility failed to maintain food service sanitation practices in accordance with acceptable professional standards for the safe preparation, handling, and service of food.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in one of three resident care units (the [NAME] Resident Unit).

Inspectors wroteBased on observations, a review of clinical records, select facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in the facility. Specifically, the administration failed to ensure resident safety when the facility's dietary department served a hazardous cleaning chemical to residents and failed to prevent ten out of fifty-seven residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) from ingesting the chemical. This deficient practice placed all fifty-seven residents residing in the East Wing at risk of consuming a hazardous cleaning substance and resulted in an immediate jeopardy to resident health and safety.

Inspectors wroteBased on a review of clinical records, select facility policy, and facility provided investigative documentation, the facility displayed past non-compliance by failing to protect one of 32 sampled residents (Resident 25) from neglect by not implementing the individualized care plan intervention for transfers, resulting in actual harm in the form of a left tibial periprosthetic fracture.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.

Inspectors wroteBased on a review of facility provided documentation, clinical records, the facility's abuse prohibition policy, and staff interviews, it was determined the facility failed to conduct an investigation to rule out a reported allegation of misappropriation of a resident's finances and failed to report to the State Survey Agency within five working days of the incident, for one resident (Resident 104) out of 32 sampled residents.

Inspectors wroteBased on observation, a review of clinical records, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address a resident's need for oxygen therapy for one out of 32 residents sampled (Resident 1) and failed to address a resident's hydration needs for one resident out of 32 sampled (Resident 140).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed nurses followed physician orders for the administration of medications as prescribed to one resident of the 32 sampled residents (Resident 82).

Inspectors wroteBased on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 32 residents sampled (Resident 8).

Inspectors wroteBased on observation, clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure the availability of necessary emergency supplies for one of three residents reviewed who received hemodialysis (Resident 70).

Inspectors wroteBased on review of select facility policy and controlled substance records, observation, and staff interview, it was determined the facility failed to implement established pharmacy procedures for the reconciliation of controlled substances on one of five medication carts reviewed (Pavilion cart #2).

Inspectors wroteBased on a review of resident clinical records, select facility policy, facility investigative reports, and staff interviews, it was determined the facility failed to ensure that one of 32 residents reviewed was free of significant medication errors. (Resident 123).

Inspectors wroteBased on observation, a review of select facility policy, and staff interview, it was determined the facility failed to ensure that medications and pharmaceutical products were stored in accordance with expiration date guidelines in one of three medication storage areas (Pavilion medication storage room).

Inspectors wroteBased on a review of select facility policy, clinical records, and staff interview, it was determined the facility failed to ensure the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization for one of five residents reviewed. (Resident 47)A review of facility policy titled Pneumococcal Vaccine, last reviewed in January 2025, revealed it is the facility's policy that all residents shall be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Furthermore, the policy indicates residents and resident representatives have the right to refuse the vaccination. If refused, appropriate entries shall be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. [...]

Inspectors wroteBased on a review of clinical records, relevant facility policies, resident and staff interviews, and direct observations, it was determined the facility failed to follow its established policy and procedures related to safe smoking practices for one of 32 sampled residents (Resident 139).

Inspectors wroteBased on a review of clinical records, select facility investigative reports, select facility policy, and staff interviews, it was determined the facility failed to implement effective safety measures to mitigate fall risk for one out of 12 sampled residents (Resident 1).

Inspectors wroteBased on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the toileting needs of one of 12 sampled residents (Resident 2), including the timely provision of staff assistance with toileting and management of urinary and bowel incontinence.

Inspectors wroteBased on observation, resident and staff interviews, review of facility policy, and test tray analysis, it was determined the facility failed to ensure that meals were served at palatable temperatures and in a manner that met resident preferences for 5 out of 9 residents interviewed (Residents 1,2,3,4 and 5), and for one of one test tray meals reviewed during lunch service on the East Unit.

Inspectors wroteBased on observation, resident and staff interviews, and review of facility policy, it was determined the facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine residents sampled (Residents 4, 5, and 6).

Inspectors wroteBased on observations, a review of the facility's planned cycle menus, and resident and staff interview it was determined the facility failed follow written planned menus for four of four residents sampled for meals. (Residents 3, 6, 4 and 8).

Inspectors wroteBased on observation, review of select facility policy, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for 3 out of 17 residents sampled (Residents 3, 4, and 5).

Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for two residents out of 8 sampled residents. (Residents 7 and 8).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living were consistently provided showers as planned to maintain adequate personal hygiene for two of 17 residents reviewed (Resident 1 and Resident 2).

Inspectors wroteBased on observations and staff interviews, it was determined the facility failed to provide food that accommodated residents' allergies, and dietary orders for thickened liquids for two of 8 residents reviewed (Residents 7 and 9).

Inspectors wroteBased on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by five residents out of the nine residents sampled (Residents 1, 2, 3, 4, and 5).

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide care and services in a manner respectful of each resident's personal dignity for one of nine residents observed (Resident 3).

Inspectors wroteBased on a resident representative interview, a clinical records review, and staff interviews, it was determined that the facility failed to develop and implement a safe discharge plan for one of the 11 residents reviewed (Resident CR1).

Inspectors wroteBased on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 5 residents reviewed (Resident 1).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to implement pharmacy procedures for medication administration and documentation for one of five residents sampled (Resident 1 ).

Inspectors wroteBased on review of clinical records and staff interview it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address the resident's needs for intravenous medication administration through a central venous line (PICC catheter) to ensure the safe delivery of antibiotic medications and the care of the line for one out 5 residents sampled. (Resident 1).

Inspectors wroteBased on observation, resident and staff interviews and a review of meal service delivery schedule it was determined the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the kitchen in one of three resident pantries (West Nursing Unit).

Inspectors wroteBased on review of select facility policies, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility.

Inspectors wroteBased on review of facility policies and staff training records, as well as staff interviews, it was determined the facility failed to provide dementia management training for five of five employees (Employees 12, 13, 14, 15, and 16).

Inspectors wroteBased on observations, review of select facility policy, and staff interview, it was determined the facility failed to ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives, and failed to make residents aware of the procedure for filing a concern/grievance, written or verbally, and the procedure to file an anonymous grievance as reported by five of five residents (Residents 111, 134, 60, 135, and 46) during a group meeting.

Inspectors wroteBased on a review of clinical records, facility staffing records, and resident and staff interviews it was determined the facility failed to efficiently deploy sufficient nursing staff to provide timely and quality care to each resident including 4 residents out of 30 sampled (Residents 101, 68, 60, and 135).

Inspectors wroteBased on observation, select facility policy review and staff interview, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use by dates for multi-dose medications on one of four medication carts and two of two medication storage rooms observed (West medication cart #3, [NAME] medication storage room, and East medication storage room).

Inspectors wroteBased on observation, a review of facility's planned menus, and resident and staff interview it was determined the facility failed to accommodate individual food preferences to the extent possible, to increase resident satisfaction with meals for residents which included 8 residents of 30 residents reviewed (Residents 48, 128, 101, 111, 134, 60, 135, and 46).

Inspectors wroteBased on review of the Menu Committee Minutes and resident and staff interviews, it was determined the facility failed to ensure that residents' drink preferences were honored for 7 of seven residents reviewed (Residents 48, 101, 111, 134, 60, 135, and 46).

Inspectors wroteBased on observation, and staff interviews, it was determined the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the caregivers for three of 3 nursing units. Observations on the Pavilion Nursing Unit on September 26, 2024, at 11:30 AM revealed when call bells are activated resident room numbers will scroll across a [NAME]. Staff assigned to care for residents must have a pager in their possession which is audible. Further observations revealed there were no pagers on the unit behind the nursing station for employees. An interview with Employee 5 RN (registered nurse) on September 26, 2024, at approximately 11:35 AM revealed she did not have a required pager on her to be alerted to the residents' call bells. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 30 sampled (Resident 300)

Inspectors wroteBased on a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 30 residents reviewed (Resident 134) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 134 was admitted to the facility on [DATE], with diagnoses to include alcohol abuse. Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated August 31, 2024, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 9 indicating moderate cognitive impairment. The resident was independent with all activities of daily living. [...]

Inspectors wroteBased on observation, review of clinical records, and resident and staff interviews it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 68) to promote normal bowel activity to the extent practicable and failed to follow physician orders for the consistent application of a prescribed therapeutic measures, wheelchair leg rests, for one resident of 30 sampled (Resident 136).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 30 residents reviewed (Resident 137).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one resident (Resident 38) out of 30 residents sampled.

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to show adequate monitoring of behaviors and potential adverse consequences of psychoactive medication and failed to consistently attempt non-pharmacological interventions prior to the administration of psychoactive drugs for one resident out of 30 residents reviewed (Resident 126).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to offer routine annual dental services for one Medicaid payor source out of four residents sampled (Resident 77) for dental services.

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on review of clinical records, resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision to monitor a resident to prevent an unsupervised exit from the facility for one resident (Resident 1) out of 10 reviewed.

Inspectors wroteBased on a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications as scheduled for two of 15 reviewed (Resident 2 and 8).

Inspectors wroteBased on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician regarding significant changes in resident condition after a fall with injury, which precipitated an additional fall for one resident out of 15 sampled (Resident 4).

Inspectors wroteBased on a review of select facility policy and clinical records and staff interview it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to record a registered nurse's assessment and communication with other members of interdisciplinary team for one resident out of 15 sampled (Resident 15).

Inspectors wroteBased on observations, a review of clinical records, manufacturer's product information, video surveillance footage, employee personnel files and select facility reports, resident, and staff interviews, it was determined that the facility failed to ensure staff properly utilized an assistive device to prevent a serious injury, a major burn, to one resident (Resident A1) and failed to provide required staff supervision of one resident with dysphagia while eating to decrease the risk of a choking episode, which resulted in the resident's death for one resident (Resident B3) out of 17 residents sampled.

Inspectors wroteBased on observation, review of controlled drug shift count records and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on nine of nine medication carts (Pavilion 1, 2, 3, East 1, 2, 3, and [NAME] 1, 2, 3).

Inspectors wroteBased on observation and staff interview and review of select facility policies, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Inspectors wroteBased on clinical record review and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that licensed and professional nursing staff conducted a timely, and thorough assessment of resident's injury for one resident out of 17 sampled (Resident A1).

Inspectors wroteBased on a review of menu committee minutes, and staff, and resident interviews, it was determined the facility failed to ensure effective management and execution of the facility's food and nutrition department by failing to demonstrate necessary communication and timely coordination, among and between facility and corporate staff, to ensure that food and nutrition services meet each resident's daily nutritional and dietary needs and choices, and with consideration to the preferences of each resident, including Residents B4 and B5.

Inspectors wroteBased on observation, clinical record review and staff and resident interview, it was determined the facility failed to to administer intravenous therapy in accordance with professional standards of practice for one of one reviewed resident receiving intravenous therapy. (Resident A2)

Inspectors wroteBased on observation and staff and resident interview it was determined the facility failed to ensure that each resident received food prepared by methods that conserve flavor and appearance for one resident out of 17 sampled (Resident B1).

Inspectors wroteBased on a review of clinical records and facility investigative reports and staff and family interviews it was determined the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to promptly identify and act upon ongoing signs and symptoms of a change in resident condition, and evaluating current resident care needs, which resulted in a delay in treatment of a serious injury, a comminuted impacted hip fracture for one resident (Resident B1), and to maintain the safety of one cognitively impaired resident with behavioral symptoms (Resident A8) out of 22 residents reviewed.

Inspectors wroteBased on observations, review of the facility's planned written menus, menu extensions, and select facility policy, and staff interviews, it was determined that the facility failed to follow planned menus, failed to ensure that the facility's dietitian periodically updated the planned menus to reflect variety, the preferences of the current resident population and nutritional adequacy and failed to assure consistent availability of food to serve the emergency menu in the event of an emergency.

Inspectors wroteBased on observation, staff interview and a review of CMS guidelines, it was determined that the facility failed to maintain acceptable practices for the storage, preparation, and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness on the Pavilion Unit Resident Pantry and [NAME] Nursing Care Unit (two of three resident units) and the facility's kitchen and in the service of unpasteurized eggs to residents.

Inspectors wroteBased on observation, resident and staff interviews and a review of select facility policy, it was determined the facility failed to consistently provide a fully functioning call system to maintain direct communication from the resident to the caregivers for six of 22 residents sampled (Residents A1, A2, A3, A4, A5, and A6)

Inspectors wroteBased on observation and staff and resident interview it was determined that the facility failed to ensure that each resident received food prepared by methods that conserve flavor and appearance for one resident out of 22 sampled (Resident B2).

Inspectors wroteBased on a review of clinical records and medication error reports and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a fall for one out of 22 residents sampled (Resident B1).

Inspectors wroteBased on a review of clinical records, select incident reports and the facility's abuse prohibition policy it was determined that the facility failed to thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment as a potential cause of the injury presented by one resident out of 22 sampled (Resident B1).

Inspectors wroteBased on review of clinical records and staff and family interview, it was determined that the facility failed to consistently monitor resident weights to timely identify and act upon a resident's weight loss, and implement necessary nutritional support to promote acceptable nutritional parameters for one resident out of 22 sampled (Resident B1).

Inspectors wroteBased on review of clinical records, select facility policy and reports, and staff and family interviews it was determined that the facility failed to timely evaluate increased pain and evaluate potential underlying causes and potential etiology for one resident out of 22 sampled (Resident B1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to provide therapeutic social services to promote the highest practicable mental and psychosocial well-being of one of the 22 residents reviewed (Residents A7).

Inspectors wroteBased on a review of clinical records, select facility incident reports and policies, and American Heart Association guidelines and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident (Resident CR1) out of three residents sampled. This failure placed 93 facility residents, desiring cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to their advanced directive, out of the 169 resident census in the facility, in immediate jeopardy to their health and safety with the potential for death as a result of a similar occurrence.

Inspectors wroteBased on resident and staff interviews and a review of clinical records and select incident reports it was determined that the facility failed to consistently implement necessary precautionary measures and adequate staff assistance to maintain resident safety during transfers resulting in a serious injuries, a fractured humerus (arm), elbow and wrist, for one resident out of four sampled (Resident B1).

Inspectors wroteBased on a review of nursing staffing, grievances filed with the facility, the facility assessment, clinical records and resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents including experiences described by eight residents (C1, C2, C3, A1, B1, B2, B3 and B4), grievances filed by four residents (Residents C4, C5, C6, and C7) and the delay or lack of care experienced by two residents (Resident 54 and CR1) out of 23 sampled residents.

Inspectors wroteBased on clinical record review and facility documentation and staff interview, it was determined that the facility failed to implement efficient pharmacy procedures for timely acquiring resident medications to ensure physician-ordered medications were readily available in a timely manner for one resident out of three sampled (Resident B1).

Inspectors wroteBased on clinical record review and staff interviews it was determined the facility failed to provide person-centered care following a resident's injury by failing to demonstrate consistent monitoring and timely follow-up care required by one resident out of five sampled (Resident 54)

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on one of the three facility nursing units (Nursing [NAME] Unit).

Inspectors wroteBased on a review of clinical records, select facility policy, and facility incident reports, and resident, family and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse for two of the 23 residents sampled (Residents C9 and C10) and submit the results of the completed investigations to the State Survey Agency within five working days of the incident.

Inspectors wroteBased on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to provide cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to an resident's advanced directive for one out of three sampled residents (Resident CR1).

Inspectors wroteBased on a review of clinical records and facility documentation it was determined that the facility failed to provide nursing staff with the necessary competencies and skills to timely identify signs and symptoms of potential changes in resident condition and evaluating currently planned care regimens to timely respond to the residents' current needs for two residents out of five sampled (Residents 1 and 3).

Inspectors wroteBased on a review of clinical records and grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by four residents out of 17 sampled (Residents 1, 2, 3 and 22).

Inspectors wroteBased on observations, review of select facility policy, controlled drug records, and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled drug records and timely disposition of resident medications (the process of returning and/or destroying unused medications) to prevent waste.

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to timely consult with the physician regarding the potential need to alter treatment due to the resident's repeated refusal of a physician ordered medication, for one out of four residents sampled (Resident 22).

Inspectors wroteBased on a review of clinical records, select facility policies, and information submitted by the facility, observation, and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident, with a known history of exit seeking behavior, and conduct planned monitoring of the resident's whereabouts to promptly identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to his health and safety for one resident out of four residents sampled (Resident 146 ).

Inspectors wroteBased on observation, a review of the facility's planned menus and resident and staff interview it was determined that the facility failed to provide preferred foods and beverages as planned for one resident (Resident A1) and accommodate individual food and beverage preferences, including the temperature served, to the extent practicable for four residents out of five sampled (Residents A1, A2, A3, and B2).

Inspectors wroteBased on review of facility scheduled mealtimes, select facility policy, the minutes from Menu Committee Meetings, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including four of five residents interviewed (Residents B2, A1, A2 and A3).

Inspectors wroteBased on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to assure that its staff implemented established procedures to maintain resident safety evidenced by one resident who eloped from the facility without staff awareness and his absence undetected for approximately three hours out of four sampled residents (Resident 146)

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to consistently implement measures planned to promote healing of an identified pressure ulcer for one of three residents sampled (Resident CR2).

Inspectors wroteBased on a review of clinical records and staff interviews it was determined that the facility failed to implement pharmacy procedures to assure timely acquiring and administration of medications to two of 13 sampled residents (Resident CR1 and CR3).

Inspectors wroteBased on a review of clinical records, and staff interview, it was determined that the facility notify the physician as ordered for the potential need to alter treatment related to blood sugar level for one resident out of 13 sampled (Resident CR2).