Grandview Post Acute

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, and interview the facility failed to ensure a medication was available from the pharmacy within 24 hours of ordering the medication for 1 resident (Resident #3) of 9 residents reviewed. Review of facility policy titled, Choice of Pharmacy and Medicare (Part D) Drug Plans revised 4/2007, revealed .The pharmacy service provider must deliver routinely prescribed medications within twenty-four hours (24) hours of the order, or sooner if needed .Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Osteomyelitis of Vertebra Thoracic Region, and Management of Vascular Access. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to execute an orderly discharge for one resident (Resident #1) of 4 residents sampled for admission, transfers, or discharges. The facility failure occurred when it referred the discharged resident to out of network providers for follow-up home health care, failed to schedule follow up appointments with the primary care physician of record, and failed to send prescriptions to the pharmacy of record at the time of discharge.

Inspectors wroteBased on facility policy review, observations, and interviews, the facility failed to ensure kitchen equipment of 1 gas cook top oven and 1 deep fryer was maintained in good working condition.

Inspectors wroteBased on facility policy review, medical record review, observations and interview the facility failed to offer hand hygiene assistance prior to meals for 5 residents (Residents #9, #33, #56, #58, and #5) of 18 residents observed on 1 of 3 hallways, the facility failed to wear adequate Personal Protective Equipment (PPE) when delivering meal trays to 3 residents (Residents #25, #35, and #64), and the facility failed to perform appropriate hand hygiene during medication administration for 1 resident (Resident #283) of 18 residents observed for infection control. The facility also failed to ensure staff wore adequate PPE when sorting soiled linens.

Inspectors wroteReview of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed Resident #19 was not coded for a PASRR Level 2 Outcome. Further review of the admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Bipolar, Anxiety, Seizures, Restless Leg Syndrome, and Nicotine Dependence. [...]

Inspectors wroteReview of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of a comprehensive care plan revised 4/2/2025, revealed Resident #19's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Anxiety, Depression, Bipolar Disorder, Insomnia, and Tobacco use. [...]

Inspectors wroteBased on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident (Resident #4) of 2 residents reviewed for hospice services.

Inspectors wroteBased on facility policy, medical record review, observation and interview, the facility failed to provide effective housekeeping and maintenance services to maintain a clean, safe, and homelike environment as evidenced by dirty walls with black vertical marks, vertical scrapes that resulted in damaged sheet rock and holes in the walls in 15 resident rooms (Rooms 204, 205, 208, 506, 508, 509, 511, 600, 601,604, 605, 606,607,608, and 609) of 48 observed rooms throughout the facility. In addition, 1 hole was observed in the drywall in 1 nutrition room (400 Hall nutrition room) of 2 nutrition rooms observed in the facility.

Inspectors wroteBased on the facility policy review, Incident Reporting System document review, medical record review and Interview, the facility failed to ensure 1 (Resident #6) of 7 residents reviewed were free from sexual abuse. Resident #12 (Perpetrator) was observed with his hand in the shirt of Resident #6.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's right to be free from misappropriation and/or exploitation for 1 (Resident #7) of 7 sampled residents reviewed when Certified Nursing Assistant (CNA) BB transferred money from Resident #7's bank card to her (CNA BB) personal account.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to notify the Physician/Nurse Practitioner and family for 1 of 5 (Resident #1) residents reviewed for falls with injury.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to revise the care plan for 1 of 5 (Resident #1) residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide mouth care for 1 of 5 (Resident #1) residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide wound care and administer medications as ordered for 1 of 5 (Resident #1) residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to maintain patient confidentiality related to 3 computer screens open with resident health information visualized with no staff attendance.

Inspectors wroteBased on facility policy review, facility documentation review, medical record review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the care needs of 5 of 44 sampled residents (Resident #19, #27, #31, #34, #37, and #51) residing on 3 of 5 hallways having the potential to affect the entire facility related to receiving showers/baths, passing meal trays, and turning and repositioning residents every 2 hours.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to maintain water temperatures for a dish machine at or above 120 F [Fahrenheit] degrees and failed to clean and sanitize 1 of 3 refrigerators located in the nourishment rooms. The facility also failed to deliver food that was covered to residents for 2 of 2 meal observations.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the spread of infection related to: staff failed to provide tracheostomy care in a sterile technique for 1 of 3 sampled residents (Resident #61); provide catheter care in a sanitary manner for 1 of 10 sampled residents (Resident #37) who required an urinary catheter; ensure oxygen tubing was not on the floor for 5 of 36 sampled residents (Resident #18, Resident #30, Resident #32, Resident #61, and Resident #72), and clean nebulizer mask for 1 of 36 sampled residents (Resident #32) who received respiratory treatments, and ensure urinary drainage bag was not laying in the floor for 2 of 10 sampled residents (Resident #64 and Resident #274) who required an urinary catheter. [...]

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to promote a homelike environment for 5 of 5 residents observed, in the dining room, during the breakfast meal on 3/28/2022.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure orders were complete for 8 of 10 sampled residents (Resident #11, #23, #27, #35, #37, #55, #61, and #274) who had an indwelling urinary catheter.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to label and date the oxygen tubing for 18 of 36 sampled residents (Resident #4, Resident #8, Resident #10, Resident #11, Resident #12, Resident #18, Resident #30, Resident #32, Resident #34, Resident #35, Resident #45, Resident #51, Resident #54, Resident #61, Resident #64, Resident #72, Resident #273 and Resident #274) reviewed with oxygen therapy and properly store 3 of 36 sampled residents (Resident #18, Resident #30, and Resident #32) with respiratory treatments, the facility also failed to have complete physician orders for 1 of 36 sampled residents (Resident #54) who received respiratory treatments.

Inspectors wroteBased on facility policy review, facility documentation review, observations, and interviews, the facility failed to have the Daily Nurse Staffing form posted on 3/27/2022, and failed to ensure the Daily Nurse Staffing forms were completed and retained for 132 days from 9/1/2020 through 3/27/2022.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure dignity for 1 of 8 sampled residents (Resident #22) who required assistance with meals, and failed to ensure dignity for 2 of 10 sampled residents (Resident #23 and Resident #325) who required an indwelling catheter.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure call lights were in reach for 2 of 44 sampled Residents (Resident #64 and #326) reviewed.

Inspectors wroteBased on facility policy review, medical record review, observations, and interview, the facility failed to implement interventions on care plan for 1 of 44 sampled residents (Resident #10).

Inspectors wroteBased on the facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings and failed to invite resident #67 to any IDT Care Plan meetings for 1 of 44 sampled residents (Resident #67).

Inspectors wroteBased on facility documentation review, medical record review, observations, and interviews, the facility failed to ensure 1 of 79 sampled residents (Resident #19) had clean and groomed fingernails. The facility also failed to ensure 4 of 44 sampled residents (Resident #27, #34, #37, and #51) received their showers and baths as scheduled.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to follow physician orders for 4 of 44 sampled residents (Resident #11, #18, #27, and #61) reviewed.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to prevent a pressure ulcer from worsening for 1 of 10 sampled residents (Resident #18) reviewed for pressure ulcers.

Inspectors wroteBased on the facility documentation, facility policy review, medical record review, and interview, the facility failed to prevent an accident for 1 of 14 sampled residents (Resident #34) who required a mechanical lift for transfers.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure orders were complete for 2 of 2 sampled residents (Resident #35 and #55) who had a colostomy.

Inspectors wroteBased on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for the 18 months reviewed. 9/1/2020 through 3/27/2022.

Inspectors wroteBased on facility policy review, manufacturer's user guide review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent an avoidable accident resulting in a fracture for 1 Resident (#91) and the facility failed to ensure a fall intervention was implemented for 1 resident (#36) of 5 residents reviewed for accidents of 22 sampled residents. The facility's failure to provide supervision resulted in actual Harm to Resident #91.

Inspectors wroteBased on review of facility policy, review of facility cleaning and sanitizing equipment schedule, observation, and interview the facility failed to remove expired food in 1 of 3 nourishment rooms; failed to date and label resident food in 3 of 3 nourishment rooms; failed to separate staff and resident food in 3 of 3 nourishment rooms; and failed to maintain clean, sanitary, and safe equipment in 3 of 3 nourishment rooms potentially affecting 98 residents.

Inspectors wroteBased on review of facility policy, observation, and interview the facility failed to follow standards of infection control for storage of resident care equipment and supplies in 3 of 3 nourishment rooms.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan intervention for 2 residents (#36, #49) of 22 sampled residents.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen as ordered by the physician for 1 resident (#49) of 9 residents reviewed for oxygen therapy of 22 sampled residents.