Grand View Care CTR

In the surveyor’s words

From the most serious findings on record at Grand View Care CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 25, 2025

  Based on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing and promote healing for 2 of 2 residents (R1 and R2) reviewed for PIs. R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. The facility failed to implement robust interventions to prevent PI development, did not assess or stage the PI weekly and did not update care plan interventions timely. R1 developed a facility acquired PI that worsened to a stage 4. […]

• Actual harm, isolatedF689Feb 25, 2025

  Based on observation, interview, and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 3 residents (R7) reviewed for accidents. R7 has a history of falls and has had 8 falls since admission. On 01/27/25, the facility failed to ensure that R7's fall interventions were in place resulting in R7 having a fall with injury requiring staples to the head, as well as a skin tear. This is cited at actual harm. Findings: The facility's Fall - Clinical Protocol policy dated 04/03/23 states in part, Assessment and Recognition 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. a. […]

• Actual harm, isolatedF600Mar 14, 2023

  Based on interview and record review, the facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA) and the facility failed to protect a resident from a physical abuse during a resident to resident altercation which resulted in injury for 2 of 3 residents reviewed (R1 and R3). R1 was on the floor when a staff person saw another staff person kick the resident with the toe of her shoe and state, Get up fat boy. R1 suffered physical and verbal abuse. R3 was walking towards R1, who was having behaviors. R1 threw their walker, striking R3's walker causing it to tip over and R3 fell to the ground and sustained a laceration and bruising. R3 sustained physical abuse from another resident. […]

• Actual harm, isolatedF609Mar 14, 2023

  Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 2 of 2 incidents reviewed. […]

• No harm, potential for more than minimal, widespreadF812Jun 17, 2026

  Based on observation, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the Memory Care Unit (MCU) were maintained with the proper temperatures, and food items are dated and labeled to prevent the potential for food-borne illness. The facility did not ensure the snack/nourishment refrigerators on the [NAME] Wing Lobby (WWL) were maintained with food items dated and labeled to prevent the potential for food-borne illness. This has the potential to affect all 45 residents in the facility.According to the US Food and Drug Administration (FDA) Food Code 2022: Annex 3-123 .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. […]