Grandview Health Care Center

In the surveyor’s words

From the most serious findings on record at Grandview Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF741Sep 6, 2023

  Based on clinical record review, staff and physician interviews, the facility failed to protect residents with a previous history of suicidal ideation from possible self harm for of 1 of 1 residents reviewed (Resident #5). The facility reported a census of 30 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on August 17, 2023 at 5:09 PM. The Facility Staff removed the IJ on [DATE] through the following actions: F741 Sufficient/Competent Staff-Behavior Health Needs Resident's Care Plan was updated to include specifically suicidal ideations. All staff currently working were audited for completed education relating to supervision requirements for residents with active suicidal ideations. […]

• Immediate jeopardy, isolatedF690Oct 20, 2022

  Based on clinical record reviews, facility policy reviews, hospital clinical records, the Centers for Disease Control and Prevention (CDC), and staff interviews the facility failed to provide adequate monitoring and assessment of 1 of 3 residents with a catheter to identify an infection (Resident #15) this resulted in an immediate jeopardy to the resident's health. Resident #15 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nurse Aide (CNA) reported signs and symptoms of a [CONDITION(S)] to the nurse. The clinical record lacked an assessment on the evening shift of 10/8/22 and on the overnight shift of 10/9/22. The nurse observed the resident shaking and complaining of freezing with a low body temperature between 5 a.m. and 6 a.m. with no report to the physician. […]

• Actual harm, isolatedF684Aug 4, 2022

  Based on observation, clinical record review, policy review, resident interview, and staff interview the facility failed to assure a complete and thorough initial assessment and weekly follow up assessments were completed for 1 of 2 residents reviewed (Resident #128) with impaired skin. Resident #128 admitted to the facility from the hospital on 6/24/22. The facility failed to complete a full skin assessment for Resident #128, including the abdominal wound, present on admission to the facility, until 7/8/22. The facility failed to complete an assessment of an additional skin impairment identified on 7/9/22, until 7/17/22 when deterioration of the area noted and revealed 2 open areas. […]

• Actual harm, isolatedF689Aug 4, 2022

  Based on observations, clinical record reviews, and staff interviews the facility failed to adequately supervise, thoroughly investigate falls that occurred, and implement interventions to prevent further falls for 1 of 1 residents (Resident #10) reviewed. Resident #10 sustained falls on 6/1, 6/10, 6/12, and 6/26/22 without a thorough investigation and/or intervention implemented to prevent further falls. On 6/12/22, Resident #10 found on the floor in Resident #10's room with a deep cut to the back of head that required transfer to the emergency room , and resulted in staples being placed. The facility reported a census of 26 residents. […]

• No harm, potential for more than minimal, widespreadF882Aug 4, 2022

  Based on staff interviews and the Centers for Medicare and Medicare Services (CMS) the facility failed to provide the residents with a certified Infection Control Nurse that completed the specialized training related to infection prevention and control. The facility reported a census of 26 residents. Findings Include: During the Entrance Conference on 7/25/22 at 10:15 AM, the Director of Nursing (DON) reported that he was working on the Infection Prevention Certification. The DON stated the facility's Corporation had a certified Infection Preventionist that assisted the facility with Infection Control. On 8/1/22 at 11:11 AM, during a follow-up interview, the DON explained that he did not have a certificate related to infection control and prevention. […]