Grandview Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Grandview Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, patternF656May 4, 2025

  49099 Based 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. […]

• Actual harm, patternF692May 4, 2025

  Based 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… […]

• No harm, potential for more than minimal, widespreadF577May 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF867May 4, 2025

  Based 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. […]