Pennsylvania Department of Health
GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are 137 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


GRANDVIEW NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an abbreviated complaint survey completed on July 25, 2024, it was determined Grandview Nursing and Rehabilitation was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:
Based 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.

Findings include:

An observation on July 25, 2024, at 10:55 AM revealed the shower room on the pavilion nursing unit had a yellow liquid on the floor. A black mold like substance was noted on the caulking on the floor in the shower. The shower curtain was noted to have multiple dark spots, the caulking around the toilet was brown. There was multiple holes in the shower room door.

Further observations on July 25, 2024, at 11:25 AM of the shower room in west nursing unit revealed a black mold substance in the shower on the caulking and on the shower curtain.

Observations on July 25, 2024, at 1:20 PM revealed Room E4 was noted to have brown streaks and spots on the toilet. Debris was noted on the floor in the bathroom and bedroom area. There was large brown and black colored stains on the carpet in the bedroom. Food particles were noted on the floor mat.

Interview with the Director of Nursing and Nursing Home Administrator on July 25, 2024, at approximately 2:15 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 09/04/2024

1. The following item were corrected during survey: Liquid soap (yellow substance) was cleaned from Pavilion shower room floor , Caulking was replaced along the edges of floor in shower rooms, Debris on the floor in room E4 was removed and bathroom toilet cleaned. Pavilion shower room door holes repaired. Shower curtains were cleaned to remove soiled areas. Carpeting in room E 4 was replaced as part of a facility wide plan to remove carpeting in all resident rooms. This was the last room to be completed.
2. Initial facility audit completed on shower rooms including curtains, floors and doors for environmental irregularities. Initial facility audit completed in resident rooms and bathrooms for environmental irregularities.
3. Administrative staff to educate EVS and Maintenance staff on maintaining a clean and sanitary environment
4. Environmental audits to be completed 3X/week for 2 weeks, weekly X's 2 weeks and monthly x's 2 months and results reported and reviewed at facility QAPI.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:
Based 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.

Findings included:

A review of the clinical record revealed that Resident 1 was admitted to the facility on June 6, 2022. The resident's diagnoses included traumatic subdural hemorrhage (brain bleed) and congestive heart failure.

A review of Resident 1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 24, 2024, revealed that the resident was severely cognitively impaired and had behaviors of wandering.

A review of an Elopement Risk Assessment dated March 21, 2024, revealed the resident independently ambulates, was cognitively impaired, and has wandering behavior. The resident was considered at risk for elopement.

A review of the resident's plan of care for mood indicators initiated March 23, 2024, revealed the resident was wandering while on isolation. Further review of the resident's plan of care revealed no new intervention for supervision to monitor the wandering to prevent any exit seeking behaviors.

A review of an incident report dated June 23, 2024, at 1:12 PM revealed staff was alerted that Resident 1 was outside of the facility. Further it was indicated that a wanderguard was in place on the resident's left wrist but the wanderguard system was not alarming in the building. The resident indicated at that time she was "going to the barn to let the horses in." Further it was indicated the resident was noted by staff to exit the facility through the open front door. The resident had been identified as an elopement risk but her wanderguard did not activate the door alarm when she exited. The resident ambulated to the east side of the main entrance where a staff member was standing and was redirected back into the facility.

A review of a written statement from Employee 1 receptionist dated June 26, 2024, indicated the employee was at the desk. He stated Resident 1's wanderguard did not beep by the door and he let her outside. The employee stated he never saw the resident before, and she seemed to walk and talk fine. The employee indicated he let her outside and he didn't know if she was a visitor or resident.

A review of a written statement from Employee 2 dietary dated June 23, 2024, indicated the employee was outside on break at the end of the parking lot. The employee stated she saw Resident 1 come outside and was by the smoking area. The employee then indicted the resident walked down to the end of the parking lot. The employee went over to Resident 1 and stayed with her while she called the building multiple times. The employee stated that 2 staff members came out to help her back into the building.

A review of a written statement from Employee 2 RN dated September 15, 2023, revealed the employee was informed Resident 55 was unable to be located and the door at the end of the peach hall was not secured and able to be opened. The employee instructed the staff to begin looking for the resident. The employee indicated the resident was found outside on the ground and brought back into the facility.

The facility failed to provide appropriate supervision to Resident 1 who has a history of wandering and exit seeking. The facility relied on the wanderguard system to prevent and elopement from the facility, but the system did not function properly.

An interview with the Nursing Home Administrator and Director of Nursing on July 25, 2024, at approximately 2:15 PM revealed the wanderguard system did not function properly and confirmed the facility failed to provide adequate supervision of a resident with an increased risk for elopement.

28 Pa Code: 201.19(e)(1) Management

28 Pa Code:201.18(e)(3) Management

28 Pa. Code: 211.12(c)(d)(3)(5) Nursing Services

Plan of Correction - To be completed: 09/04/2024

1. Resident 1 escorted back to facility safely without any pain or injury. Employee 1 was disciplined and educated on supervision for elopement prevention and front door procedure. Resident 1 care plan reviewed and updated by IDT for appropriate elopement interventions. Resident 1 wanderguard bracelet has been replaced. Front door wander system checked for proper function. Facility doors remain locked at all times and require code or button release by employee. Code is not available to residents.
2. Elopement policy reviewed and care plans have reviewed and updated if applicable for those residents determined to be at risk for elopement to ensure appropriate interventions. Facility doors are locked at all times and require code or button release by employee. Code is not available to residents. Residents with wanderguard in place have had their wanderguards checked for proper function and replaced if needed. Wander system alarms when resident with bracelet approached door however the door remains locked. Photos of residents at risk for wandering were updated at the front desk and on all units to ensure staff are aware of residents at risk.
3. Nursing administration educated facility staff on the elopement policy and procedures. Education also provided on procedure to follow when a resident at risk for elopement approaches a facility exit door. Reception staff educated on supervision of front door to prevent elopement.
4. NHA / Designee will audit supervision / front door procedures 3 X's/ week for two weeks, weekly X's 2 weeks, monthly X's 2. Audits to be reviewed at QAPI.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 12 shifts out of 63 reviewed.
Findings include:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(f.1) In addition to the director of nursing services, a facility shall provide all of the following:
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift, 1:1 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.
July 3, 2024 - 13.40 nurse aides on the day shift, versus the required 13.80 for a census of 138.
July 3, 2024 - 10.97 nurse aides on the evening shift, versus the required 12.55 for a census of 138.
July 3, 2024 - 9.10 nurse aides on the night shift, versus the required 9.20 for a census of 138.
July 6, 2024 - 5.93 nurse aides on the night shift, versus the required 9.07 for a census of 136.
July 7, 2024 - 11.03 nurse aides on the day shift, versus the required 13.5 for a census of 135.
July 7, 2024 - 6.87 nurse aides on the night shift, versus the required 9.20 for a census of 138.
July 8, 2024 - 8.10 nurse aides on the night shift, versus the required 9.00 for a census of 135.
July 14, 2024 - 12.83 nurse aides on the day shift, versus the required 13.80 for a census of 138.
July 17, 2024 - 13.13 nurse aides on the day shift, versus the required 13.70 for a census of 137.
July 18, 2024 - 12.97 nurse aides on the day shift, versus the required 13.70 for a census of 137.
July 22, 2024 - 12.80 nurse aides on the day shift, versus the required 13.70 for a census of 137.
July 23, 2024 - 12.47 nurse aides on the day shift, versus the required 13.80 for a census of 138.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on July 25, 2024, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 09/04/2024

1. Facility cannot retroactively correct.
2. A 7 Day lookback was conducted to review if required CNA ratios were met.
3. Facility will continue to use agency staff to fill in holes/call-offs, offer bonuses, continue to recruit for in-house staff and continue using social media advertising. Facility initiated services with a third-party recruitment partner to assist with recruitment efforts. Facility hired a new nursing scheduler who will receive education from NHA/designee on CNA staffing ratio requirements.
4. The NHA/designee will audit to ensure facility is meeting CNA ratios 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported and reviewed with facility QAPI.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 6 shifts out of 63 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

July 5, 2024 - 4.03 LPNs on the evening shift, versus the required 4.50 for a census of 135.
July 5, 2024 - 2.91 LPNs on the night shift, versus the required 3.38 for a census of 135.
July 6, 2024 - 2.69 LPNs on the night shift, versus the required 3.40 for a census of 136.
July 7, 2024 - 5.28 LPNs on the day shift, versus the required 5.40 for a census of 135.
July 7, 2024 - 2.69 LPNs on the night shift, versus the required 3.45 for a census of 138.
July 8, 2024 - 3.03 LPNs on the night shift, versus the required 3.38 for a census of 135.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on July 25, 2024, approximately 2:15 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 09/04/2024

1. Facility cannot retroactively correct.
2. A 7 Day lookback was conducted to review if required LPN ratios were met.
3. Facility will continue to use agency staff to fill in holes/call-offs, offer bonuses, continue to recruit for in-house staff and continue using social media advertising. Facility initiated services with a third-party recruitment partner to assist with recruitment efforts. Facility hired a new nursing scheduler who will receive education from NHA/designee on LPN staffing ratio requirements.
4. The NHA/designee will audit to ensure facility is meeting LPN ratios 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported and reviewed with facility QAPI.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 09/04/2024

1. Facility cannot retroactively correct.
2. A 7 Day lookback was conducted to review if required general direct care nursing care hours (PPD) were met.
3. Facility will continue to use agency staff to fill in holes/call-offs, offer bonuses, continue to recruit for in-house staff and continue using social media advertising. Facility initiated services with a third-party recruitment partner to assist with recruitment efforts. Facility hired a new nursing scheduler who will receive education from NHA/designee on general direct care nursing care hours requirements.
4. The NHA/designee will audit to ensure facility is meeting requirement for general direct care nursing care hours 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported and reviewed with facility QAPI.

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