Grand View Care Ctr

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that snack and nourishment refrigerators on the Memory Care Unit (MCU) were maintained at proper temperatures and that food items were dated and labeled to prevent the potential for food-borne illness. Surveyors observed the MCU refrigerator on 06/17/26 at 8:13 AM and found the refrigerator temperature log for June 2026 missing entries for 6/9/26 through 6/14/26 and 6/16/26. In the same refrigerator, surveyors observed an open container of nonfat yogurt with a label date of 05/27, a half pitcher of orange juice dated 06/05, a sippy cup half filled with clear liquid that was unlabeled and undated, and an opened container of coffee creamer that was unlabeled and undated. The facility also did not ensure that the snack and nourishment refrigerator/freezer in the [NAME] Wing Lobby (WWL) had food items dated and labeled. On 06/17/26 at 8:18 AM, surveyors observed an opened container of Thick & Easy, an opened container of Coffee Mate Cold Foam, an opened container of Power Aide Lemon Lime, and a sandwich-size plastic bag of fresh strawberries, all without dates or labels. A CNA stated that resident items could be stored in the refrigerator and confirmed the WWL items were not labeled or dated. The NHA was shown the observations and stated staff were expected to label items with the resident's name and open date, and that items over 5 days would be discarded. A CNA later confirmed the MCU refrigerator contents were unlabeled and undated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not notify the Ombudsman when a resident was transferred from the facility to a hospital on two occasions for a change in condition. The resident was transferred to an emergency department on 03/27/26 and again on 05/06/26, but these emergency transfers were not included in the facility’s monthly email notification process to the Ombudsman. During record review, the surveyor requested Ombudsman notification documentation for March and May 2026, and the Social Worker provided discharge notification logs and instructions for monthly email reporting; however, the resident’s two emergency room transfers were not listed on those logs. When interviewed, the Social Worker stated they were not aware that the notification requirement included transfers to emergency rooms. The facility policy titled Notice of a Transfer and/or Discharge, updated in 2011, did not address the requirement to notify the Ombudsman.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not complete an accurate admission assessment for a resident with PTSD, and no trauma-informed plan of care or assessment was found in the record. The resident was admitted with a diagnosis of PTSD, and review of the physician orders, social services progress notes, assessments, and care plan showed no trauma-informed assessment had been completed. During interview, the NHA stated the PTSD-related questionnaire was not completed upon admission, even though the expectation was that these forms be completed for any resident requiring trauma-informed care. The SW stated they had not been trained on how to complete the trauma-informed care process and reported being present at the resident’s admission but not completing the questionnaire because they believed there were no issues.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that a resident with a diagnosis of post-traumatic stress disorder (PTSD) received culturally competent, trauma-informed care in accordance with professional standards of practice. The resident’s most recent MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and also identified PTSD. The resident’s care plan only stated, “I have anxiety and PTSD,” with no additional information about the cause of the PTSD, possible triggers, or interventions to prevent re-traumatization. The facility also did not complete the trauma-informed care questionnaire on admission, and the Nursing Home Administrator stated this was expected for residents requiring trauma-informed care. Interviews showed staff did not have a completed trauma-informed care process or training in place for this resident. The Social Services Assistant stated the trauma-informed care questionnaire was used during admission but was not completed for this resident, and the Social Worker stated they had not been trained on how to complete the trauma-informed care process or care plan. The Social Worker also stated they did not know how to obtain medical records related to the resident’s PTSD history and had not completed the questionnaire because they believed there were no issues. The LPN and CNA both stated they had not received training specific to PTSD or trauma-informed care, and the NHA stated there was no formal training for floor staff and no policy or procedure available for PTSD or trauma-informed care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure a medication error rate of 5% or less, with 4 medication errors in 38 opportunities for a 10.53% error rate. During observation, RN D prepared R30’s medications by crushing multiple tablets and placing them into applesauce, including divalproex DR 250 mg, along with other medications. RN D also opened R30’s omeprazole 40 mg DR capsule and tamsulosin 0.4 mg capsule and sprinkled the contents into the same applesauce before administering the medications. When questioned, RN D stated the pharmacy had reviewed medications for safety in crushed or sprinkled form, but she could not confirm whether R30’s delayed release medications had been reviewed by the pharmacist for that purpose. RN E was observed preparing R10’s medications by crushing several tablets and placing them into applesauce, then opening omeprazole 40 mg DR capsule and sprinkling the contents into the same applesauce before administration. RN E stated that crushed administration could be based on speech therapy recommendation, provider order, or nursing judgment, and said pharmacy reviews medications for safety prior to crushing or sprinkling. The DON later stated that nursing staff were expected to contact the provider for approval if a medication was ER or DR, and confirmed that before the observations there had not been a pharmacy review of R30’s and R10’s medications for appropriateness to be administered in crushed or sprinkled form.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure residents were free from significant medication errors for 2 of 4 residents reviewed for medication administration. For one resident, physician orders included divalproex sodium delayed release 250 mg daily, omeprazole delayed release 40 mg daily, and tamsulosin 0.4 mg daily. The resident also had a nursing order stating “may crush meds FYI,” but the record showed no pharmacy review documenting that these medications were appropriate to crush or administer in altered form. During observation, an RN crushed the divalproex delayed release tablet and opened the omeprazole delayed release capsule and tamsulosin capsule, then mixed them in applesauce and administered them to the resident. For a second resident, the physician ordered omeprazole 40 mg delayed release capsule daily, and the nursing record again included a general “may crush meds FYI” note. The record showed no pharmacy review of whether the medication could be crushed or sprinkled. During observation, an RN opened the omeprazole delayed release capsule and sprinkled the contents into applesauce before administering it. When interviewed, the DON stated the nurse would be expected to contact the provider for approval if the medication was in delayed release form, and later confirmed that pharmacy review had not been completed before these medications were administered in crushed or sprinkled form.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services to prevent and manage pressure injuries (PIs) for two residents, R1 and R2, leading to the development and worsening of PIs. R1 was admitted without a PI but was at risk for developing one. The facility did not implement adequate interventions, failed to conduct weekly comprehensive assessments, and did not update the care plan timely. As a result, R1 developed a facility-acquired PI that progressed to a stage 4. The facility's inaction included not staging the PI, not offering alternative repositioning schedules, and not educating R1 on the importance of repositioning. R2 was also admitted without a PI but was at risk due to severe cognitive impairment and other medical conditions. The facility did not complete comprehensive assessments or offer alternative interventions when R2 refused repositioning. Consequently, R2 developed two deep tissue injuries that worsened into multiple PIs, including an unstageable PI with undermining. The facility failed to stage the wounds when first noted and did not provide adequate interventions to prevent further deterioration. The deficiencies were identified through observations, interviews, and record reviews, revealing that the facility did not adhere to professional standards for PI prevention and management. The lack of timely assessments, staging, and care plan updates contributed to the worsening of the residents' conditions, indicating a failure to provide appropriate care and services to prevent harm.

Removal Plan

• Full facility skin assessment sweep completed by facility nursing leadership.
• Wound Care Consultant rounded for residents with areas of wound concerns.
• Full facility Braden Scale Sweep completed by nursing leadership.
• Interventions put in place based on Braden scale score.
• All care plans for residents with any skin concerns reviewed for appropriate interventions and updated.
• Review each resident's nutrition, appetites, weights, blood sugar, hydration by nursing leadership to ensure appropriate interventions are in place.
• Inventory of all mattresses and cushions that residents utilize and identify the stages for each.
• Order an Alternating Air Mattress that supports up to a Stage IV wound.
• Obtain mattress and cushion information from manufacturer or supplier to ensure they meet the correct needs of the residents.
• Hydration assessments on residents identified for Pressure Ulcers.
• Training for RNs and LPNs initiated.
• Implement weekly Wound Rounds to be completed on Tuesday Mornings.
• Update Admission and Re-admission checklist to clarify expectations upon admission for the Skin assessment, Braden scale, and interventions implemented in the baseline care plan.
• Implement checklist for nursing to use when a new skin concern is identified.
• Implement new documentation for meals, fluids, and snacks.
• Implement provider and resident representative being updated weekly after wound rounds with current wound measurements and wound assessment.
• Update policy and procedures related to skin, wounds, Braden scales, and repositioning.
• Conduct audits daily for residents with pressure injuries.
• QAPI will review all residents with wounds monthly.
• QA will review all residents with wounds quarterly and review/update skin care policies as needed.
• Facility Assessment will be updated related to any wound resident care requirements.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as R7. R7, who has a history of falls and severe cognitive impairment due to end-stage Alzheimer's disease, experienced a fall resulting in a head injury that required staples. The incident occurred because the care plan intervention of ensuring R7 wore non-skid footwear was not followed, leading to the resident being barefoot at the time of the fall. R7 had a documented history of multiple falls since admission, with eight falls recorded. The facility's fall protocol required staff to implement specific interventions to prevent falls, including ensuring that R7 wore non-skid footwear. Despite this, on the day of the incident, R7 was found barefoot, which was a direct violation of the care plan. The fall occurred at the nurse's station, where R7 was seen sleeping in a recliner chair shortly before the fall, suggesting a lack of adequate supervision. Interviews with facility staff, including the Director of Nursing, Certified Nursing Assistants, and a Registered Nurse, confirmed that the care plan was not followed. The staff acknowledged that R7 was barefoot at the time of the fall, and the Director of Nursing admitted that the care plan was not adhered to. This failure to implement the care plan interventions directly contributed to the fall and subsequent injury, highlighting a deficiency in the facility's fall prevention measures.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program, as required by their own QAPI plan dated January 2024. This plan mandates that all staff participate in ongoing annual QAPI training and that new employees receive QAPI education during orientation. However, upon review of the facility's new orientation and annual education records, the surveyor found no evidence of QAPI training being provided. During an interview, the Nursing Home Administrator confirmed that QAPI education was not included in the orientation or annual education for employees, acknowledging it as a missing component of staff education.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged incident of abuse within the required timeframe. A resident, who has moderate cognitive impairment, alleged that a CNA physically abused them by banging their head against the wall during care. This incident was reported to an LPN by the resident, who then assessed the resident and found no visible injuries or pain. The LPN reported the incident to the Nursing Home Administrator (NHA) and the Director of Nursing (DON) within two hours, and the CNA involved was sent home pending investigation. However, the facility did not report the incident to the state agency until more than two days later, which is beyond the required two-hour reporting window for allegations involving abuse. The NHA determined that the incident was not a willful or intentional act of abuse by the CNA, partly based on the resident's history of making derogatory statements about minority staff and the lack of injuries. The NHA concluded that the resident may have accidentally hit their head on the wall during a roll, but this determination was not made within the initial two-hour period after the allegation was reported. Consequently, the facility did not comply with the regulatory requirement to report the alleged abuse to the state agency within the specified timeframe.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a compliance and ethics program that is reasonably designed, implemented, and enforced to effectively prevent and detect violations and promote quality of care. This deficiency has the potential to affect all 43 residents in the facility. During the survey, it was found that the facility assessment, revised on 02/20/24, did not include ethics and compliance training. When interviewed, the Nursing Home Administrator (NHA) acknowledged the need for such a program but admitted that it was not implemented due to other priorities taking precedence.

Penalty

Inspection fine: $59,0856 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective ethics and compliance training program, which has the potential to affect all 43 residents. The facility assessment, revised on 02/20/24, did not include ethics and compliance training. Upon review of training records, it was found that three Certified Nursing Assistants (CNAs) and two licensed staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), did not receive any ethics and compliance training. During an interview, the Nursing Home Administrator (NHA) admitted awareness of the need for such a program but stated that it was deprioritized due to other issues, resulting in the absence of training.