Grandview Nursing and Rehab: Fatal Fall Monitoring Failure - PA
Thirteen hours passed between the fall and the transfer.
Inspectors from the Centers for Medicare and Medicaid Services cited Grandview Nursing and Rehabilitation on October 4, 2025, following a complaint investigation into the death of the resident identified in records as Resident CR1. The citation carries a finding of actual harm.
The fall happened at 7:40 p.m. The resident was not witnessed falling, and there was the possibility of head impact. That combination mattered: the resident was on anticoagulation therapy, blood thinners that dramatically increase the risk of internal bleeding from even a minor head injury. An on-call physician was notified.
What the physician ordered after that notification, according to the inspection record, were 15-minute safety checks and a series of neurological assessments, the kind of monitoring designed specifically to catch early signs of brain injury, confusion, unequal pupils, a sudden drop in responsiveness.
Neither the safety checks nor the required neurological assessments were completed. The Director of Nursing confirmed it directly to inspectors: the documentation for those checks, and for all required neurological assessments following the fall, was not present in the resident's medical record.
The last documented neurological assessment in the record was at 4:00 a.m. Five hours later, at 9:00 a.m., a staff member found the resident unresponsive, not responding to voice, not responding to touch.
The on-call physician was notified again. Emergency services were called. Paramedics arrived and intubated the resident, inserting a breathing tube to maintain an airway, before transport to the emergency department.
At the hospital, a CT scan of the brain showed a large left subdural hematoma, a collection of blood that had been building between the brain's surface and its outer covering. It had grown large enough to cause a substantial midline shift, the physical displacement of brain structures pushed out of position by pressure. The scan also showed bleeding in multiple compartments within the skull.
A separate CT scan of the abdomen and pelvis showed bruising under the skin of the left thigh.
A nurse's progress note, written by an LPN identified as Employee 12 at 5:42 p.m. on the day of transfer, documented that Resident CR1 had been admitted to the hospital for evaluation of brain bleeding. Hospital records confirmed that the resident underwent further neurological evaluation and was pronounced deceased.
The Director of Nursing also confirmed to inspectors that Resident CR1 had a history of falls at the facility. That history made the monitoring orders after this fall more urgent, not less.
The inspection record is precise about what the failure looked like in sequence: an unwitnessed fall with possible head impact, a resident on blood thinners, a physician who ordered specific monitoring, and then nothing. No documented safety checks. No documented neurological assessments through the overnight hours. A five-hour gap between the last recorded check and the moment someone found the resident unable to respond.
The subdural hematoma that killed this resident is a known, treatable injury when caught in time. Blood accumulates gradually after a bleed. Neurological checks exist precisely to catch the window when intervention is still possible. Confusion, a change in speech, one pupil larger than the other, a sudden headache, any of these can appear in the hours after a fall and signal that something is wrong before it becomes catastrophic.
None of those checks were recorded as having been done.
The resident was transferred to the hospital 13 hours after the fall, pronounced deceased, and Grandview Nursing and Rehabilitation now carries a citation for actual harm in connection with their death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grandview Nursing and Rehabilitation from 2025-10-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
GRANDVIEW NURSING AND REHABILITATION in DANVILLE, PA was cited for violations during a health inspection on October 4, 2025.
Thirteen hours passed between the fall and the transfer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.