Grandview Nursing And Rehabilitation

F-F550

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 395623 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395623 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 28 Pa. Code 201.29(a) Resident rights.

Level of Harm - Minimal harm or 28 Pa. Code 211.10(c) Resident care policies. potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing services. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 395623 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395623 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0660 Plan the resident's discharge to meet the resident's goals and needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 potential for actual harm Based on a resident representative interview, a clinical records review, and staff interviews, it was Residents Affected - Few determined that the facility failed to develop and implement a safe discharge plan for one of the 11 residents reviewed (Resident CR1).

Findings included:

A clinical record review revealed Resident CR1 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic kidney disease (gradual loss of kidney function) and traumatic brain injury (a brain injury caused by a sudden, external force to the head).

A review of a discharge Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 27, 2024, revealed that Resident CR1 is moderately cognitively impaired with a BIMS score of 08 (Brief Interview for Mental Status-

a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment).

A progress note dated December 17, 2024, at 11:14 AM indicated Resident CR1 requires 30 hours a week of caregiver support. The note indicated an external service provider is assisting with coordinating discharge care.

A physical therapy discharge summary dated December 26, 2024, revealed discharge recommendations for Resident CR1 to receive continued physical therapy services to maximize safe functional mobility. Additionally, the discharge summary indicated recommendations for Resident CR1 to have significant supervision and assistance greater than 12 hours a day due to impaired cognition and safety.

A clinical record review revealed no documented evidence indicating the total amount of supervision and assistance that would be available for Resident CR1 upon discharge.

An interdisciplinary team discharge summary dated December 26, 2024, revealed Resident CR1 is to be discharged home on December 27, 2024, with occupational therapy and physical therapy home health services. There was no documented evidence in the discharge summary to include and ensure safe resident medication administration upon discharge. There was no documented evidence in the discharge summary indicating the total amount of supervision and assistance that would be available to the resident upon discharge.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 395623 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395623 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0660 During an interview on January 15, 2025, at approximately 11:00 AM, the Director of Nursing (DON) and Director of Social Services (SS) confirmed Resident CR1 was to be discharged to her home. The DON and Level of Harm - Minimal harm or Director of SS were unable to provide documented evidence that Resident CR1 would receive the required potential for actual harm care and services to ensure safe administration of medication upon discharge. The DON and Director of SS confirmed Resident CR1 had moderate cognitive impairment. The DON and Director of SS were unable to Residents Affected - Few provide documented evidence of self-medication training or education. The Director of SS explained that Resident CR1 was discharged with a plan to receive home nursing care, but medication administration was not provided through the planned home health service. The DON confirmed Resident CR1's discharge was not against medical advice.

A clinical record review failed to provide documented evidence indicating Resident CR1 received any training or was able to safely self-administer her medications from her admission on December 10, 2024, through her discharge on December 27, 2024.

A physician discharge note dated December 27, 2024, indicating Resident CR1 arrived at the facility fairly altered and confused, did well in therapy, and was to be discharged home.

A medication review report dated December 27, 2024, revealed Resident CR1 was discharged with twenty-four medications, including Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine), with instructions to inject 30 units subcutaneously one time a day for diabetes.

During an interview on January 15, 2025, at approximately 1:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure a safe discharge plan is developed and implemented for each resident. The DON and NHA confirmed that Resident CR1 was hospitalized on [DATE REDACTED], two days after her discharge.

An interview with Resident CR1's resident representative on January 16, 2025, at 10:35 AM revealed Resident CR1 was discharged home on December 27, 2024. Resident CR1's resident representative indicated Resident CR1 lives at home alone and there was no plan in place to ensure Resident CR1 would be able to safely administer her medication upon discharge. Resident CR1's resident representative explained that Resident CR1 was admitted to the emergency department on December 29, 2024, related to

the need for continued care.

28 Pa. Code 201.18 (b)(1) Management

28 Pa. Code 211.10 (c) Resident care policies.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 395623

F-F557

28 Pa. Code 201.18 (e)(1) Management.

28 Pa. Code 201.29 (a) Resident rights.

28 Pa. Code 211.12 (d)(4) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 395623 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395623 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 potential for actual harm Based on observations and resident and staff interviews, it was determined the facility failed to provide care Residents Affected - Few and services in a manner respectful of each resident's personal dignity for one of nine residents observed (Resident 3).

Findings include:

A clinical record review revealed Resident 3 was admitted to the facility on [DATE REDACTED], with diagnoses that include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 14, 2024, revealed that Resident 3 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

Further review of the MDS, Section GG Function Abilities GG 0130. Self-Care revealed Resident 2 is usually dependent on staff to maintain perineal hygiene, adjust clothes before and after voiding, showering or bathing, and dressing his lower body.

An observation on January 15, 2025, at 10:45 AM revealed Resident 3 lying on his back in his bed with his pants pulled down to his thighs and his stomach was exposed. The resident was wearing a white incontinence brief. Resident 3 was visible from the hallway. The privacy curtains were not drawn. The resident's fingers were covered in a yellow-orange film. He had black and tan debris under the tips of his fingernails.

The resident was observed to be lying in the position from 10:45 AM until 11:05 AM when two nurse aides entered his room to provide him care. During the twenty-minute observation, other residents and facility staff were observed walking past his room.

During an interview on January 15, 2025, at 10:45 AM, Resident 3 indicated that staff were getting him ready earlier this morning and left him with his pants at his thighs. Resident 3 described feeling like a piece of furniture and experiencing anger and frustration regarding his care. He explained that he has Parkinson's disease and is dependent on the facility staff for assistance. Resident 3 indicated he is unable to pull his pants up without assistance.

During an interview on January 15, 2025, at approximately 1:30 PM, the Director of Nursing (DON) confirmed that Resident 3 should not be left with his pants at his thighs without privacy curtains drawn. The DON also indicated that residents' fingernails should be cleaned as needed. The DON confirmed that the facility has the responsibility to ensure all residents receive care in a manner that promotes their personal dignity and respect.

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