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Complaint Investigation

Grandview Nursing And Rehabilitation

January 15, 2025 · Danville, PA · 78 Woodbine Lane
Citations 10
Beds 172
Provider ID 395623
Healthcare Facility
Grandview Nursing And Rehabilitation
Danville, PA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

GRANDVIEW NURSING AND REHABILITATION in DANVILLE, PA — inspection on January 15, 2025.

Found 10 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0550
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise

28 Pa.

Code 211.12 (d)(4) Nursing services.

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

395623 01/15/2025

Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

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], 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.

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

updated, be reviewed by dietician, and meet the needs of the resident.

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

intolerances, and preferences, as well as appealing options.

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Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

assistance.

Findings included:

A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], 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.

395623

Form Approved OMB

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

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.

Refer

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DANVILLE, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRANDVIEW NURSING AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.