Grandview Nursing And Rehabilitation
GRANDVIEW NURSING AND REHABILITATION in DANVILLE, PA — inspection on October 4, 2025.
Found 5 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
Based on observation and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in one of three resident care units (the [NAME] Resident Unit).Findings include: An environmental tour of the [NAME] Resident Unit was conducted on October 3, 2025.An observation of Room W-16 revealed a large amount of a white substance inside an incontinent brief (a disposable garment worn to manage urinary or fecal incontinence) that was strewn under and around Bed 3.
The floor contained liquid stains, visible dirt, and paper debris. A fall mat (a cushioned floor pad placed beside a bed to minimize injury if a resident falls) was propped against the bathroom door frame.
The fall mat was visibly soiled with dark liquid stains and dirt.
Rooms W-9 and W-11 were observed to have dried liquid stains and dirt on the floors. At 9:30 AM, Resident 12 was observed seated in her wheelchair outside of the room. A brown liquid substance was noted on the resident's clothing, wheelchair seat, and wheelchair tires.
Multiple large puddles of the same brown liquid were present under the wheelchair and extended along the floor leading to Bed 1 of Room W-08.
During an interview at the time of the observation, Resident 12 stated she had an accident (a bowel incontinence episode with liquid stool) while seated in the chair.
She reported activating her call bell (a device used by residents to request assistance from staff) and being told by staff that someone would come to assist her. Resident 12 stated she had been sitting in the soiled condition for more than fifteen minutes.
During an interview conducted on October 3, 2025, at 9:40 AM, the Assistant Director of Nursing (ADON) stated that the nurse aide assigned to Resident 12 that shift had to leave the facility due to an emergency.
The ADON stated that other nurse aides were completing their assigned resident care tasks and that assistance would be provided shortly. At 10:00 AM, the Director of Nursing (DON) confirmed that all resident care and common areas are required to be kept clean and sanitary. Pa Code 211.12 (D)(1)(3)(5) Nursing services.Pa Code 201.18(b)(1) (3) Management.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Grandview Nursing and Rehabilitation
78 Woodbine Lane Danville, PA 17821
SUMMARY STATEMENT OF DEFICIENCIES
neurologic impairment).
Upon the arrival of paramedics, the resident was intubated (a breathing tube was inserted into the airway to provide mechanical ventilation) and transported to the emergency department.A review of the clinical record further revealed that five hours had elapsed between the last documented neurological assessment (4:00 a.m.) and the time the resident was found unresponsive at 9:00 a.m. on [DATE]. At that time, the resident was noted to be unresponsive to verbal and tactile stimulation.
The on-call physician was again notified, and emergency medical services were called.
The resident was subsequently transferred to the hospital for evaluation, 13 hours after the fall occurred. A review of a nurse's progress note documented by Employee 12, LPN, dated [DATE], at 5:42 p.m. revealed that Resident CR1 was admitted to the hospital for evaluation of brain bleeding. A review of outside hospital documentation provided by the facility, dated [DATE], revealed that a computed tomography (CT) scan of the brain (a diagnostic imaging test that uses X-rays and computer processing to create detailed cross-sectional images) showed a large left subdural hematoma (a collection of blood between the brain surface and its outer covering), a substantial midline shift (movement of brain structures away from their normal position due to pressure from bleeding), and multi-compartmental intracranial hemorrhage (bleeding in multiple areas within the skull). A CT scan of the abdomen and pelvis also showed a left lateral thigh subcutaneous contusion (a bruise under the skin).
Hospital records indicated that the resident underwent further neurological evaluation and was pronounced deceased on [DATE].An interview with the Director of Nursing (DON) on [DATE], at 5:00 p.m. confirmed that Resident CR1 had a history of falls in the facility.
The DON stated that documentation of the 15-minute safety checks ordered on [DATE], following the fall at 7:40 p.m., and documentation of completion of all required neurological assessments, were not present in the resident's medical record.
The record and documentation reviews revealed that after an unwitnessed fall with possible head impact Resident CR1, who was receiving anticoagulation therapy, was not transferred for immediate medical evaluation or diagnostic imaging.
Neurological assessments and safety monitoring were not completed as ordered after the fall.
The resident was found unresponsive 13 hours later and was transferred to the hospital, where diagnostic imaging identified multiple areas of brain bleeding. 28 Pa.
Code 211.12 (d)(1)(5) Nursing services. 28 Pa Code 211.10 (a)(c) Resident care policies.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Grandview Nursing and Rehabilitation
78 Woodbine Lane Danville, PA 17821
SUMMARY STATEMENT OF DEFICIENCIES
During an interview conducted on October 3, 2025, at 3:30 PM the facility's Dietary Manager stated that most of the kitchen staff were newly hired and had been employed for only a few months.
She confirmed that the kitchen was operated under contract with an outside food-service agency and that she was employed by that agency.
The manager stated that education and training for dietary employees were completed upon hire and annually but described the process as informal, consisting of being walked through the job duties on the first day of employment.
She confirmed that there were no written competencies or job descriptions available for staff reference.
Immediate Jeopardy was identified and declared on October 3, 2025, at 3:30 PM due to the facility's failure to properly label and identify a pitcher that contained a sanitizing solution used in the three-compartment sink.
The unlabeled solution was mistaken for pink lemonade and subsequently served to approximately ten residents.
This failure resulted in the exposure of residents to a hazardous chemical substance and placed them in a condition of Immediate Jeopardy to health and safety.
The facility was notified of the Immediate Jeopardy findings at 3:30 PM on October 3, 2025, and the Immediate Jeopardy Template was provided to the Nursing Home Administrator at that time. In response, the facility submitted a written Immediate Jeopardy action plan at 7:30 PM on October 3, 2025.
The plan included the following corrective actions:A root-cause analysis was completed, which determined that a staff member had improperly used a drink pitcher to mix and store a sanitizing chemical in the kitchen.
All residents on the East Unit were reassessed for injury or adverse effects, and physician orders were implemented for care and monitoring.
All chemicals in the kitchen were reviewed for proper labeling and storage.
Education was provided to all dietary and nursing staff regarding chemical safety, labeling, and segregation of food and cleaning supplies.
All chemicals not in active use were removed from the kitchen area and placed in a secure, designated chemical-storage area.
Facility dietary policies regarding chemical labeling, storage, and use were reviewed and revised.
Post-education audits were initiated to verify continued staff compliance with labeling and storage procedures.
Verification of implementation of the Immediate Jeopardy action plan was completed, and the Immediate Jeopardy was determined to have been removed on October 4, 2025, at 11:30 AM, after it was verified that the corrective actions had been fully implemented and were effective in removing the immediate threat to resident health and safety.28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 201.18 (e)(1) (2.1) (3) Management 28 Pa.
Code 211.6 (f) Dietary services 28 Pa.
Code 211.10 (d) Resident care policies
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Grandview Nursing and Rehabilitation
78 Woodbine Lane Danville, PA 17821
SUMMARY STATEMENT OF DEFICIENCIES
During an additional interview on October 3, 2025, at approximately 3:00 PM, the Nursing Home Administrator confirmed that the above conditions constituted food safety and sanitation issues. 28 Pa.
Code 211.6 (f) Dietary services.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Grandview Nursing and Rehabilitation
78 Woodbine Lane Danville, PA 17821
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, a review of clinical records, select facility policies, documentation provided by the facility, and interviews with residents and staff, it was determined that the facility's administration failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental well-being of residents in the facility.
Specifically, the administration failed to ensure resident safety when the facility's dietary department served a hazardous cleaning chemical to residents and failed to prevent ten out of fifty-seven residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) from ingesting the chemical.
This deficient practice placed all fifty-seven residents residing in the East Wing at risk of consuming a hazardous cleaning substance and resulted in an immediate jeopardy to resident health and safety.
Findings included:A review of the job description for the Nursing Home Administrator (NHA) dated June 3, 2024, revealed the administrator will lead and direct the overall operations of the facility.
The NHA's essential duties and responsibilities include hiring, training, and developing department staff, verifying that the building and grounds are maintained appropriately, and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed, overseeing regular rounds to monitor operation of support departments, and consulting with department managers concerning the operation of their departments to assist in eliminating/ correcting problem areas and/ or improving services.
The Job Description for Director of Nursing (DON) Services dated March 10, 2025, revealed the DON in the absence of the NHA will assume responsibility for the facility, participate in safety committee meetings, quality assessment and assurance committee meetings, and assuring residents a comfortable, clean, orderly, and safe environment.
The facility failed to ensure these administrative responsibilities were carried out, as evidenced by the facility served a hazardous cleaning chemical to residents during meal service, and ten out of fifty-seven residents ingested the chemical. (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).
This event demonstrated a lack of effective oversight to address a failure to implement safe handling, storage and labeling of hazardous chemicals.
Interviews with staff confirmed that dietary personnel had not received effective training or competency evaluation regarding the safe handling, storage, and labeling of hazardous chemicals in accordance with facility policy and procedure to ensure the safety of residents.The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F-F689) 483.25(d)(1)(2) Accidents, revealed the Administrator and Director of Nursing failed to fulfill essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety.
The lack of oversight and resource utilization contributed to the immediate jeopardy situation.
Refer F-F689 28 Pa.
Code: 201.14 (a) Responsibility of licensee28 Pa.
Code: 201.18 (e)(1) Management28 Pa Code 211.6(f) Dietary services.28 Pa.
Code 211.12 (d)(3) Nursing services
Facility ID: