Grandview Nursing And Rehabilitation

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/04/2025

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 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED]. 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 REDACTED], 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 REDACTED], 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 REDACTED].An interview with the Director of Nursing (DON) on [DATE REDACTED], 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 REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/04/2025

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

September 30, 2025, and was not available for a telephone interview at the time of the survey. A review of Employee 5's personnel file revealed that he was hired on July 20, 2025, and voluntarily terminated employment on September 30, 2025. The file contained no documentation of a job description or evidence of education or training provided by the contracted dietary company or the facility. Interviews conducted on October 3, 2025, with current dietary staff revealed the following: Employee 15, dietary aide, stated that she had been employed in the kitchen for a few months. She reported that she received education regarding labeling drink pitchers only after the September 22, 2025, event and stated that she had not received any prior education regarding her kitchen duties. Employee 16, dietary aide, stated that he had worked in the kitchen for a few months and had not received any education or training related to kitchen operations.

Employee 17 (cook) stated that she had been employed in the kitchen for several months and had never received any education or training regarding her job responsibilities in the kitchen. 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/04/2025

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

bacteria) were present.The surrounding area was dirty with paper debris, liquid stains, and a sticky residue

on the floor.A mop bucket filled with dirty water and cleaning equipment was stored adjacent to the sink, creating potential for contamination of food-contact areas.During an interview at that time, the Corporate Dietary Manager confirmed the observations and stated sanitizer test strips could not be located. He further stated there was no documentation verifying that sanitizer concentrations were checked in accordance with facility policy. He reported that most dietary staff were recently hired and had not been trained (in-serviced)

on proper three-compartment sink use.Additional environmental observations conducted between 10:00 AM and 3:00 PM revealed widespread sanitation concerns throughout the kitchen, maintenance, storage, and service areas:Four unlabeled drink pitchers stored upside-down on a dirty windowsill with food particles and lint.An unlabeled bucket containing a rag in chemical solution stored on a shelf next to food items such as cooking oil and spices.In the kitchen maintenance room, two portable machines were observed, which the Dietary Manager could not identify. An open bottle of degreaser was placed on one of

the machines. Several electrical extension cords were strewn across the machines and floor, posing both contamination and safety concerns. A nearby metal cart was visibly soiled with food debris, paper waste, and an open bottle of dish detergent. The floor throughout the area contained visible dirt, paper, and plastic debris, with a black sticky substance on the vinyl flooring that adhered to shoes when walked upon.In the storage room, an uncovered three-tiered metal shelving unit held metal banquet pans, cooking racks, serving utensils, and bowls, several of which contained standing water and water stains. Dust, dirt, cobwebs, empty cardboard boxes, and open containers of paper dining products were observed scattered across the floor.During the lunch meal service at 12:30 PM, the kitchen's meal tray delivery cart had visible liquid stains on its exterior. On both the east and west resident hallways, open food carts were noted with food and liquid stains on their exteriors.In the kitchen refrigerator, a heavy buildup of lint-like material was observed on the two fans along the back wall, along with a black sticky residue on the ceiling surface. A zip-lock bag containing sliced deli meat lacked any label or date, as did another open bag of lunch meat. An open container of soup labeled use by 10/1/25 was also present.Observation of the Pavilion resident dining area on October 3, 2025, at 12:45 PM revealed multiple clean coffee cups with a white film on the inside,

an open bag of cereal in a cardboard box, and several metal banquet pans with liquid stains. The refrigerator was dirty with food debris, paper waste, and dirt accumulation. Four sandwiches were dated September 30, 2025, and three covered bowls of peaches were undated and unlabeled.Observation of the Pavilion resident pantry revealed dirty dishes on the counter, a microwave with dried food residue, and sticky countertops with visible food and liquid stains. The cabinet under the sink contained dirty trays, a plastic bag of dishwasher pods (chemical cleaning agents), and was unlocked at the time of observation.

Additional cabinets contained disorganized, open packages of paper napkins, plastic lids, and plates. A drawer contained an open container of cookies. The refrigerator held multiple unlabeled and undated food containers, including an open plastic container of sweet tea with a use-by date of September 18, 2025, three unlabeled bags of pizza slices, and an unlabeled cup of coffee from an outside restaurant. The freezer contained an open, undated package of waffles. The refrigerator interior was dirty with food, liquid, and dirt debris.During an interview on October 3, 2025, at 2:45 PM, the Corporate Dietary Manager confirmed that dietary staff were responsible for cleaning and maintaining both the resident pantry and dining areas. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/04/2025

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 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

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

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet