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
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395623 10/04/2025
Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821
intracranial hemorrhage (bleeding in multiple areas within the skull). A CT scan of the abdomen and
records indicated that the resident underwent further neurological evaluation and was pronounced
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.
395623 10/04/2025
Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821
solution was mistaken for pink lemonade and subsequently served to approximately ten residents.
jeopardy to resident health or in a condition of Immediate Jeopardy to health and safety.
The facility was notified of the Immediate safety 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
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
395623 10/04/2025
Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821
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.
395623 10/04/2025
Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821
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
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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.