Health inspection·April 10, 2025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, review of facility policy, and test tray analysis, it was determined the facility failed to ensure that meals were served at palatable temperatures and in a manner that met resident preferences for 5 out of 9 residents interviewed (Residents 1,2,3,4 and 5), and for one of one test tray meals reviewed during lunch service on the East Unit. Residents Affected - Some Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, specifies that food temperatures between 41°F and 135°F allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Hot foods must be maintained at or above 135°F and cold foods at or below 41°F. Review of the facility policy titled Food Temperatures last reviewed by the facility on January 23, 2025, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. All cold food items must be stored and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during holding and plating process and until food leaves the service area. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. A review of a resident concern form completed by the facility's Registered Dietitian (RD) on April 6, 2025, revealed that Resident 1 reported her lunch on April 3, 2025 (chicken [NAME] with noodles) was served cold. During an interview with Resident 1 on April 9, 2025, at 11:15 AM, reported that her meals were often served cold and not at a palatable temperature. During on-site survey April 9, 2025, interviews were conducted with Residents 2, 3, 4, and 5 and they reported meals were frequently served lukewarm or cold and were unappetizing as a result. A review of the planned lunch menu for April 9, 2025, included hamburger steak with gravy, oven browned potatoes, seasoned green beans, angel food cake, and fruit drink. Observation of the East Unit tray pass on April 9, 2025, at 11:30 AM revealed that the first meal cart arrived on the unit and tray distribution began immediately. The last meal tray was delivered to Resident 2 at 11:55 AM. Page 1 of 4 395623 395623 04/10/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0804 Tray temperatures obtained for Resident 2 were as follows: Level of Harm - Minimal harm or potential for actual harm Hamburger steak with gravy: 126.1°F Oven browned potatoes: 119°F Residents Affected - Some Seasoned green beans: 113°F Angel food cake: 63°F Fruit drink: 59.9°F A taste analysis of the meal revealed that the hot food items were lukewarm and not served at a palatable temperature. The green beans had an overwhelming oregano flavor that left an aftertaste, and the fruit drink was also lukewarm, further reducing meal palatability. The results of the test tray were discussed with the Nursing Home Administrator (NHA) and the facility's contracted Corporate Dietary Manager on April 9, 2025, at 12:30 PM. The Dietary Manager stated that 135°F was a holding temperature and indicated the hamburger steak temperature of 126.1°F was acceptable. However, this statement was inconsistent with the facility's own policy and failed to address multiple resident concerns regarding cold and unpalatable meals. An interview with the NHA confirmed that the facility had not ensured meals were consistently served at palatable temperatures and in accordance with resident preferences. 28 Pa. Code 201.18 (e)(3) Management 395623 Page 2 of 4 395623 04/10/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and review of facility policy, it was determined the facility failed to maintain a fully functioning resident call bell system that ensured direct and timely communication between residents and caregivers for three of nine residents sampled (Residents 4, 5, and 6). Residents Affected - Some Findings include: A review of the facility policy titled Answering Call Bell last reviewed by the facility on January 23, 2025, revealed it is the responsibility of all staff to respond to call bells, as displayed on a scrolling [NAME] on each unit. The policy stated that nurse aides, charge nurses, and RN supervisors are required to carry a pager to receive notifications of activated call bells. Walkie-talkies are to be used to request assistance for two-person tasks. If a pager or call bell device is non-functioning, maintenance must be notified immediately, and residents are to be provided a handbell until the system is repaired. The policy also stated that Administration and the QA Committee will review the timeliness of call bell responses as needed. During an interview conducted on April 10, 2025, at 10:20 AM, Resident 4 stated that she does not frequently use the call bell, but when she does, staff response can take up to an hour. During an interview on April 10, 2025, at 10:35 AM, Resident 5 reported that on some days it takes staff over 30 minutes to respond to her call bell. An observation conducted on the Second Floor [NAME] Wing on April 10, 2025, at 12:50 PM, revealed that visual call bell indicators located above the threshold of each hallway door showed that multiple residents had active call bell requests. However, there was no audible alert to notify staff unless they were physically present in the hallway and could see the visual indicator. During a separate interview on April 10, 2025, at 10:35 AM, Resident 6 also reported that staff sometimes took over 30 minutes to respond to his call bell. An additional observation on the Second Floor East Wing on April 10, 2025, at 1:05 PM, revealed the same issue: visual indicators were present, but there was no audible alert. As with the [NAME] Wing, staff would not be notified unless standing in the hallway. An interview with Employee 1CNA (Certified Nursing Assistant) revealed that although the unit has enough pagers, some pagers were not working correctly. She reported that malfunctioning screens prevented identification of which resident had activated their call bell. She confirmed that if pagers malfunction, the only method to identify an active call bell is by visually checking the hallway signs, as no alternative notification system exists. In contrast, an observation on the First Floor Pavilion Unit revealed that this unit utilized an upgraded call bell system which transmitted alerts directly to the nurses' station, including a monitor display and audible alerts to identify the resident's call. During an interview, Employee 2 (Registered Nurse) stated that the Pavilion Unit system was recently upgraded and has led to faster response times compared to the outdated systems on the second floor. 395623 Page 3 of 4 395623 04/10/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0919 Level of Harm - Minimal harm or potential for actual harm An interview with the Nursing Home Administrator (NHA) on April 10, 2025, at 2:50 PM, confirmed the call bell system on the second floor was not functioning as intended as per manufactures instructions that resulted in delayed resident call bell response. 28 Pa Code 207.2(a) Administrators responsibility Residents Affected - Some 28 Pa Code 205.28 © (1)(4) Nurses station 395623 Page 4 of 4