Health inspection·May 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility investigative reports, select facility policy, and staff interviews, it was determined the facility failed to implement effective safety measures to mitigate fall risk for one out of 12 sampled residents (Resident 1). Findings include: A review of the facility's policy entitled Managing Falls and Fall Risk, last reviewed by the facility on January 23, 2025, revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included generalized muscle weakness, difficulty in walking, and a history of falling. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 1, dated November 16, 2024, revealed the resident was severely cognitively impaired with a BIMS score of 00 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). Review of the resident's care plan, initiated on October 7, 2022, identified the resident as being at risk for falls due to a history of falls. Interventions included: placement of bilateral fall mats, triangular wedges on the upper bilateral sides of the bed, use of a tab alarm while in bed, and maintaining the bed in a low position. A fall risk assessment completed on October 14, 2024, confirmed the resident remained at high risk for falls. Further review of the clinical record revealed physician's orders dated October 15, 2024, for triangular wedges to be positioned at the bilateral upper bed rails while the resident was in bed. These interventions were in place due to a fall that had occurred on October 14, 2024. Further clinical record review revealed a nurse progress note dated November 22, 2024, at 5:30 PM, which revealed that Resident 1 experienced an unwitnessed fall from the bed on the left side and was found lying on the floor on his left side with his upper body on the floor and lower body on the fall mat. Resident 1 stated he wanted to turn from side to side and rolled out of bed. A resident assessment was done at that time and revealed a bump to the left temporal area measuring 0.4 cm with no discoloration. It was noted the bed alarm was not sounding, and that the left-side bed wedge was Page 1 of 4 395623 395623 05/28/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting on the window frame at the time of the fall. The right-side bed wedge was in place at the time of the fall. A facility investigation report dated November 22, 2024, concluded the fall occurred due to failure to follow the resident's plan of care. Specifically, the left-side bed wedge was not in place as required, and the bed alarm, which the resident had a known history of disabling, was nonfunctional at the time of the incident. Post-fall interventions included staff being directed to verify the placement of fall prevention devices at the start and throughout each shift. During an interview conducted on May 28, 2025, at approximately 2:30 PM, the Director of Nursing (DON) confirmed that the facility failed to ensure that effective fall prevention measures were consistently implemented for Resident 1 on November 22, 2024. The DON acknowledged it is the facility's responsibility to ensure that individualized safety interventions are in place and functioning to mitigate fall risks. 28 Pa. Code 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 395623 Page 2 of 4 395623 05/28/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the toileting needs of one of 12 sampled residents (Resident 2), including the timely provision of staff assistance with toileting and management of urinary and bowel incontinence. Findings include: A review of facility policy titled Urinary Incontinence - Clinical Protocol provided by the facility on May 28, 2025, revealed that, as appropriate, and based on assessment of the category and causes of incontinence, staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. A review of Resident 2's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). A review of the resident's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 13, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 3 (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 0-7 indicates severe cognitive impairment), she required substantial/extensive assistance from staff for bed mobility, transfers, and toileting, was always incontinent of urine, frequently incontinent of bowel, and was not on a toileting program. A review of the resident's person-centered plan of care, dated July 13, 2023, included a focus area related to toileting and incontinence, with documented problems such as overactive bladder, frequent urinary and bowel incontinence, hemorrhoid pain, urinary pain, recurrent urinary tract infections (UTIs), and atrophic vaginitis (dryness and inflammation of the vaginal wall). Resident goals included maintaining skin integrity and preventing breakdown from incontinence. Interventions included providing hemorrhoid cream, using wet washcloths instead of wipes, applying vaginal cream as ordered, recording incontinent episodes, utilizing protective skin creams, cleansing and drying after incontinent episodes, and use of pull-ups. However, the care plan failed to identify or implement a structured toileting schedule or individualized incontinence program (e.g., check-and-change protocols, scheduled toileting, or prompted voiding) to manage the resident's known incontinence and promote timely care to prevent the potential of skin breakdown. A review of the resident's [NAME] (a nursing information system used to obtain specific care information for each resident) in effect at the time of the survey ending May 28, 2025, failed to include 395623 Page 3 of 4 395623 05/28/2025 Grandview Nursing and Rehabilitation 78 Woodbine Lane Danville, PA 17821

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the incontinence management needs of the resident. There was no documented evidence on the [NAME] that staff were instructed to provide the resident with timely toileting or incontinence care. A quarterly toileting review, documented by nursing staff on May 27, 2025, at 2:22 PM, noted that the resident was always incontinent of bladder, frequently incontinent of bowel, had shown decline in continence, and required extensive assist of two staff with toileting. It further documented use of a gait belt for transfers. However, the review did not include individualized interventions such as scheduled toileting or specific timing of care to address or reduce incontinence events. A review of a grievance filed on behalf of Resident 2 by a family member dated May 11, 2025, at 1:30 PM revealed the resident was soaked with urine through her pull ups and pants. A review of Documentation Survey Report v2 (general care nursing tasks completed for the resident) from May 1, 2025, through May 27, 2025, revealed the resident was incontinent of urine 100% of the time, every day during every shift. There was no evidence the facility had developed and implemented a plan to address the resident's toileting needs based on an evaluation of the resident's habits and voiding patterns and assure timely care was provided to meet the resident's toileting needs and manage the resident's urinary incontinence to prevent extended periods of time without toileting, checking for incontinence and changing the resident. An interview with the Director of Nursing on May 28, 2025, at 11:15 AM, confirmed that the facility was unable to provide documented evidence the facility developed and implemented planned incontinence management for Resident 2. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies 395623 Page 4 of 4