Grandview Manor Care Center

The facility failed to ensure that one of three sampled staff members was properly tested for tuberculosis disease upon employment. Specifically, there was no documentation of a step two TB skin test for a staff member, and no documentation of a step one TB skin test was provided upon their rehire.

The facility failed to ensure a rehired staff member (Staff B) received a required tuberculosis (TB) skin test upon re-employment. Documentation showed a step one test from a previous employment period was used instead of a new test upon the employee's return on 02/02/26.

The facility failed to obtain a signed consent for a criminal background check for a rehired staff member (Staff B). Although a background check from a previous employment period existed, the facility did not secure new consent or a new check upon the employee's rehire on 02/02/26.

The facility failed to maintain a matching therapeutic diet menu for a resident's physician-ordered mechanical soft and ground meat diet. Specifically, the fall cycle menu lacked consistent columns for both diet types and included items like bacon and sausage without the required texture alterations. This error was compounded by staff training that incorrectly taught the cook to prepare both diets identically.

The facility failed to maintain matching therapeutic diet menus for physician-ordered diets to guide food service staff. Specifically, for a resident requiring a mechanical soft and ground meat diet, the menu lacked consistent columns for both diet types and included high-risk choking hazards like crispy bacon and hard sausage. Staff also reported preparing both mechanical soft and mechanical ground diets using the same method due to the lack of proper menu guidance.

The facility failed to ensure proper referral and follow-up for two residents to meet their health care needs. Specifically, one resident suffered second-degree burns from a coffee spill without documented immediate medical attention or physician notification, and another resident experienced a fall resulting in a pubic fracture.

The facility failed to ensure proper medical referral and follow-up for two residents. Specifically, one resident did not receive adequate follow-up after sustaining second-degree burns from spilled coffee, and another resident did not receive appropriate follow-up following a fall that resulted in a pubis fracture.

The facility failed to notify the county Department of Social Services (DSS) of an incident involving Resident #1 that required emergency medical evaluation. Specifically, the facility did not report a hospitalization occurring on 12/26/24 until 01/06/25, after the county DSS had already been notified by the hospital regarding a drug overdose issue.

The facility failed to notify the county Department of Social Services (DSS) of an incident involving Resident #1 that required emergency medical evaluation. Specifically, the facility did not report an event involving a drug overdose and subsequent hospitalization for liver failure and COPD exacerbation.