Grandview Villa Assisted Living

The facility failed to administer medications as ordered for one resident regarding a cholesterol medication. Specifically, fenofibrate 145mg was not documented as administered in the eMAR from 07/11/25 through 08/18/25, and the medication was not available on hand during the survey. The error occurred because the pharmacy did not receive the necessary physician orders and the primary care physician overlooked the medication in the discharge summary.

The facility failed to administer medications as ordered for one resident related to a cholesterol medication. Specifically, fenofibrate 145mg was not documented as administered in the eMAR from 07/11/25 through 08/18/25, and the medication was not available on hand during the survey. The error occurred because the MA supervisor failed to fax discharge instructions to the pharmacy and the PCP overlooked the order during review.

The facility failed to ensure that each resident was tested for tuberculosis upon admission. This is required to comply with the control measures adopted by the Commission to prevent the spread of the disease.

The facility failed to ensure that 2 of 3 sampled residents were tested for tuberculosis in compliance with required control measures. Specifically, one resident had no documentation of TB testing upon admission, and another resident lacked documentation of a required second-step TB test.

The Administrator was observed not wearing a mask when entering the office and greeting surveyors. Additionally, a PCA in the living area was not wearing a mask as required by facility policy.

The Administrator was seated at a table with others without maintaining the required six feet of distance. There were also instances where two residents were seated at the same table without adequate distance between them.

The facility failed to consistently ensure that all visitors and staff were screened for COVID-19 symptoms and temperature at the beginning of each shift or upon entry. Documentation for outside workers' screening was also noted as being inaccessible to the Administrator.

The facility failed to ensure residents were free from neglect related to infection control during the COVID-19 pandemic. Specifically, staff members, including a Personal Care Aide, a Medication Aide, and the Administrator, were observed not wearing masks and failing to perform required temperature checks or symptom screenings upon entry.

The facility failed to ensure residents were free from neglect related to infection control during the COVID-19 pandemic. Specifically, staff members, including a Personal Care Aide, a Medication Aide, and the Administrator, were observed not wearing masks and failing to perform required temperature checks or symptom screenings upon entry.

The facility failed to ensure at least one staff person on the premises at all times had completed CPR and choking management training within the last 24 months. Specifically, three out of four sampled staff members were found to have expired or missing CPR documentation, and the master schedule showed no staff on duty with valid training during the third shift on 12/02/19.