Sun Health Grandview Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records review, resident and staff interviews, and policy review, the facility failed to ensure that medications were not left at the resident's bedside for 2 of 61 sampled residents (#36, #39). The deficient practice could result in the overmedication or undermedication of residents.-Regarding Resident #36Resident #36 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, unspecified fall, acute post hemorrhagic anemia, and hypotension.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicating intact cognition.During an initial observation of Resident #36's room on July 29, 2025 at 1:40 p.m., a container of Refresh lubricant eye drops 0.5 fl oz (fluid ounce) medication was observed lying on the resident's bedside table.Review of provider orders, revealed no evidence of orders for the Refresh lubricant eye drops. An interview was conducted on July 29, 2025, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure two (#21 and #104) of 61 sampled residents' privacy was respected.Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, urinary tract infection, and unspecified dementia. The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 4 indicating the resident severe cognitive impairment. The care plan dated July 17, 2025 revealed that resident #21 has impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions included to ask yes/no questions in order to determine the resident's needs and present just one thought, idea, question or command at a time. -Resident #104 was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included acute kidney failure, chronic kidney disease, and sepsis due to escherichia. The MDS dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure proper infection control was followed and maintained regarding placement of the catheter bag for one of 1 sampled residents (#23). The deficient practice could result in development and transmission of infections.Findings include:Resident #23 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure, retention of urine, type 2 diabetes mellitus with a foot ulcer, and depression.The admission minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident had intact cognition. The assessment also included that the resident had an indwelling catheter.The foley catheter care plan initiated on July 6, 2025, included interventions to maintain a closed drainage system with the drainage bag lower than the bladder at all times and on a privacy bag.During an interview with Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored in accordance with appropriate temperature guidelines for facility refrigerators and the kitchen freezer. The universe was 57. The deficient practice could increase the risk for foodborne illness. Findings include: An observation was conducted on July 29, 2024 at approximately 7:40 A.M on the third floor of the facility. The refrigerator temperature log identified with the location of Canyon revealed that on July 22, 2024, the refrigerator had a temperature of 44 degrees Fahrenheit at 8:00 A.M. Per the temperature log, there was not documented evidence that any corrective action had taken place or that the manager had reviewed the temperature log for that day. A further review of refrigerator temperature logs, revealed that for the Red Rock location on July 7, 2024 and July 20, 2024 the refrigerator was outside of designated parameters. The temperature noted for July 7, 2024 at 4:28 P.M. was noted to be 45 degrees Fahrenheit and the temperature noted on July 20, 2024 at 4:31 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a Discharge Minimum Data Set (MDS) assessment within the required timeframe for Resident # 11. The deficient practice could result in delayed identification of potential risks and care needs of the residents. Findings include: Resident # 11 was admitted into the facility on February 24, 2024 at 09:05 PM with diagnoses that included atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, acute respiratory failure with hypoxia, and unspecified chronic kidney disease. Review of the MDS assessment history, revealed an Admissions MDS Assessment was completed and accepted March 01, 2024. Resident # 11 was discharged on March 09, 2024 at 11:00 AM; however, medical records revealed no discharge MDS was completed at this time. An interview was conducted on July 30, 2024 at 08:55 AM with MDS Coordinator (Staff #970) who stated the MDS Coordinator role was to complete admission entry records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that a physician order for the use of a foley catheter was in place for one resident (#20). The sample size was 15. The deficient practice could result in inappropriate use of a catheter. Findings include: Resident #20 was admitted on [DATE] with diagnosis including sepsis, UTI (urinary tract infection), klebsiella pneumoniae, hypertension and hypothyroidism. A review of the admission MDS (minimum data set) dated July 24, 2024 revelaed that resident #20 had a BIMS (brief interview of mental score) of 14, suggesting that the resident was cognitively intact. A review of the physician orders in the electronic health records revealed no evidence of a physician order for a catheter or catheter care. A review of the TAR (treatment administration record) since admission of the resident, revealed no evidence of an order for catheter care or that catheter care was being tracked or that input or output were being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, interviews and policies and procedures, the facility failed to ensure one resident was appropriately supervised to prevent a fall with major injury. The deficient practice can contribute to residents being injured during a fall. Resident #19 was admitted to the facility December 7, 2023 and discharged to the hospital December 17, 2023. Resident #19 was re-admitted to the facility December 21, 2023 with diagnoses to include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, transient cerebral ischemic attack, unspecified, weakness. The MDS (minimum data set) dated December 13, 2023 indicate a brief interview for mental status was conducted revealing a BIMS score of 15suggesting resident is cognitively intact. The resident was assessed to be partial to moderate assist with upper dressing, substantial to maximal assist with lower dressing and partial to moderate assist with sit to stand and with toilet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical review, staff interviews, and the facility policy and procedures, the facility failed to update the fall care plan for one resident (#13). The deficient practice could result in more falls. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis, dementia, cellulitis of left lower limb, and muscle weakness. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident needed a two-person extensive assist with bed mobility, transfers, and toileting and a one-person extensive assist with locomotion on the unit. Review of the fall risk assessment dated [DATE] revealed that the resident's last fall was on July 1, 2023 and was a high risk for falls. The care plan dated July 7, 2023 revealed the resident was at risk for falls related to recent and history of falls, left hip pain, her left leg is shorter than the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, interviews, and policies, the facility failed to ensure skin assessment was conducted as ordered by the physician for one resident (#1). The deficient practice could result in skin issues not identified and treated as appropriate. Findings include: Resident #1 was admitted on [DATE] with diagnoses of unilateral primary osteoarthritis, cognitive communication deficit, and type 2 diabetes. An undated care plan included that the resident was at risk for skin breakdown and poor skin integrity related to limited mobility. The goal was for the resident to maintain skin integrity and resident's problematic areas will improve or be healed. Interventions included to monitor for and report all red areas. A physician orders dated October 14, 2022 included the following: -Braden Scale Risk Assessment every one week for four weeks; -Braden Scale Risk Assessment quarterly and as needed; and, -Weekly skin assessment. Review of the admission Minimum Data Set (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.