Inspection Reports for
The Grandview Nursing and Rehabilitation Facility
640 WATER TOWER BYPASS, CAMPBELLSVILLE, KY, 42719
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program compliance, including adherence to CDC guidelines and facility policies related to enhanced barrier precautions and transmission-based precautions.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, with multiple staff observed not properly donning or doffing PPE and failing to perform hand hygiene as required. Several staff members, including nursing aides and housekeeping, demonstrated lack of understanding or adherence to infection control policies, posing potential cross-contamination risks.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff were observed not wearing required PPE and not performing hand hygiene when entering or exiting rooms under contact or enhanced barrier precautions.
Report Facts
Residents sampled: 39
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Trained Nursing Aide (STNA) 1 | Observed failing to don PPE and perform hand hygiene in contact and EBP rooms | |
| State Trained Nursing Aide (STNA) 2 | Observed making bed without PPE and unable to explain EBP direct care tasks | |
| Housekeeper (HSK) 2 | Observed improper handling of contaminated trash bags and failure to perform hand hygiene | |
| Registered Nurse (RN) 3 | Observed performing blood glucose fingerstick without donning gown in EBP room | |
| Housekeeping Supervisor (HS) | Provided information on housekeeping staff training and expectations | |
| Infection Preventionist (IP) | Provided expectations and information on infection control audits and training | |
| Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC) | Provided information on staff education and training on infection control | |
| Administrator | Stated expectations for staff adherence to infection control policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 12, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding resident-to-resident abuse involving Resident #284 and Resident #286 on 08/19/2023.
Complaint Details
The complaint investigation substantiated that Resident #284 physically abused Resident #286 on 08/19/2023. The facility conducted a thorough investigation including interviews with witnesses and staff, confirming the incident occurred. Resident #284 was placed on increased monitoring following the incident.
Findings
The facility failed to protect Resident #286 from physical abuse by Resident #284. The incident was witnessed by staff and verified by the facility's investigation, which included interviews and review of care plans and progress notes.
Deficiencies (1)
F 0600: The facility failed to protect Resident #286 from physical abuse perpetrated by Resident #284 on 08/19/2023. The incident involved hitting and kicking and was witnessed by multiple staff members.
Report Facts
Residents reviewed for abuse: 7
Residents affected: 1
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Director of Nursing | Provided interview details about the incident and facility response |
| Kentucky Medication Aide #21 | Witnessed the altercation and notified Licensed Practical Nurse | |
| Licensed Practical Nurse #23 | Notified about the incident by KMA #21 | |
| State Registered Nursing Assistant #24 | Witnessed the altercation and provided interview | |
| Administrator | Provided interview about incident and policy expectations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
The inspection was conducted to investigate complaints related to resident-to-resident abuse and failure to address pharmacy recommendations in a timely manner.
Complaint Details
The complaint investigation substantiated that Resident #286 was physically abused by Resident #284 on 08/19/2023. The facility's investigation confirmed the incident occurred and that staff followed abuse policies. Additionally, the investigation found delays in addressing a pharmacy recommendation for Resident #34, with the physician responding over two months late and staff delaying implementation of the order.
Findings
The facility failed to protect one resident from physical abuse by another resident and failed to ensure timely physician response and implementation of a pharmacy recommendation for unnecessary medications for one resident. Both incidents were verified through interviews, record reviews, and facility documentation.
Deficiencies (2)
F 0600: The facility failed to protect Resident #286 from physical abuse by Resident #284 on 08/19/2023 despite policies and monitoring. The incident was witnessed and verified by staff.
F 0756: The facility failed to ensure a pharmacy recommendation for Resident #34 was addressed by the physician in a timely manner and failed to implement the physician's order promptly, resulting in delayed medication adjustment.
Report Facts
Residents reviewed for abuse: 7
Residents reviewed for unnecessary medications: 5
BIMS score Resident #284: 3
BIMS score Resident #286: 5
BIMS score Resident #34: 15
Date of abuse incident: Aug 19, 2023
Date of pharmacy recommendation: Oct 2, 2023
Date physician responded: Dec 8, 2023
Date medication order changed: Dec 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Director of Nursing (DON) | Named in abuse incident investigation and staff supervision |
| Kentucky Medication Aide #21 | Witnessed resident-to-resident abuse incident | |
| State Registered Nursing Assistant #24 | Witnessed resident-to-resident abuse incident | |
| Licensed Practical Nurse #23 | Notified about resident-to-resident abuse incident | |
| Administrator | Interviewed regarding abuse incident and pharmacy recommendation process | |
| Medical Provider for Resident #34 | Interviewed regarding pharmacy recommendation and medication orders |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 25, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements including resident rights, care planning, fall prevention, medication management, catheter care, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during feeding, incomplete and untimely revisions of comprehensive care plans after falls and re-admissions, inadequate supervision to prevent falls, improper medication storage and administration, failure to properly assess and care for residents with indwelling urinary catheters, and failure to maintain food service sanitation standards including dish machine temperature documentation and dust accumulation in the kitchen.
Deficiencies (5)
F 0550: The facility failed to ensure residents were treated with dignity during feeding; a staff member stood over a resident while feeding instead of sitting at eye level.
F 0657: The facility failed to revise the comprehensive care plan timely for three residents after falls and re-admission, missing interventions to prevent further falls and to manage indwelling catheter care.
F 0689: The facility failed to provide adequate supervision to prevent accidents for three residents who sustained falls while unsupervised, and failed to thoroughly investigate and revise care plans accordingly.
F 0690: The facility failed to ensure appropriate care and assessment for a resident with an indwelling urinary catheter, including lack of documented indication, ongoing care, removal criteria, and monitoring for infection.
F 0812: The facility failed to maintain food safety standards by not documenting dish machine temperatures consistently and allowing dust accumulation on a fan and ceiling in the kitchen area.
Report Facts
Dish machine temperature missing documentation: 13
Residents sampled: 22
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #5 | State Registered Nurse Aide | Named in dignity issue during feeding of Resident #4 |
| LPN #3 | Licensed Practical Nurse | Responsible for care plan revisions and assessments related to falls and catheter care |
| Director of Nursing | Director of Nursing | Provided expectations for care plan revisions, catheter care, and fall management |
| Administrator | Administrator | Provided expectations for nursing staff compliance with care plan and fall management policies |
| KMA | Kentucky Medication Aide | Provided statements on feeding dignity and catheter care |
| Dietary Aide #3 | Dietary Aide | Provided statements on dish machine temperature documentation and dust contamination risk |
| Certified Medical Assistant #9 | Certified Medical Assistant | Provided statements on feeding dignity and medication storage |
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