Deficiencies (last 5 years)
Deficiencies (over 5 years)
17.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
412% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
94% occupied
Based on a August 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 29, 2025
Visit Reason
An off-site desk audit was conducted on September 29, 2025, to review all previous deficiencies cited on August 21, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted following a community complaint alleging that the facility failed to accept back a resident who was appealing a discharge and did not ensure the resident's right to return pending the appeal.
Complaint Details
The complaint alleged that Resident ID #2 was admitted to the hospital but the facility would not accept the resident back. An appeal was filed for an eviction notice issued on July 18th, and the family believed the resident could not be discharged during an active appeal. The resident was discharged on 7/29/2025 and did not return while appealing. The facility could not provide evidence that the resident's right to return pending appeal was provided.
Findings
The facility failed to ensure that residents appealing a discharge remain or return to the facility pending their appeal. Specifically, Resident ID #2 was discharged and did not return despite an active appeal, and the facility could not provide evidence that the resident's right to return was honored.
Deficiencies (1)
Failed to ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Report Facts
Dates related to discharge and appeal: Eviction notice issued July 18, 2025; appeal requested July 28, 2025; resident discharged July 29, 2025; hospital documentation dated August 2, 2025; facility census reviewed September 9, 2025.
Recertification period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on 9/9/2025 acknowledging the resident's discharge notice, appeal, and failure to return to the facility. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
A complaint survey was conducted at Grandview Center on 09/09/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, based on complaints submitted to the Rhode Island Department of Health.
Complaint Details
The complaint alleged that Resident ID #2 was admitted to the hospital and Grandview Center would not accept the resident back. The complainant stated there was no ramp and no help available. The complaint also alleged an eviction notice was issued while the resident was in active appeal. The family was under the impression the resident could not be discharged during appeal and did not have appropriate time to resolve Medicaid issues. The resident was discharged and admitted to an acute care hospital on 7/29/2025. The facility failed to provide evidence that the resident returned to the facility during the appeal process.
Findings
The facility was found deficient for inappropriate discharge practices, specifically failing to ensure that residents appealing a discharge remain or return to the facility pending appeal. The complaint involved Resident ID #2, who was discharged despite an active appeal and the facility's refusal to accept the resident back.
Deficiencies (1)
Inappropriate discharge of a resident who was appealing the discharge, failing to ensure the resident remained or returned to the facility pending appeal.
Report Facts
Date of survey: Sep 9, 2025
Date of discharge notice: Jul 18, 2025
Date of hospital admission: Jul 29, 2025
Date of Medicaid cancellation: Jul 9, 2025
Date of recertification form: Jul 15, 2025
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with professional standards of care, medication administration, wound care, drug regimen appropriateness, food service safety, and infection control in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to notify providers of resident medication refusals, inadequate pressure ulcer care, administration of unnecessary drugs, unsafe food service practices, and lack of an effective antibiotic stewardship program.
Deficiencies (5)
Failure to ensure residents receive treatment and care in accordance with professional standards related to medication refusals for Resident ID #5, including lack of provider notification.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident ID #55, including inadequate pain management and improper wound cleansing.
Failure to ensure the resident's drug regimen is free from unnecessary drugs for Resident ID #19, including administration of Lovenox after it should have been discontinued.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including black matter on ice machine and lack of proper air gap in plumbing.
Failure to implement an antibiotic stewardship program including lack of antibiotic time outs for Residents ID #20, #22, and #36.
Report Facts
Medication refusal dates: 20
Pressure ulcer size: 4
Lovenox unnecessary doses: 2
Antibiotic orders reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Technician (CMT) | Interviewed regarding medication refusal notification process |
| Staff B | Registered Nurse | Interviewed regarding medication refusal notification and documentation |
| Staff C | Nurse Practitioner | Interviewed regarding awareness of medication refusals |
| Staff D | Physician | Authored progress note acknowledging medication refusals |
| Staff E | Licensed Practical Nurse (LPN) | Observed and interviewed regarding wound care and pain management |
| Staff F | Registered Nurse | Observed wound care, administered Lovenox doses, and interviewed regarding medication administration and wound care |
| Staff G | Resident's Provider | Interviewed regarding expectations for discontinuing Lovenox |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding medication refusal notification, wound care standards, and Lovenox administration |
| Food Service Director (FSD) | Food Service Director | Interviewed regarding kitchen sanitation and ice machine cleaning |
| Maintenance Director | Maintenance Director | Interviewed regarding plumbing fixture air gap in kitchen |
| Infection Preventionist | Infection Preventionist | Interviewed regarding antibiotic stewardship program and antibiotic time outs |
Inspection Report
Annual Inspection
Census: 68
Capacity: 72
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The annual Federal Life Safety Code survey and recertification survey were conducted at Grandview Center to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Findings
Deficiencies were identified related to medication administration refusals, pressure ulcer care, unnecessary drug use, food safety, and antibiotic stewardship. The facility provided plans of correction including staff re-education, audits, and monitoring to address these issues. No Life Safety Code deficiencies were found.
Deficiencies (5)
Failure to ensure residents receive treatment and care in accordance with professional standards for medication refusals.
Failure to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards.
Failure to ensure residents' drug regimens are free from unnecessary drugs.
Failure to store, prepare, distribute, and serve food in accordance with professional standards for food safety.
Failure to establish an infection prevention and control program including antibiotic stewardship.
Report Facts
Census: 68
Total Capacity: 72
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 68
Capacity: 72
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
A recertification survey and state licensure survey were conducted at Grandview Center from 08/18/2025 through 08/21/2025 to determine compliance with 42 C.F.R. Part 483, including licensure and emergency preparedness requirements.
Findings
Multiple deficiencies were identified including failure to meet professional standards in medication administration and refusal documentation, inadequate treatment and prevention of pressure ulcers, failure to ensure drug regimens were free from unnecessary drugs, food safety violations, and failure to establish an effective antibiotic stewardship program. No life safety code deficiencies were found.
Deficiencies (5)
Failure to ensure residents receive treatment and care in accordance with professional standards, specifically related to medication refusals documentation for Resident ID #5.
Failure to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing and prevent infection, Resident ID #55.
Failure to ensure the drug regimen is free from unnecessary drugs, including anticoagulant monitoring for Resident ID #19.
Failure to store, prepare, distribute, and serve food in accordance with professional food safety standards.
Failure to establish an infection prevention and control program including an antibiotic stewardship program to monitor antibiotic use for Residents #20, 22, and 36.
Report Facts
Capacity: 72
Census: 68
Medication refusal dates: 20
Pressure ulcer size: 4
Pressure ulcer size: 8.4
Pressure ulcer size: 0.1
Medication doses: 3
Inspection Report
Deficiencies: 3
Date: May 7, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, specifically regarding the use of borrowed medications and accurate documentation in the narcotic count book for two residents.
Findings
The facility failed to ensure professional standards of quality related to borrowing medications between residents and inaccurate narcotic documentation. Specifically, Lorazepam Intensol was borrowed from Resident #2 for Resident #3 due to a pharmacy backorder, and the narcotic count book contained transcription errors and incomplete documentation.
Deficiencies (3)
Use of borrowed medications between residents, violating facility policy.
Inaccurate and incomplete documentation in the narcotic count book.
Physician's order entered incorrectly as subcutaneous instead of sublingual.
Report Facts
Medication volume: 30
Medication volume: 15
Medication administration times: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, Staff A | Interviewed regarding transcription error and borrowing medication | |
| Staff Educator, Staff B | Interviewed acknowledging medication borrowing and documentation errors |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
An off-site desk audit was conducted on September 9, 2024, to review all previous deficiencies cited on July 30, 2024, and August 1, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Deficiencies: 10
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, and quality of services at Grandview Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely one-to-one feeding assistance, inadequate monitoring of residents on anticoagulant therapy, lack of trauma informed care assessment, failure to provide appropriate adaptive eating equipment, inadequate supervision during resident transfers, failure to maintain and date oxygen tubing, and failure to provide activities consistent with resident preferences.
Deficiencies (10)
Failed to provide timely one-to-one feeding assistance for residents requiring supervision or assistance with eating.
Failed to monitor and assess residents on anticoagulant therapy for signs and symptoms of bleeding as outlined by the comprehensive care plan.
Failed to provide an ongoing program to support a resident's choice of activities based on assessment and preferences.
Failed to ensure a resident received proper treatment to maintain hearing abilities, including follow-up after a cancelled ear wax removal appointment.
Failed to provide adequate supervision to prevent accident hazards during transfers requiring two staff members.
Failed to provide respiratory care consistent with professional standards, including failure to change and date oxygen tubing and use clean equipment.
Failed to provide trauma informed care assessment to identify triggers related to PTSD for a resident.
Failed to ensure a resident's drug regimen was free from unnecessary drugs by administering medication outside of ordered parameters.
Failed to provide special adaptive eating equipment (divided lip plate) for a resident with one-sided weakness.
Failed to implement an effective Quality Assurance and Performance Improvement program to monitor and evaluate oxygen tubing changes and dating.
Report Facts
Medication administration outside parameters: 20
Oxygen tubing change dates: Oxygen tubing bags dated 5/28 and 6/30 found in use on 7/31/2024.
Observation times of delayed feeding assistance: Resident #16 observed waiting 18-23 minutes after meal tray delivery before receiving feeding assistance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged lack of monitoring for anticoagulant therapy bleeding signs and oxygen tubing issues. |
| Staff B | Licensed Practical Nurse | Unable to provide evidence of monitoring for anticoagulant therapy for residents #41 and #373. |
| Staff C | Nurse Practitioner | Expected hearing difficulty of resident #10 to be addressed. |
| Staff D | Nursing Assistant | Transferred resident #9 alone despite order for two staff assistance. |
| Staff E | Nursing Assistant | Unaware resident #9 required divided lip plate. |
| Director of Nursing Services | Director of Nursing Services | Acknowledged multiple deficiencies including feeding assistance delays, oxygen tubing issues, lack of trauma informed care assessment, and medication administration outside parameters. |
| Lead Clinical Specialist | Lead Clinical Specialist | Acknowledged lack of monitoring and evaluation program for oxygen orders and tubing. |
| Recreational Director | Recreational Director | Acknowledged failure to provide activities consistent with resident #27's preferences. |
Inspection Report
Re-Inspection
Census: 68
Capacity: 72
Deficiencies: 11
Date: Aug 1, 2024
Visit Reason
A Recertification Survey and complaint survey were conducted at Grandview Center from 7/29/2024 through 8/1/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Complaint Details
The survey included a complaint investigation as part of the recertification survey, but specific substantiation status is not stated.
Findings
Deficiencies were cited related to resident rights, comprehensive care plans, activities, treatment to maintain hearing/vision, free of accident hazards, drug regimen, assistive devices, oxygen therapy, trauma informed care, and life safety code violations. Facility-wide audits and staff education plans were implemented to address these deficiencies.
Deficiencies (11)
Facility failed to treat residents with respect and dignity and failed to provide assistance with eating for residents requiring supervision or one-to-one assistance.
Facility failed to monitor and assess anticoagulant therapy for residents receiving blood thinners.
Facility failed to provide an ongoing program to support resident activities based on preferences and assessments.
Facility failed to ensure residents received proper treatment and assistive devices to maintain hearing and vision.
Facility failed to provide adequate supervision and assistance to prevent accident hazards for residents requiring assistance with transfers.
Facility failed to provide respiratory care consistent with professional standards including proper oxygen tubing labeling and monitoring.
Facility failed to ensure trauma informed care for a resident with PTSD.
Facility failed to ensure drug regimen was free from unnecessary drugs and monitored medication administration parameters.
Facility failed to provide special adaptive eating equipment and utensils for residents requiring them.
Facility failed to maintain effective quality assessment and performance improvement systems.
Facility failed to maintain minimum 18-inch clearance between sprinkler head and stored combustible materials in linen closet.
Report Facts
Census: 68
Total Capacity: 72
Residents reviewed for anticoagulant therapy: 6
Residents reviewed for medication regimen: 1
Residents reviewed for respiratory care: 3
Residents reviewed for accident hazards: 1
Residents reviewed for trauma informed care: 1
Residents reviewed for adaptive eating equipment: 1
Residents reviewed for activities: 1
Residents reviewed for hearing/vision: 1
Residents reviewed for medication administration: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela R. Holbert | Administrator | Signed multiple pages of the report |
| Staff A | Licensed Practical Nurse | Interviewed regarding resident assistance and monitoring |
| Staff B | Licensed Practical Nurse | Interviewed regarding anticoagulation therapy monitoring |
| Staff C | Nurse Practitioner | Interviewed regarding hearing difficulty |
| Staff D | Nursing Assistant | Interviewed regarding resident transfers |
| Staff E | Nursing Assistant | Interviewed regarding resident feeding assistance |
| Director of Nursing Services | Interviewed regarding meal assistance and hearing loss follow-up | |
| Lead Clinical Specialist | Interviewed regarding anticoagulant therapy and oxygen therapy | |
| Recreational Director | Interviewed regarding resident activity preferences | |
| Maintenance Director | Interviewed regarding life safety code deficiency |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
An off-site desk audit was conducted on September 13, 2023, to review all previous deficiencies cited on August 4, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, the deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
A complaint investigation was conducted at the facility on 09/12/2023 to determine compliance with Federal and State Laws and Regulations.
Complaint Details
Complaint investigation, ACTS reference number 91993, conducted to determine compliance; no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigation.
Inspection Report
Routine
Deficiencies: 5
Date: Aug 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, treatment, and facility operations at Grandview Center.
Findings
The facility was found deficient in multiple areas including failure to develop baseline care plans for communication needs, failure to ensure continuous use of supplemental oxygen as ordered, failure to provide transportation for a scheduled orthopedic follow-up appointment, inadequate pressure ulcer care, and improper food temperature control during meal service.
Deficiencies (5)
Failed to develop and implement a baseline care plan within 48 hours of admission for communication needs for Resident ID #62.
Failed to ensure services met professional standards of quality related to physician's orders for continuous supplemental oxygen use for Resident ID #12.
Failed to provide appropriate treatment and care according to orders and resident preferences, including failure to arrange transportation for orthopedic follow-up for Resident ID #62.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident ID #59, including improper use of pressure redistribution mattress.
Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards, with cold food items served above acceptable temperature limits during lunch meal service.
Report Facts
Deficiencies cited: 5
Oxygen order date: Oct 24, 2022
Post operative follow-up appointment date: Aug 1, 2023
Wound management review dates: Jul 24, 2023
Wound management review dates: Jul 31, 2023
Cold holding temperature: 49.1
Cold holding temperature: 47.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged resident only speaks Creole and was unsure of air mattress setting |
| Staff B | Registered Nurse | Acknowledged resident was not using oxygen continuously as ordered |
| Staff C | Registered Nurse | Acknowledged resident had orthopedic appointment and was unable to provide evidence resident attended |
| Director of Nursing Services | Acknowledged communication needs, oxygen order noncompliance, missed orthopedic appointment, and improper air mattress use | |
| Food Service Director | Acknowledged cold holding temperatures were not within acceptable range |
Inspection Report
Renewal
Deficiencies: 5
Date: Aug 4, 2023
Visit Reason
A Recertification Survey was conducted at Grandview Center from 08/01/2023 through 08/04/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited as a result of the survey related to baseline care planning, services meeting professional standards, quality of care, treatment and services to prevent pressure ulcers, and food safety requirements. Specific failures included lack of timely baseline care plans, inadequate communication plans for residents, failure to ensure oxygen therapy orders were followed, insufficient treatment for pressure ulcers, and improper food temperature controls.
Deficiencies (5)
The facility failed to develop and implement a baseline care plan within 48 hours of admission for identified communication concerns and instructions for effective person-centered care.
The facility failed to provide services that meet professional standards of quality related to physician's orders for supplemental oxygen use.
The facility failed to ensure residents receive treatment and care in accordance with professional standards for an orthopedic follow-up appointment and transportation.
The facility failed to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards to promote healing and prevent infection.
The facility failed to ensure food safety requirements were met, including maintaining cold food temperatures within acceptable ranges during meal service.
Report Facts
Date survey completed: Aug 4, 2023
Dates of oxygen use observation: 4
Number of residents reviewed for baseline care plan deficiency: 1
Number of residents reviewed for oxygen use deficiency: 1
Number of residents reviewed for pressure ulcer deficiency: 1
Number of cold food temperature observations out of range: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela R. Ideburt | Administrator | Signed the report and plan of correction on 8/24/23 |
| Staff A | Licensed Practical Nurse | Interviewed regarding resident communication and oxygen use |
| Staff B | Registered Nurse | Interviewed regarding resident oxygen use |
| Staff C | Registered Nurse | Interviewed regarding resident post-operative appointment |
| Director of Nursing Services | Interviewed regarding resident communication, oxygen use, and follow-up appointment | |
| Food Service Director | Interviewed regarding food temperature compliance |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition.
Findings
The facility failed to maintain a minimum 18-inch clearance between the sprinkler deflector and the top of storage in the activity storage room and basement, which could affect all 67 residents and an undetermined number of visitors and staff. The Maintenance Director acknowledged the deficiency during the survey.
Deficiencies (1)
Failed to maintain a minimum 18-inch clearance between the sprinkler deflector and the top of storage in accordance with NFPA 13 2010 edition Section 8.5.6.1 and NFPA 101 2012 edition.
Report Facts
Residents potentially affected: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela R. Hebard | Administrator | Signed the report and noted in relation to the deficiency |
| Maintenance Director | Acknowledged the deficiency during surveyor interview |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to wound treatment, pressure ulcer prevention, and nutritional status for residents at the facility.
Findings
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident, did not consistently follow physician orders for wound dressing and heel offloading, and failed to maintain acceptable nutritional parameters by not addressing significant weight loss or notifying the physician or dietitian.
Deficiencies (4)
Failure to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for Resident ID #1.
Failure to follow physician's order for wound dressing application, including incorrect use of Maxorb dressing.
Failure to offload heels with heel offloading boots as ordered, causing discomfort to the resident.
Failure to maintain acceptable nutritional status due to significant weight loss without notifying physician or dietitian or implementing interventions.
Report Facts
Weight loss: 5.1
Weight loss: 10
Pressure ulcer measurement: 1.6
Pressure ulcer measurement: 2.11
Pressure ulcer measurement: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in findings related to wound dressing and heel offloading failures |
| Director of Nursing Services | Interviewed regarding expectations for following physician orders and lack of evidence for notification or interventions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 4, 2023
Visit Reason
The inspection was conducted following a community-reported complaint alleging that a diabetic resident was hospitalized due to a very low blood sugar level and that the facility failed to prevent significant medication errors related to insulin administration and hypoglycemia management.
Complaint Details
The complaint alleged that Resident ID #1 was hospitalized for very low blood sugar in the 20's upon arrival at the hospital. The investigation confirmed the resident's blood glucose was critically low, insulin was administered inappropriately, and the hypoglycemia protocol was not followed.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically administering insulin to a resident with a critically low blood glucose level of 45 MG/DL, not following the hypoglycemia protocol, and inaccurate medical record documentation regarding glucagon administration. The resident was hospitalized with severe hypoglycemia. Staff interviews confirmed failures in medication administration, communication with the physician, and documentation.
Deficiencies (2)
Facility failed to ensure residents are free from significant medication errors, including administering insulin when blood glucose was critically low.
Facility failed to maintain accurate medical records, including inaccurate documentation of glucagon administration after the resident was hospitalized.
Report Facts
Blood glucose level: 45
Insulin dose: 20
Insulin dose administered: 10
Glucagon injections: 2
Blood glucose level: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administered insulin at low blood glucose level and failed to follow hypoglycemia protocol |
| Staff B | Registered Nurse | Administered glucagon injections and inaccurately documented medication administration |
| Medical Director | Provided orders to send resident to hospital and confirmed no instructions were given to administer insulin at low blood glucose | |
| Director of Nursing Services | Unable to explain failures in medication administration and documentation | |
| Administrator | Unable to explain failures in medication administration and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's right to refuse medication and failure to notify the physician when medication was refused.
Complaint Details
The complaint investigation found substantiated failure to honor the resident's right to refuse medication and failure to notify the physician of medication refusals for Resident ID #1.
Findings
The facility failed to honor the right of Resident ID #1 to refuse insulin medication, as staff administered the medication against the resident's will. Additionally, the facility failed to notify the physician of multiple instances when the resident refused medication, violating professional standards of quality.
Deficiencies (2)
Failed to honor the resident's right to refuse medication for 1 of 3 residents reviewed.
Failed to notify the physician when medication was refused for 1 of 3 residents reviewed.
Report Facts
Medication refusal dates: 9
Medication administration time: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administered insulin to resident against resident's refusal on 4/11/2023 |
| Director of Nursing Services | Interviewed and stated expectation that resident's right to refuse medication be honored and physician notified | |
| Medical Director | Interviewed and acknowledged resident's right to refuse medication and expectation to be notified of refusals |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 7, 2023
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2023-02-06 alleging issues with a resident's access to a telephone, meal assistance, oxygen therapy documentation, and infection control related to a pressure wound.
Complaint Details
The complaint alleged that a resident's phone was placed out of reach, staff were not taking time to feed the resident, oxygen therapy was not properly documented, and a bedsore was not improving due to inadequate infection control.
Findings
The facility failed to ensure a resident had reasonable access to a telephone, accurately document meal consumption, properly label and document oxygen therapy, and follow infection prevention protocols during incontinence care, resulting in minimal harm or potential for actual harm to a few residents.
Deficiencies (4)
Failed to ensure a resident had reasonable access to the use of a telephone; the phone was placed out of reach despite a posted sign indicating it should be within reach.
Failed to maintain accurate medical records regarding meal consumption; documented intake did not match observed intake.
Failed to label oxygen tubing with date and time of initial set-up and to document oxygen administration on the Treatment Administration Record as required.
Failed to follow infection prevention protocols during incontinence care; staff wiped from rectal area to genital area, placed soiled washcloth with visible fecal matter on resident's over the bed table, and did not clean or disinfect the table afterward.
Report Facts
Observation times: 7
Oxygen therapy documented dates: 6
Meal consumption documented percentage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Staff A | Licensed Practical Nurse | Acknowledged that the resident's phone was out of reach and that the oxygen tubing was not labeled; also indicated that meal consumption documentation was inaccurate |
| Director of Nursing Services | Director of Nursing Services | Unable to provide evidence that the resident's right to reasonable telephone access was honored; expected accurate meal documentation and proper oxygen therapy documentation; expected staff to perform incontinence care per protocol |
| Nursing Assistant Staff B | Nursing Assistant | Observed performing incontinence care incorrectly by wiping from rectal area to genital area, placing soiled washcloth on over the bed table, and not disinfecting the table |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
A Federal Infection Control Survey was conducted at Grandview Nursing Home on 12/13/2022.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 25, 2022
Visit Reason
An off-site desk audit was conducted on July 25, 2022, to review all previous deficiencies cited on June 29, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Deficiencies: 5
Date: Jun 29, 2022
Visit Reason
A Recertification Survey, vaccination compliance, and complaint investigation survey were conducted from 06/27/2022 through 06/29/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Complaint Details
Complaint investigation was part of the survey process as noted in the initial comments and throughout the findings, including failure to follow physician orders and infection control issues.
Findings
Deficiencies were cited related to comprehensive care plans, medication storage and labeling, food safety and sanitation, infection prevention and control, and proper use of personal protective equipment (PPE). Specific issues included failure to follow physician orders for offloading boots, expired medications, improper food storage, and inadequate infection control practices.
Deficiencies (5)
Failure to assure services meet professional standards of quality for 1 of 5 residents reviewed for pressure relieving devices.
Failure to store medications in accordance with accepted professional principles for 2 of 4 medication storage carts and 1 of 2 medication storage rooms.
Expired medications found in medication storage areas.
Failure to properly store food under sanitary conditions in main kitchen and 1 of 2 kitchenettes.
Failure to establish and maintain an infection prevention and control program including proper PPE use and disinfection of equipment.
Report Facts
Survey dates: 3
Expired medication counts: 13
Medication storage carts inspected: 4
Medication storage rooms inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela R. Webster | Administrator | Signed multiple pages of the report |
| Staff A | Observed during survey related to offloading boots | |
| Director of Nursing | Director of Nursing | Named in education and audit plans for offloading boots and medication storage |
| Staff B | Observed doffing PPE incorrectly during infection control survey | |
| Staff C | Observed exiting COVID positive room without mask change | |
| Staff D | Observed wearing N-95 mask with only one strap | |
| Staff E | Housekeeping Supervisor | Observed wearing N-95 mask with only one strap |
| Staff F | Medication Aide | Observed with mask pulled down and acknowledged mask should cover nose and mouth |
| Staff G | Unit Manager who provided education on PPE use |
Inspection Report
Re-Inspection
Deficiencies: 18
Date: May 3, 2021
Visit Reason
A Recertification Survey was conducted at Grandview Center from 04/26/2021 through 04/29/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
The facility was found not in compliance with several regulatory requirements including advance directives, comprehensive care plans, professional standards of care, pressure ulcer prevention, accident hazard supervision, medication administration, infection control, and drug regimen review. Corrective actions and re-education plans were outlined for each deficiency.
Deficiencies (18)
Failure to ensure the resident's formulated advance directive was followed due to inconsistency between paper medical record and EMR for Resident #244.
Failure to develop and implement a comprehensive person-centered care plan for residents, including catheterization status and anticoagulant use.
Failure to meet professional standards of quality for nursing services related to physician orders and resident weights.
Failure to provide necessary treatment and services to prevent pressure ulcers for Resident #196.
Failure to ensure each resident environment remains free of accident hazards and adequate supervision for Resident #32.
Failure to ensure residents who require catheterization receive appropriate catheterization services and documentation for Resident #194.
Failure to provide appropriate treatment and services for residents fed by feeding tubes to prevent complications for Resident #196.
Failure to provide routine and emergency drugs and biologicals according to professional standards and facility policies.
Failure to maintain accurate records of receipt and disposition of controlled drugs and provide routine medications for Resident #254.
Failure to ensure drug regimen review was conducted and free from unnecessary drugs for residents including Resident #32 and #254.
Failure to properly label and store drugs and biologicals, including expired medications and opened medication carts.
Failure to properly store and label medications in medication storage rooms and carts.
Failure to properly store and discard expired medications and maintain medication cart integrity.
Failure to maintain infection prevention and control program including PPE use and screening for tuberculosis.
Failure to ensure residents wore gowns and gloves and nursing staff followed proper infection control protocols.
Failure to ensure proper hand hygiene and infection control practices by nursing staff.
Failure to conduct and document tuberculosis screening and testing for residents.
Failure to ensure food safety requirements including proper storage, labeling, and dating of food and beverages in the kitchen.
Report Facts
Residents reviewed: 14
Residents reviewed: 9
Residents reviewed: 4
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse | Interviewed regarding medication administration and alarm checks |
| Staff B | Nurse | Interviewed regarding transmission based precautions and medication administration |
| Staff C | Nurse | Observed medication storage and interviewed regarding expired medications |
| Staff D | Nurse | Observed medication storage and interviewed regarding expired medications |
| Staff E | Nursing Assistant | Observed infection control practices and meal tray delivery |
| Staff F | Nursing Assistant | Observed infection control practices and meal tray delivery |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding care plans, catheterization, medication administration, infection control, and other deficiencies |
| Medical Director | Medical Director | Made aware of medication and care plan deficiencies |
| Charge Nurse | Charge Nurse | Involved in medication administration and care plan audits |
| CNE | Clinical Nurse Educator | Responsible for re-education and audits related to medication administration and care plans |
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