Inspection Report
Follow-Up
Deficiencies: 0
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
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.
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.
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.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Inappropriate discharge of a resident who was appealing the discharge, failing to ensure the resident remained or returned to the facility pending appeal. | SS = D |
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
Census: 68
Capacity: 72
Deficiencies: 5
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.
Severity Breakdown
Level 3: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards for medication refusals. | Level 3 |
| Failure to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards. | Level 3 |
| Failure to ensure residents' drug regimens are free from unnecessary drugs. | Level 3 |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards for food safety. | Level 3 |
| Failure to establish an infection prevention and control program including antibiotic stewardship. | Level 3 |
Report Facts
Census: 68
Total Capacity: 72
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 68
Capacity: 72
Deficiencies: 5
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.
Severity Breakdown
E: 2
D: 2
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards, specifically related to medication refusals documentation for Resident ID #5. | E |
| Failure to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing and prevent infection, Resident ID #55. | D |
| Failure to ensure the drug regimen is free from unnecessary drugs, including anticoagulant monitoring for Resident ID #19. | D |
| Failure to store, prepare, distribute, and serve food in accordance with professional food safety standards. | F |
| Failure to establish an infection prevention and control program including an antibiotic stewardship program to monitor antibiotic use for Residents #20, 22, and 36. | E |
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
Plan of Correction
Deficiencies: 0
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
Re-Inspection
Census: 68
Capacity: 72
Deficiencies: 11
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.
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.
Complaint Details
The survey included a complaint investigation as part of the recertification survey, but specific substantiation status is not stated.
Deficiencies (11)
| Description |
|---|
| 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
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
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.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint investigation, ACTS reference number 91993, conducted to determine compliance; no deficiencies cited.
Inspection Report
Renewal
Deficiencies: 5
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.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| 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. | SS=D |
| The facility failed to provide services that meet professional standards of quality related to physician's orders for supplemental oxygen use. | SS=D |
| The facility failed to ensure residents receive treatment and care in accordance with professional standards for an orthopedic follow-up appointment and transportation. | SS=D |
| The facility failed to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards to promote healing and prevent infection. | SS=D |
| The facility failed to ensure food safety requirements were met, including maintaining cold food temperatures within acceptable ranges during meal service. | SS=F |
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
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.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=F |
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
Abbreviated Survey
Deficiencies: 0
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
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
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.
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.
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.
Deficiencies (5)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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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