Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grandview Center during CMS and state inspections, most recent first.
A resident with complex medical needs, including end stage renal disease and recent amputation, was discharged and not permitted to return to the facility while actively appealing the discharge. Despite the resident and family pursuing an appeal and being unable to provide care at home, the facility did not ensure the resident's right to remain or return during the appeal process.
Ice Machine Cleanliness and Drain Air Gap Deficiency: Surveyors observed black wipeable matter on the white plastic cover of the ice dispenser inside the ice machine in the main kitchen, and the FSD acknowledged it was cleaned monthly by the facility and quarterly by an outside company. Surveyors also observed the ice machine pipe resting inside the floor drain without the required 1-inch air gap, which the Maintenance Director acknowledged.
A resident with DM2, vascular dementia, HTN, GERD, PMR, and other chronic conditions repeatedly refused multiple scheduled meds, including aspirin, bowel meds, insulin-related blood sugar checks, cardiac meds, diuretics, antihypertensives, prednisone, Prilosec, glaucoma drops, and Tylenol. The MAR showed numerous refusals across the month, but the record did not show provider notification for the refusals. Staff interviews confirmed that refusals should be reported and documented, yet the DON was unaware of the extent of the refusals and the NP was not aware of how extensive they were.
Failure to Complete Antibiotic Time Outs: The facility did not complete required antibiotic time outs for 3 of 4 residents reviewed for antibiotic use. A resident with osteomyelitis and cellulitis, another resident with osteomyelitis, and a third resident receiving Amoxicillin all had antibiotic orders, but the record did not show the required 48 to 72 hour review was completed. The IP acknowledged the missing time outs during interview.
A resident with a stage IV pressure ulcer and DM2 was observed during wound care screaming in pain, but an LPN and RN did not stop to assess or treat the pain during the dressing change. The LPN removed a soiled ABD pad, found calcium alginate still in the wound bed from the prior dressing, applied Vashe wash and Bactroban without removing it, and the RN later removed the soiled material; neither nurse cleansed the wound bed afterward. The DON stated staff should stop wound care to assess and treat pain and cleanse the wound bed after removing a soiled dressing, but no evidence was provided that the resident received care consistent with professional standards.
A resident with anticoagulant use and stroke had orders for Coumadin and Lovenox, with Lovenox to stop after two days of therapeutic INR results. Although the INR was therapeutic, the MAR showed two extra Lovenox doses were given after the medication should have been discontinued. The RN acknowledged giving one dose without recalling checking the INR, and the provider and DON stated the order should have been stopped earlier.
Nursing staff administered a controlled medication prescribed for one resident to another hospice resident due to a pharmacy backorder, in violation of facility policy. The transfer and administration of the medication were inaccurately documented in the narcotic count book, and the physician's order was entered with the incorrect route. Staff acknowledged the errors in both medication handling and documentation.
The facility failed to provide timely one-to-one feeding assistance to residents requiring it, compromising their dignity and care. A resident with hand contractures and intact cognition was left to struggle with meals without assistance, despite orders for one-to-one feeding. Another resident with weight loss was left unattended with meal trays, and a resident with severe cognitive impairment was observed without required supervision. Staff practices and lack of oversight contributed to these deficiencies.
The facility failed to monitor residents on anticoagulant therapy as outlined in their care plans, affecting four residents with conditions like atrial fibrillation and venous thrombosis. Despite care plans requiring monitoring for bleeding, no evidence of such monitoring was found. Staff interviews confirmed the absence of orders to ensure monitoring, highlighting a systemic issue in care plan adherence.
A resident with impaired communication due to hearing loss did not receive proper treatment to maintain hearing abilities. Despite a care plan intervention for an ENT or audiologist consultation, an appointment for ear wax removal was cancelled in November 2023, and no follow-up actions were taken. Observations confirmed the resident's hearing difficulties, and interviews with staff and family indicated a lack of rescheduling or additional interventions.
The facility failed to provide proper respiratory care for two residents using oxygen therapy. One resident's oxygen tubing was not labeled as required, and another's tubing was not changed weekly, with discolored nasal cannula prongs observed. These issues were acknowledged by an LPN and the DON.
A resident with hypertension, heart murmur, and dementia received Losartan potassium outside of prescribed parameters, despite orders to hold the medication if systolic blood pressure was below 110. This occurred multiple times over three months, and the DON acknowledged the error.
The facility failed to track and implement QAPI actions for changing and dating oxygen tubing. Despite identifying this as a problem area, two residents had undated oxygen tubing, which was not caught by QA processes. The Lead Clinical Specialist could not provide evidence of a monitoring program for oxygen orders.
A non-English speaking resident with major depressive disorder and dementia was not provided with activities according to their care plan. Despite documented interests in leisure activities and spirituality, the resident was observed without a TV, radio, or reading materials, and staff interviews confirmed the lack of provided activities. The DON was unaware of this deficiency.
A resident requiring two-person assistance for transfers was frequently moved by a single NA, contrary to the care plan and physician's order. Despite the resident's cognitive awareness and medical history of hemiplegia and unsteadiness, staff interviews revealed a pattern of non-compliance with the prescribed transfer protocol.
A facility failed to conduct a Trauma Informed Care evaluation for a resident with PTSD and anxiety disorder, as required by their care plan. Despite the resident's admission in early 2024 and the care plan's stipulation for specialized services, no assessment was completed to identify PTSD triggers. The DON and Lead Clinical Specialist acknowledged this oversight during a surveyor interview.
A resident with hemiplegia and hemiparesis was not provided with a required divided lip plate for meals, as observed by surveyors. Despite the care plan and diet slip indicating the need for this adaptive equipment, staff interviews revealed a lack of awareness and acknowledgment of the oversight. The DON confirmed the expectation that the resident should have been provided with the necessary equipment.
Failure to Allow Resident to Remain During Discharge Appeal
Penalty
Summary
The facility failed to ensure that a resident who was appealing a discharge was allowed to remain in or return to the facility pending the outcome of the appeal. The resident, who had end stage renal disease requiring dialysis, a recent transmetatarsal amputation, and other diabetic ulcers, was given a 30-day discharge notice due to lack of an active payer. Despite submitting an appeal of the discharge, the resident was sent to the hospital and was not readmitted to the facility while the appeal was active. Documentation showed that the resident and family were actively seeking to resolve Medicaid issues and had requested a hearing to appeal the discharge. The family expressed that they were unable to care for the resident at home due to the resident's complex medical needs and lack of accessibility. The facility administrator confirmed that the resident was not allowed to return to the facility during the appeal process and could not provide evidence that the resident's right to remain or return pending the appeal was honored.
Ice Machine Cleanliness and Drain Air Gap Deficiency
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During the initial tour, surveyors observed an ice machine with black wipeable matter on the white plastic cover of the ice dispenser inside the machine. In interview immediately after the observation, the Food Service Director acknowledged the black wipeable matter and stated that it is cleaned monthly by the facility and quarterly by an outside company. Surveyors also observed that the pipe from the ice machine was resting inside the floor plumbing fixture drain and did not have the required minimum one-inch air gap. In interview immediately after this observation, the Maintenance Director acknowledged that there was not an air gap between the pipe and the plumbing fixture as required.
Failure to Document and Report Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure that Resident ID #5 received treatment and care in accordance with professional standards of practice related to repeated medication refusals. The resident was readmitted in July 2014 with diagnoses including type 2 diabetes mellitus, vascular dementia, hypertension, GERD, and polymyalgia rheumatica. The record showed multiple physician orders for medications including aspirin, docusate sodium, Humalog based on sliding-scale blood sugars, isosorbide mononitrate, Lasix, lisinopril, Lopressor, magnesium oxide, Metamucil, prednisone, Prilosec, Senna, Travoprost, and Tylenol ER. Review of the August 2025 MAR showed numerous refusals of these medications and, in one instance, refusal to have a morning blood sugar obtained for insulin administration. The refusals occurred repeatedly across the month for several scheduled medications, including aspirin, docusate sodium, isosorbide mononitrate, Lasix, lisinopril, Lopressor, magnesium oxide, Metamucil, prednisone, Prilosec, Senna, Travoprost, and Tylenol. The record review failed to reveal evidence that the provider was notified of these refusals. The report also states that the resident frequently refused medications, and staff acknowledged that the resident refused medications, but the documentation did not show provider notification for the refusals identified by surveyors. During interviews, a CMT stated that when a resident refuses medication, the nurse is informed and speaks with the resident. An RN stated that the nurse should notify the resident’s physician of the refusal and that the notification should be documented in a progress note or MAR note. The DNS stated that if a resident refuses any medications, the physician should be notified and the notification documented in a progress note, and she was not aware of the August 2025 refusals. The NP stated he was aware of some prior refusals but was not aware of the extent of the August refusals. After the concern was brought to the facility’s attention, the DNS documented a call to the NP and noted that several 6 AM medications were changed to 9 AM, but the record also showed that provider awareness of the August refusals was not documented before the surveyor’s findings.
Failure to Complete Antibiotic Time Outs
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. The report states that, based on record review and staff interview, the facility did not complete required antibiotic time outs for 3 of 4 residents reviewed for antibiotic use. The facility policy titled Antibiotic Stewardship required nursing to monitor the initiation of antibiotics and conduct an antibiotic time out within 48 to 72 hours of therapy to review response to treatment and laboratory results. Resident ID #20 had diagnoses including osteomyelitis and cellulitis and was ordered Cefazolin three times a day, with an antibiotic time out scheduled for 8/15/2025, but the record did not show that it was completed. Resident ID #22 had a diagnosis including osteomyelitis and was ordered Bactrim DS twice daily, with an antibiotic time out scheduled for 8/5/2025, but there was no evidence it was completed. Resident ID #36 was ordered Amoxicillin twice daily, and the record also failed to show an antibiotic time out was completed. During interview, the Infection Preventionist acknowledged that these three residents did not have antibiotic time outs completed per regulation or facility policy.
Failure to Provide Proper Wound Care and Pain Management
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with a stage IV pressure ulcer to the left lateral foot and a history of type II diabetes. The resident was readmitted to the facility with the pressure ulcer and had a wound evaluation showing the ulcer measured 4 cm x 8.4 cm x 0.1 cm. The care plan included monitoring for pain and medicating as needed, and the physician ordered daily cleansing of the wound bed with Vashe wash, application of Bactroban cream, and coverage with an ABD pad and kerlix. During observed wound care, the resident was screaming and swearing in pain throughout the dressing change, but the LPN and RN did not stop to assess the resident's pain or attempt to treat it during the procedure. The LPN stated pain medication would be given after wound care, while the resident asked for it immediately. The LPN removed a soiled ABD pad and found calcium alginate still in the wound bed from the prior dressing change, then applied Vashe wash to the soiled calcium alginate and began applying Bactroban without removing it. The RN later removed the soiled calcium alginate, and neither nurse cleansed the wound bed after its removal. The DNS stated staff should stop a wound dressing to assess and treat pain if needed and should cleanse the wound bed after removal of a soiled dressing, but was unable to provide evidence that the resident received treatment and services consistent with professional standards of practice.
Unnecessary Lovenox Doses Given After Therapeutic INR
Penalty
Summary
The facility failed to ensure that Resident ID #19’s drug regimen was free from unnecessary drugs. The resident was readmitted in August 2025 with diagnoses including long-term use of anticoagulants and stroke, and had physician orders for Coumadin 6 mg once daily for valve replacement with a goal INR of 2.5-3.5, along with Enoxaparin Sodium (Lovenox) 80 mg at 8:00 AM and 8:00 PM related to a stroke. The Lovenox order stated it was to be discontinued after two days of achieving a therapeutic INR of 2.5-3.5. The resident’s INR was documented as 3.0 on 8/12/2025 and 3.6 on 8/13/2025, yet the August 2025 MAR showed Lovenox was still administered at 8:00 PM on 8/13 and at 8:00 AM on 8/14. The Lovenox order was not discontinued until 8/14/2025 at 1:29 PM. During interview, the RN who administered the 8/14 8:00 AM dose stated she did not recall checking the INR before giving the medication and acknowledged she should not have administered it based on the INR level and physician’s order. The provider stated the Lovenox order should have been discontinued once the second therapeutic INR result was received on 8/13, and the DON acknowledged the resident received 2 unnecessary doses of Lovenox.
Failure to Adhere to Medication Administration Standards and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering medication prescribed for one resident to another and inaccurately documenting the transfer and administration of a controlled substance. Specifically, a resident on hospice care with a diagnosis of malignant neoplasm of the bronchus and secondary malignant neoplasm of the digestive organs was ordered Lorazepam Intensol for restlessness and anxiety. Due to a pharmacy backorder, nursing staff borrowed an unused bottle of Lorazepam Intensol prescribed for another resident and administered it to the hospice resident. Documentation in the narcotic count book was inaccurate, as 15 ml was recorded as transferred when in fact 30 ml was moved, and there was no clear evidence of the medication being properly transferred or received from the pharmacy. Facility policy explicitly prohibits administering medications supplied for one resident to another. The medication administration record confirmed that the hospice resident received doses from the borrowed medication on multiple occasions. Staff interviews revealed acknowledgment of the errors, including the incorrect route of administration entered in the physician's order and the improper borrowing and documentation of the medication. The staff educator confirmed that the medication should not have been borrowed and that the narcotic documentation was incomplete and inaccurate.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide necessary one-to-one feeding assistance to residents who required it, compromising their dignity and care. Resident ID #16, with intact cognition but bilateral hand contractures, was observed multiple times attempting to eat without assistance, despite a physician's order for one-to-one feeding assistance. The resident was left to struggle with finding food on the plate, and staff assistance was delayed by 18 to 23 minutes during several meal observations. Interviews with staff and the resident confirmed the need for assistance due to the resident's inability to see the food. Resident ID #54, also with intact cognition, required one-to-one assistance with eating due to weight loss. However, the resident was left with meal trays unattended for 14 minutes before receiving help. Staff interviews revealed a practice of delivering meal trays and returning later to assist, which contributed to the delay. Resident ID #60, with severe cognitive impairment, required supervision for meals but was observed with untouched meal trays and no staff supervision for up to 25 minutes. The Director of Nursing Services was unaware of these issues, indicating a lack of oversight in ensuring timely assistance as ordered.
Failure to Monitor Residents on Anticoagulant Therapy
Penalty
Summary
The facility failed to monitor and assess residents on anticoagulant therapy as outlined by their comprehensive care plans, which is a deficiency in meeting professional standards of quality. Four residents, identified as having conditions such as atrial fibrillation and a history of venous thrombosis, were prescribed blood thinners like Eliquis, Coumadin, and Xarelto. Despite the care plans specifying the need to monitor for signs and symptoms of bleeding, there was no evidence that such monitoring was conducted for these residents. Interviews with staff, including LPNs and the Lead Clinical Specialist, revealed that there was an expectation for nurses to monitor for bleeding and bruising in residents on anticoagulation therapy. However, it was acknowledged that there were no orders in place to ensure this monitoring was documented or carried out. This lack of monitoring was confirmed through record reviews and staff interviews, indicating a systemic issue in adhering to the care plans for residents receiving anticoagulant therapy.
Failure to Address Resident's Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing abilities. The resident, who was admitted in May 2023 with diagnoses including diabetes mellitus type 2 and chronic obstructive pulmonary disease, was identified as having impaired communication due to being hard of hearing. The care plan dated June 1, 2023, included an intervention for a consultation with an ENT specialist or audiologist to evaluate new or worsening hearing loss. However, an appointment for ear wax removal scheduled for November 16, 2023, was cancelled, and no follow-up actions were taken by the facility. Surveyor observations on multiple occasions in July 2024 confirmed the resident's difficulty in hearing, as evidenced by the resident pointing and cupping their ears. Interviews with the resident's family member, a Licensed Practical Nurse, the Director of Nursing Services, and a Nurse Practitioner revealed that the facility did not reschedule the cancelled appointment or implement any additional interventions to address the resident's hearing loss. The staff acknowledged the resident's hearing difficulties but could not provide evidence of any follow-up actions since the cancellation of the appointment.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents who were using oxygen therapy. Resident ID #5, admitted with chronic obstructive pulmonary disease and chronic respiratory failure, had a physician's order for oxygen at 2 liters per minute via nasal cannula, with instructions to change the oxygen tubing weekly and label each component with the date and initials. However, during surveyor observations on multiple occasions, it was noted that the resident's oxygen tubing was not labeled with a date, which was acknowledged by the LPN, Staff A. Similarly, Resident ID #10, also diagnosed with chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters per minute via nasal cannula at bedtime, with the same instructions for tubing change and labeling. Surveyor observations revealed that the oxygen tubing was not labeled, and the nasal cannula prongs were discolored and yellow. The oxygen tubing bag was found to be dated incorrectly, indicating it had not been changed as per the schedule. This was confirmed by Staff A and the Director of Nursing Services, who stated that the tubing should be changed every Thursday and dated.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of Losartan potassium. The resident, who was readmitted to the facility with diagnoses including hypertension, heart murmur, and dementia, had a physician's order to hold Losartan if the systolic blood pressure was less than 110. Despite this order, the medication was administered outside of these parameters on multiple occasions: 5 times in May, 6 times in June, and 9 times in July 2024. A pharmacy consultation report had previously highlighted the importance of adhering to these parameters, and staff were educated on this matter. However, during an interview, the Director of Nursing Services acknowledged the medication was administered contrary to the ordered parameters.
Failure to Track and Implement Oxygen Tubing Protocols
Penalty
Summary
The facility failed to measure success and track performance of Quality Assurance and Performance Improvement (QAPI) actions related to changing and dating oxygen tubing. A review of the QAPI plan and meeting minutes from January 2024 to July 2024 identified this as a problem area requiring improvement. An oxygen audit document indicated that oxygen tubing and filters should be changed on Thursdays per policy. However, during surveyor observations from July 29 to July 31, 2024, it was found that two out of three residents reviewed for oxygen therapy had oxygen tubing that was not dated as ordered. This issue was not identified by the QA process or ongoing audits. During an interview on August 1, 2024, the Lead Clinical Specialist was unable to provide evidence that the facility had successfully implemented a program for monitoring and evaluating oxygen orders. This deficiency was cross-referenced with F 695.
Failure to Provide Activities for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the well-being of a non-English speaking resident, identified as Resident ID #27. The resident, who was readmitted to the facility in October 2020, has diagnoses including major depressive disorder, adjustment disorder, and dementia with agitation, and is dependent on staff for all care needs. The care plan dated April 27, 2023, indicated the resident's interest in leisure activities such as magazines, books, materials related to Europe, Portuguese recipes, spirituality, and music. A subsequent care plan dated November 15, 2023, emphasized the resident's need for self-directed involvement in meaningful activities, including Spanish/Portuguese chronicles, pet visits, and spirituality. Despite these documented preferences, surveyor observations from July 29, 2024, to August 1, 2024, revealed that the resident was not participating in group activities and was often found awake in their room without a TV, radio, or reading materials. Interviews with staff, including a Licensed Practical Nurse and the Recreational Director, confirmed that the resident was not provided with activities in accordance with the care plan. The Director of Nursing Services was also unaware of the lack of activities and the absence of entertainment options in the resident's room, indicating a failure to implement the planned activities for the resident.
Inadequate Supervision During Resident Transfers
Penalty
Summary
The facility failed to provide adequate supervision to prevent an accident hazard for a resident who requires the assistance of two staff members for transfers with a gait belt. The resident, who has a history of hemiplegia and hemiparesis following a cerebral infarction, unsteadiness on the feet, and abnormality of gait and mobility, was observed being transferred by a single Nursing Assistant (NA), despite having a care plan and physician's order requiring two staff members for transfers. The resident expressed feeling unsafe due to frequent transfers with only one staff member. Interviews with staff revealed a lack of adherence to the care plan and physician's order. The NA involved admitted to transferring the resident alone and stated that she often does so, believing the resident only requires two staff members when weak. A Licensed Practical Nurse (LPN) confirmed that the resident is sometimes transferred with only one staff member, acknowledging the active care plan and physician's order for two-person assistance. The Director of Nursing Services also confirmed that the resident should be transferred with two staff members as ordered.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD and anxiety disorder. The resident was admitted in February 2024, and the care plan dated April 2024 indicated the need for specialized services to maintain the resident's psychological, physical, functional, and psychosocial well-being. However, there was no evidence of a completed Trauma Informed Care evaluation to identify PTSD triggers. During an interview, the Director of Nursing Services and the Lead Clinical Specialist confirmed that no such assessment had been conducted since the resident's admission, acknowledging the necessity of completing this evaluation to identify PTSD triggers.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special adaptive eating equipment and utensils for a resident who requires a divided lip plate. The resident, admitted in April 2019, has diagnoses including hemiplegia, hemiparesis, and muscle weakness, necessitating the use of a divided lip plate and built-up utensils for self-feeding as per the care plan dated 8/15/2019. Despite the diet slip indicating the need for a divided lip plate at all meals, surveyor observations on multiple occasions revealed the resident was not provided with the required equipment. Interviews with staff, including a Nursing Assistant and an LPN, confirmed the oversight, with the Nursing Assistant unaware of the requirement and the LPN acknowledging the resident should have been provided with the divided lip plate. The Director of Nursing Services also indicated that the resident should have been provided with the appropriate equipment for all meals.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harris Health Care Center North | 0.9 mi | ★★★★★ | 24 | 0 |
| Mansion Nursing And Rehab Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Jeanne Jugan Residence | 2.9 mi | ★★★★★ | 3 | 0 |
| Adviniacare Pawtucket Pleasant Rehab Center, Llc | 3.1 mi | ★★★★★ | 14 | 0 |
| Adviniacare Summit Commons, Llc | 3.5 mi | ★★★★★ | 15 | 2 |
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