Grand Islander Center

Based on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident reviewed who had actual fall with injury, Resident ID #1, and for 1 of 6 residents reviewed for transfers, Resident ID #2.Findings are as follows:1.

Record review revealed Resident ID #1 was re-admitted to the facility in July of 2025 with diagnoses including, but not limited to, displaced intertrochanteric fracture of left femur (a broken hip).

Record review of a progress note dated 7/20/2025 revealed, Resident ID #1 had been found lying on the floor at 8:00 AM in the doorway of his/her room.

The resident indicated that s/he had pain to his/her left hip with swelling noted.

The resident was emergently sent out to the hospital for further evaluation.Further review of his/her progress notes revealed that the resident was admitted to the hospital with a hip fracture and would require surgery to repair prior to returning to the facility.Review of a care plan focus area for falls dated 9/12/2023, failed to reveal evidence that the resident sustained an actual fall with injury on 7/20/2025.During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she was unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately address the resident's fall with injury.2.

Record review revealed Resident ID #2 was admitted to the facility in February of 2025 with diagnoses including, but not limited to, unspecified fracture of left patella (kneecap) pain in left hip, and dementia.Review of a care plan initiated on 2/11/2025, revealed the resident requires total assistance of 2 staff persons for transfers, using a mechanical lift (a mechanical device that is used to transfer individuals who cannot bear weight or actively assist with transfers themselves).Additional review of the resident's care plan revealed a focused area for Special Instruction which states in part Slide Board (a specialized board that acts as a bridge to allow individuals to move from one seated surface to another seated surface) for transfers.4/17/25.Review of a document titled CAA Triggers Summary dated 7/29/2025 revealed in part, that the resident was dependent (the resident does not actively assist in the transfers) for all transfers.

During a surveyor interview on 8/20/2025 at 3:48 PM, with the Director of Nursing Services, she acknowledged that two different devices used for resident transfers were identified on the care plan.

She was also unable to provide evidence that a comprehensive person-centered care plan was developed and implemented to accurately indicate a specific transfer device for Resident ID #2.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Islander Center

333 Green End Avenue Middletown, RI 02842

SUMMARY STATEMENT OF DEFICIENCIES