Grand Islander Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Islander Center

333 Green End Avenue Middletown, RI 02842

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care related to abuse and neglect training for 1 of 3 Nursing Assistants (NA) reviewed, Staff A. Findings are as follows:Review of a facility reported incident of alleged staff to resident abuse that was reported to the Rhode Island Department of Health on 7/28/2025, revealed

on 7/27/2025 Resident ID #5 alleged that s/he was abused by NA, Staff A.Record review of a facility policy titled Abuse Prohibition Policy last revised 10/24/2022 states in part, .Training and reporting obligations will be provided to all employees -through orientation, Code of Conduct training, and a minimum of annually-and will include. the Abuse Prohibition policy.Record review revealed Resident ID #5 was admitted to the facility in May of 2025 with diagnoses including, but not limited to, multiple sclerosis (a chronic, often disabling disease that affects the brain and spinal cord) and rheumatoid arthritis (a chronic autoimmune disease that primarily causes inflammation of the joints, leading to pain, swelling, stiffness, and potential joint damage).Record review of a Minimum Data Set assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident is cognitively intact.Record review revealed Staff A was hired by the facility on 6/23/2025. Record review failed to reveal evidence that Staff A had completed education relative to Abuse Prohibition upon hire, as required. During a surveyor interview

on 8/20/2025 at 3:48 PM with the Director of Nursing Services, in the presence of the Administrator, she was unable to provide evidence that Staff A had completed training in abuse. Additionally, she indicated that

she would have expected Staff A to have received additional Abuse Prohibition training following the allegations made by Resident ID #5 on 7/27/2025.

Event ID:

Facility ID:

If continuation sheet