Grand Islander Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, the facility failed to ensure that a resident receives care consistent with professional standards of practice relative to physician's orders for 1 of 2 residents reviewed for wound care, Resident ID #1Findings are as follows:Review of a facility reported incident submitted to
the Rhode Island of Health on 10/1/2025 states in part, that the resident's daughter had made an allegation of neglect against the facility.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states
in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe that the orders are in error or wound harm the clients.Record review revealed the resident was admitted to the facility in August of 2022, with a diagnosis including, but not limited to, basal cell carcinoma (skin cancer).Record review of a progress note dated 8/21/2025 revealed,
the resident had a MOHS surgery (a surgical procedure to remove skin cancer) on 8/19/2025.Record
review of a Continuity of Care Consultation and Referral Form signed and dated 9/26/2025 by the dermatologist, states in part, .white vinegar and water, 50:50-soaks daily to left temple x 2 weeks. Manuka Honey (a medical honey used for wound healing) twice a day to raw areas on face/neck.do twice a day until healed.Record review of the Treatment Administration Records (TAR) from September 2025 through November 2025 failed to reveal evidence that the above-mentioned physician's orders were implemented.
Additional record review failed to reveal evidence the physician at the facility had declined the dermatologist's orders dated 9/26/2025. During a surveyor interview on 11/25/2025 at 12:40 PM with the Administrator, she was unable to provide evidence that the above-mentioned physician's orders had been followed. Additionally, she indicated that she would expect the staff to verify the dermatologist order with the physician at the facility and was unable to provide evidence the order was verified or declined by the physician at the facility.
Residents Affected - Few
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
11/25/2025
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-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
interview on 11/25/2025 at 12:15 PM with NA, Staff A, he recalled an incident prior to the resident's hospitalization, that when transferring the resident in the bathroom, the resident pulled up to the bar from his/her wheelchair, he assisted the resident to raise from the wheelchair, and s/he suddenly went backwards into the wheelchair. At the time the resident stated the s/he was unable to get out of the wheelchair. Staff A stated he then repositioned the resident in the wheelchair and proceeded to get assistance from Staff B to put the resident in bed to perform care.Record review of documents titled, Daily Staffing Sheets revealed the assignments for Resident ID #2's unit:NA, Staff A, worked the following shifts: 8/31/2025- 5:00 PM -11:00 PM and 11:00 PM -7:00 AM 9/1/2025 -3:00 PM- 11-00 PM and 11:00 PM - 7:00 AM 9/2/2025- 11:00 PM - 7:00 AMNA, Staff B, worked the following shifts: 8/31/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PM 9/1/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PM 9/2/2025 - 7:00 AM-3:00 PM and 3:00 PM - 11:00 PMDuring a surveyor interview on 11/25/2025 at 3:39 PM with the Administrator,
in the presence of the Director of Nursing Services, she was unable to provide evidence that the resident was provided with two members during a transfer as indicated on his/her care plan and Lift Transfer Evaluation.It was determined that Resident ID #2 sustained significant, non-operable fractures to the left tibia and fibula consistent with improper or inadequate assistance during a SPT. Although the resident's care plan and transfer evaluation clearly required the assistance of two staff members with a gait belt, multiple interviews revealed that staff routinely transferred the resident independently. Both the resident and staff reported incidents in which the resident twisted or fell backward during transfers, and the Director of Rehabilitation confirmed that the type of fractures sustained are consistent with twisting during a SPT when
the leg is not properly advanced.Staff schedules confirm that the staff members involved were on duty
during the relevant time frame. Despite this, the facility was unable to produce evidence that appropriate assistance was provided in accordance with the resident's assessed transfer needs. As a result, the investigation concludes that the facility did not ensure that the resident received adequate supervision and assistance to prevent accidents, which likely contributed to the injuries sustained.During a surveyor
interview with the Director of Nursing on 11/21/2025 at approximately 9:50 AM, she provided evidence of
the interventions which were initiated after a citation for a similar incident was discovered during a complaint investigation at the facility on 10/23/2025 through 10/24/2025. The following interventions were initiated and or completed with a substantial date of compliance of 11/20/2025:a. A facility wide review was conducted on 11/20/2025 to identify residents who may be at risk related to supervision and use of assistive devices. All residents were verified to have an accurate transfer status and appropriate assistive devices.b. Staff education was provided to direct care staff regarding safe resident handling and fall prevention, which was completed on 11/20/2025.c. The Rehabilitation Department initiated education to their staff regarding timely communication and documentation of resident transfer updates, education was initiated in 11/1/2025. Compliance data will be submitted to Quality Assurance and Performance Improvement (QAPI). Education on the care plan process and updating assessments, with any changes was initiated on 11/6/2025.d. Random gait belt audits are to be conducted for 4 weeks, followed monthly for 3 months, to ensure proper use of assistive devices during transfers. Findings will be submitted to QAPI.e.
Weekly fall audits were initiated on 10/14/2025 and will continue to be conducted for 4 weeks, followed monthly for 3 months, to ensure proper use of assistive devices during transfers. Findings will be reviewed
during QAPI meetings.f. Weekly audit of Quality Measure rounds for any residents with a change in condition for 4 weeks, followed monthly for 2 months. Findings will be discussed during QAPI meetings.
Event ID:
Facility ID:
If continuation sheet
Grand Islander Center in Middletown, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Middletown, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Grand Islander Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.