Grand Islander Center

In the surveyor’s words

From the most serious findings on record at Grand Islander Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 9, 2023

  Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to ensure that the residents' environment remains as free of accident hazards as is possible for residents residing on a secured memory care unit relative to controlled substances and sharps contraband for 2 residents reviewed, Resident ID's #1 and #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. […]

• Immediate jeopardy, patternF921Jan 9, 2023

  Based on surveyor observation, record review, and staff and resident representative interview, it has been determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on the secured memory care unit relative to controlled substances and sharps contraband, Resident ID's #1 and #2. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health on 12/31/2022 revealed that a resident's family member went into the resident's room to visit when they observed a razor blade and a white powdery substance on a mirror on the bedside table. […]

• Immediate jeopardy, isolatedF700Aug 18, 2026

  Based on record review and staff interview, the facility failed to ensure that a comprehensive resident assessment was completed for bed rails, including the risk of entrapment, during the bed rail installation for Resident ID #1's bed. Subsequently, the resident was found unresponsive with his/her head and neck caught between the bed rail and the mattress. Findings are as follows:Record review of a facility reported incident submitted to the Rhode Island Department of Health revealed that on [DATE] the resident was found deceased , in a sitting position on the floor, with his/her right elbow resting on the floor and his/her left hand holding the left bed rail. The bed was noted in low position. […]

• Immediate jeopardy, isolatedF711May 19, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure a physician review the resident's total program of care, including medications and treatments, at each visit, for 1 of 6 new admissions reviewed, Resident ID #108. Findings are as follows: According to Healthline.com, [MEDICATION(S)] toxicity is another term for a [MEDICATION(S)] overdose. It occurs when you take too much [MEDICATION(S)] .A safe blood level of [MEDICATION(S)] is 0.6 to 1.2 milliequivalents per liter (mEq/L). [MEDICATION(S)] toxicity can happen when this level reaches 1.5 mEq/L or higher. […]

• Immediate jeopardy, isolatedF757May 19, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 14 residents reviewed, Resident ID #108. Findings are as follows: According to State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, an unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring. According to Healthline.com, [MEDICATION(S)] toxicity is another term for a [MEDICATION(S)] overdose. It occurs when you take too much [MEDICATION(S)] .A safe blood level of [MEDICATION(S)] is 0.6 and 1.2 milliequivalents per liter (mEq/L). […]