ElderGrade

Inspection citations at Grand Islander Center

40 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 22 2
2024 13 0
2023 5 0
D December 5, 2025 Tag F0745 Complaint investigation Corrected Jan 2026

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

No actual harm, potential for more than minimal harm

D December 5, 2025 Tag F0658 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D November 25, 2025 Tag F0658 Complaint investigation Corrected Jan 2026

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

G November 25, 2025 Tag F0689 Complaint investigation Corrected Nov 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

G October 24, 2025 Tag F0689 Complaint investigation Corrected Nov 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D August 20, 2025 Tag F0726 Complaint investigation Corrected Sep 2025

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 20, 2025 Tag F0656 Complaint investigation Corrected Sep 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0881 Corrected Jun 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0814 Corrected Jun 2025

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0760 Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0756 Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0698 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0694 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0692 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0686 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D May 14, 2025 Tag F0679 Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

E May 14, 2025 Tag F0880 Corrected Jun 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E May 14, 2025 Tag F0761 Corrected Jun 2025

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

E May 14, 2025 Tag F0726 Corrected Jun 2025

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

E May 14, 2025 Tag F0656 Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0658 Complaint investigation Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D April 22, 2025 Tag F0580 Complaint investigation Corrected May 2025

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D November 22, 2024 Tag F0692 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D August 27, 2024 Tag F0578 Complaint investigation Corrected Sep 2024

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D July 31, 2024 Tag F0757 Complaint investigation Corrected Aug 2024

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D July 31, 2024 Tag F0658 Complaint investigation Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0825 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0698 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0690 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0688 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0685 Corrected Jun 2024

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0658 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E May 31, 2024 Tag F0880 Corrected Jun 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E May 31, 2024 Tag F0791 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

F May 31, 2024 Tag F0812 Corrected Jun 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0757 Corrected May 2023

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0658 Corrected May 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D April 27, 2023 Tag F0656 Corrected May 2023

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E April 27, 2023 Tag F0689 Corrected May 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

F April 27, 2023 Tag F0812 Corrected May 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.