Deficiency Records for Islands Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Islands Skilled Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-06 | 2023-09-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-06 | 2023-09-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-25 | 2023-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-25 | 2023-07-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-25 | 2023-07-05 | N |
| 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. | Health | 2023-05-25 | 2023-07-05 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-05-25 | 2023-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-06-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-25 | 2023-06-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-25 | 2023-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-06-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-25 | 2023-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-06-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-25 | 2023-06-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-25 | 2023-06-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-25 | 2023-06-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-25 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-06-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-25 | 2023-06-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-06-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-25 | 2023-06-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-25 | 2023-06-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-25 | 2023-05-26 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-09 | 2022-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-13 | 2022-07-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-13 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-13 | 2022-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-11 | 2022-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-11 | 2022-06-30 | N |
| Keep all essential equipment working safely. | Health | 2022-05-13 | 2022-06-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-13 | 2022-06-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-13 | 2022-06-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-13 | 2022-06-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-13 | 2022-06-20 | N |
| Develop a communication plan. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-12-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-16 | 2021-06-23 | N |
| 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. | Health | 2021-04-16 | 2021-06-23 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-16 | 2021-06-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-16 | 2021-06-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-04-16 | 2021-06-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-16 | 2021-06-23 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-04-16 | 2021-06-23 | N |
