A list of the most recent deficiencies for Our Island Home. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-08 | 2023-06-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-26 | 2023-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-06-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-26 | 2023-06-07 | 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 | 2023-04-26 | 2023-06-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-04-26 | 2023-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-06 | 2023-03-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-06 | 2023-03-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-03-05 | 2020-10-21 | 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 | 2020-03-05 | 2020-10-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-03-05 | 2020-10-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-03-05 | 2020-10-21 | 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 | 2020-03-05 | 2020-10-21 | 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 | 2020-03-05 | 2020-10-21 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-03-05 | 2020-10-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-03-05 | 2020-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-10-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-03-05 | 2020-10-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-05 | 2020-10-21 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2020-03-05 | 2020-10-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-03-05 | 2020-04-19 | 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 | 2020-03-05 | 2020-04-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-05 | 2020-04-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-05 | 2020-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-05 | 2020-04-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-03-05 | 2020-04-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-19 | 2019-04-26 | 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 | 2019-02-27 | 2019-04-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-02-27 | 2019-04-19 | 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 | 2019-02-27 | 2019-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-27 | 2019-04-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-27 | 2019-04-19 | N |
