Island Home Park Health and Rehab

In the surveyor’s words

From the most serious findings on record at Island Home Park Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF760Apr 27, 2022

  Based on facility policy review, medical record review, facility documentation review, hospital record review, and interview, the facility failed to prevent a significant medication error for 1 resident (Resident #1) of 7 residents reviewed for medication errors. Resident #1 received 7 medications that were prescribed for Resident #3. The medication error resulted in Resident #1 experiencing [CONDITION(S)] (low blood pressure) and being admitted to an Intensive Care Unit (ICU) in the hospital, which constitutes Harm for Resident #1. […]

• No harm, potential for more than minimal, isolatedF550May 20, 2026

  Based on medical record review, observations, and interviews, the facility failed to protect the resident's right to dignity when an indwelling catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #25) of 3 residents observed for dignity. The findings include: Review of the facility's policy Resident Rights, revised 2/2021, revealed .be treated with dignity . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Obstructive/Reflux Uropathy (Urine Blockage) and Personal History of Malignant Neoplasm of Prostate (Cancer). […]

• No harm, potential for more than minimal, isolatedF645May 20, 2026

  Based on Long-Term Care Facility Resident Assessment Instrument (RAI) review, medical record review, and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) screen was accurate after mental health diagnoses was identified for 2 of 7 residents (Resident #13 and #57) reviewed for PASRR.The findings include:Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 dated 10/1/2025, revealed .facilities are responsible for accurately reflecting active diagnoses within the assessment process and ensuring coordination with PASRR requirements when residents have serious mental illness, intellectual disability, or related conditions .Review of the Level 1 PASRR for Resident #13 dated 8/29/2025, revealed .no… […]

• No harm, potential for more than minimal, isolatedF880May 20, 2026

  Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 3 residents (Residents #11, #23, and #101) on 1 of 4 units observed for meal tray distribution.The findings include:Review of the facility's policy titled, Handwashing/Hand Hygiene, revealed All personnel shall follow the handwashing/hand hygiene procedures .Hand hygiene products shall be readily accessible .before and after eating .Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Dysphagia, and Anxiety.Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 15 on the Brief… […]

• No harm, potential for more than minimal, isolatedF636Mar 25, 2025

  Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record reviews, and interviews the facility failed to ensure MDS assessments were accurate for 3 residents (Resident #33, #40, and #55) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-Admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes if PASRR Level II screening determined that the resident has a serious mental illness .Determination of Pressure Ulcer/Injury Risk .Pressure ulcers/injuries occur when tissue is compressed between a bony… […]