Island Lake Center

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services to prevent the development and/or worsening of a pressure ulcer. The facility failed to adequately evaluate, monitor, and treat the resident's wound and failed to consistently implement wound care interventions identified in the resident's comprehensive care plan. These failures resulted in the resident developing and/or experiencing worsening of a stage 4 pressure ulcer which resulted in actual harm to the resident for one of two residents reviewed for pressure ulcers, of a total sample of six residents, (#5).Findings: Cross reference F725, F867 Resident #5 was admitted to the facility on [DATE] from an acute care hospital after sustaining a fall at home which resulted in… […]

• No harm, potential for more than minimal, patternF725Aug 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure they had sufficient staff to provide care as per physician orders and/or per care plans for 2 of 2 residents reviewed for wound care, (#5, and #2); 1 of 1 resident reviewed for tracheostomy care, (#2); and 1 of 1 resident reviewed for Intravenous (IV) lines, (#6), out of a total sample of 6 residents.Cross Reference F686, F694, F8671. Resident #5 was admitted to the facility on [DATE] after he sustained a fall at home and had surgery at an acute care hospital.Review of State Agency Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form 5000-3008 dated 5/30/26, revealed resident #5 had a surgical fracture repair to his right hip. […]

• No harm, potential for more than minimal, patternF867Mar 26, 2026

  Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained which had possibility to affect 113 of 113 residents in the facility.Findings: Review of the undated facility's QAPI Program revealed the objective of the program was to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. […]

• No harm, potential for more than minimal, patternF584Jan 30, 2025

  Based on observation, and interview, and record review, the facility failed to provide a homelike environment for resident dining in the upstairs Vista View unit dayroom for 9 of 40 residents sampled. Findings: On 1/27/25 at 11:55 AM, in the Vista View dayroom nine residents were sitting around tables waiting for lunch. There were no tablecloths or centerpieces on the tables and staticky music was playing from a radio in the background. The Social Services Assistant (SSA) changed the channel several times in an attempt to find appropriate dining music but the static persisted. A short time later at 12:07 PM, lunch trays were delivered to the residents in the dayroom. The plates, cups, bowls and eating utensils were left on the trays and not set on the table for dining. […]

• No harm, potential for more than minimal, patternF812Jul 15, 2021

  Based on observation, interview, and record review, the facility failed to provide proper storage and sanitation practices for the clean storage of nested pans and cooking sheets, failed to provide appropriate and scheduled cleaning of kitchen equipment, and failed to provide proper training for the washing and storage of pots and pans to prevent potential food contamination. Findings: On 07/12/21 at 9:57 AM, during the initial kitchen observation, the cook and dietary aides prepared food that would be placed onto the steam table for the lunch meal and prepped the steam table with metal warming pan inserts. An open rack of washed and nested metal pots and pans was observed on the wall by the walk-in freezer. […]