Islands Skilled Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Islands Skilled Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF726Jul 18, 2024

  Based on interviews, document and record review, the facility nursing staff did not demonstrate the competency and skill set to provide one Resident (R)1 the services needed to safely care for him. Specifically, when R1 had ongoing symptoms that were not his baseline requiring additional intervention, they did not implement the process to obtain emergency physician services when unable to reach the on call provider. In addition, nursing applied a scopolamine patch (used to control secretions) on R1, that was not ordered by the physician. The patch may have resulted in significant side effects. As a result of these deficiencies, R1 suffered harm and experienced hallucinations, and increased heart rate. He as ultimately transferred to acute care facility, where he was admitted . […]

• No harm, potential for more than minimal, widespreadF578May 1, 2026

  Based on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD), did not inform the resident of his/her right to develop an AHCD and/or provide assist in doing so, and was unable to provide documentation of physician determination that the resident lacked capacity for decision making in relation to the Declaration of Authority to act as Surrogate for a Patient for 7 of 10 residents (Residents (R) 1, R7, R12, R28, R33, R36, and R38) sampled. This deficient practice does not allow residents, when incapacitated, the right to have their health care choices identified and honored.Findings include: 1) On 04/29/26 at 07:01 AM, A record review of R28's electronic health record (EHR). […]

• No harm, potential for more than minimal, widespreadF812May 1, 2026

  Based on observation, interview, and review of the facility's policies, the facility failed to ensure that food items stored in the refrigerator and freezer were labeled properly and old food discarded by its used by date. The facility also failed to check the temperature of the hot and cold foods prior to being served and accidentally served old, hard-boiled eggs for breakfast. This deficient practice places residents in the facility at risk for foodborne illness.Findings Include:1) On 04/28/26 at 06:30 AM, during the initial walkthrough of the kitchen with Dietary Manager (DM) observed freezer with multiple meat, seafood, and a box of papaya not properly labeled. There were also meat items with a used by date of 04/14/26 that was not discarded. […]

• No harm, potential for more than minimal, widespreadF851Apr 30, 2025

  Based on record review and interview the facility failed to submit their staffing information based on payroll data for direct care staffing (including information for agency and contract staff) for fiscal quarter 3 of 2024 (April 1 - June 30), to the Center of Medicare and Medicaid Services (CMS) on the schedule specified by CMS. Findings Include: Review of the CMS Payroll-Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D for fiscal year Quarter 3 of 2024 (April 1 - June 30) revealed the facility Triggered for Failed to Submit Data for the Quarter which states Triggered = No Data Submitted for Quarter. On 04/30/25 at 02:30 PM an interview was conducted with the Administrator and Interim Director of Nursing (DON) in the Administrator's office. […]

• No harm, potential for more than minimal, widespreadF921Apr 30, 2025

  Based on observation, staff interview and policy review, the facility failed to keep record of dryer lint removal and cleaning. As a result of this deficient practice, the facility did not show that there was any dryer lint removal and/or cleaning being done. Findings include: During observation of the dryer lint traps on 04/30/25 at 10:00 AM, observation was done mid-cycle, and the lint traps had a thin layer of lint. Staff interview on 04/30/25 @ 10:05 AM, Environmental Services Director (EVS Dir) revealed that they recently stopped keeping record of dryer lint removal and cleaning but later said that they would start to keep the records again. […]