Isle Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Isle Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Mar 14, 2025

  Based on a review of resident records, the facility's standards and guidelines, facility reports, hospital records, and interviews with staff, the facility failed to act in accordance with a resident's advance directives in accordance with her Do Not Resuscitate (DNR) status (the desire have cardiopulmonary resuscitation (CPR) withheld in the event of cardiac or respiratory arrest) after finding her unresponsive. This affected one (Resident #2) of four residents reviewed for advance directives. The facility's failure to review and honor Resident #2's DNR status prolonged her dying process, deprived her of a natural death, and likely resulted in severe pain and organ damage. Additionally, Resident #2 could not express her reaction to this event. […]

• No harm, potential for more than minimal, widespreadF568Mar 14, 2025

  Based on resident and staff interviews, record review, and a review of facility policies and procedures, the facility failed to ensure that individual financial records were available through quarterly statements and upon request for 56 of 56 residents with personal funds accounts in the facility. Quarterly statements were not provided to the residents since at least May 2024. The findings include: During an interview with Resident #1 on 3/14/25 at 12:13 p.m., she stated she did not know what her personal funds account balance was, and she was unaware that the facility was to provide her with statements of her account. A review of Resident #1's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Oct 14, 2021

  Based on observations and interviews, the facility failed to store and serve food in accordance with professional standards for food service safety. This failure could lead to the spread of foodborne illness, and potentially impacted every resident who consumed food from the facility's kitchen. The findings include: On 10/11/21 at 1:30 p.m., an observation of the dry storage closet was made. A scoop was discovered inside a plastic container of sugar. A flour container had plastic wrap over it, but it was not securely covered. A plastic bin labeled bread crumbs was open as well. In the area of the dry storage closet where loaves of bread and bread products were kept, bags were observed without dates on them, not securely closed, and a bag of muffins that was wide open, was also observed. […]

• No harm, potential for more than minimal, patternF657Apr 22, 2021

  Based on medical record reviews and staff interviews, the facility failed to ensure that the care plans were reviewed and revised quarterly by an interdisciplinary team for two (Resident #3 & #4) of five residents sampled for multiple medical conditions. Failing to revise care plans places residents at risk of not receiving appropriate care. The findings include: 1. A review of Resident #3's clinical record revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's care plan revealed he had multiple medical conditions that needed support with a next care plan review date of 3/18/21. (Photographic evidence obtained) 2. A review of Resident #4's clinical record revealed an admitted [DATE] followed by a readmitted [DATE]. […]

• No harm, potential for more than minimal, isolatedF689May 22, 2025

  Based on observations, interviews, and record review, the facility failed to maintain a safe environment for two (Resident #20 and #44) of six residents reviewed for smoking safety. Specifically, cigarette lighters were found in the residents' rooms, in violation of the facility's smoking policy, which prohibits residents from possessing smoking materials in their personal living spaces, placing residents at risk for fire and smoke related injuries. The findings include: 1. A review of Resident #20's medical record revealed an admitted [DATE] and diagnoses including atherosclerotic heart disease, chronic congestive heart failure, use of a cardiac pacemaker, major depressive disorder, cognitive/communication deficit, and anxiety disorder. […]