Our Island Home

In the surveyor’s words

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

• Actual harm, isolatedF656Feb 6, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing to be at high risk for falls, and required the use of a fall mat on the floor on the left side of the bed (right side of his/her bed had been positioned up against the wall) while in bed for safety, the Facility failed to ensure that staff consistently implemented and followed interventions identified in his/her plan of care related to safety. On 12/30/22, Restorative Nurse Aide (RNA) #1, who was assigned to care for Resident #2, left him/her sitting up bed in with the bedside table in front of him/her, however prior to leaving the room, RNA #1 did not place the fall mat on the floor next to the left side of his/her bed, per the plan of care. […]

• Actual harm, isolatedF689Feb 6, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing to be at high risk for falls, had decreased safety awareness, and required the use of a fall mat on the left side of his/her bed when in bed, the Facility failed to ensure he/she was provided with adequate safety measures in an effort to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 12/30/22, Restorative Nurse Aide (RNA) #1 who was assisting Resident #2, who was in bed, with dinner time intake, left the room to redirect another resident, leaving him/her unattended. […]

• No harm, potential for more than minimal, patternF585Apr 9, 2026

  Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, the facility failed to ensure their grievance policy included notification that residents and their representatives have the right to file grievances anonymously, should they choose not to alert a staff member of their concern(s), and failed to include the contact information of the grievance official with whom a grievance can be filed, that is, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or… […]

• No harm, potential for more than minimal, patternF658Apr 9, 2026

  Based on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for three Residents (#13, #17, and #25), out of a total sample of 33 residents. Specifically, the facility failed: 1. For Resident #13, to ensure physician's orders for opioid administration were followed; and2. For Resident #17 to ensure physician's orders for opioid administration were followed; and3. For Resident #25, to ensure physician's orders for inhaled medication were followed. […]

• No harm, potential for more than minimal, patternF658May 8, 2025

  Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for one Resident (#6), out of a total sample of 12 residents. Specifically, for Resident #6, the facility failed to ensure pain medication was not administered outside of parameters identified in the Physician's orders. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. […]