Island Nursing and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure the resident's right to self-administer medications. This was identified for one (Resident #8) of six (6) residents reviewed for Accidents. Specifically, Resident #8 was observed with a souffle medication cup containing four pills on their bedside table. There was no documented evidence Resident #8 was assessed to self-administer medications, and the resident did not have a physician's order to self-administer their medications. The finding is: The facility policy titled Medication, Self-Administration, dated 2/2017, documented that each resident shall have the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Self-administering medications is [permitted] by physician order only. Medications kept at bedside are in a locked box. Resident #8 was admitted with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure person-centered comprehensive care plans that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs were developed and implemented. This was identified for one (Resident #8) of two residents reviewed for Behavioral and Emotional Status. Specifically, Resident #8 had a Physician's order for a two-person approach in care and a Comprehensive Care Plan for Accusatory Behaviors with interventions that included a two-person approach. During an observation on 07/31/2025 at 11:05 AM, Certified Nursing Assistant #1 provided care to Resident #8 without a second caregiver in the resident's room.The finding is:Resident #8 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Osteoarthritis. The Quarterly Minimum Data Set assessment dated [DATE], documented a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 07/31/2025 and completed on 08/06/2025, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified for one (Unit 3) of two units reviewed for medication storage and medication administration tasks. Specifically, during the medication storage task/medication administration task on Unit 3 on 08/01/2025 at 5:46 AM, the Controlled Substance Administration Record was not reconciled to reflect Resident #60's refusal of Tramadol hydrochloric acid medications on 07/31/2025 at 9:00 PM. The finding is: The Facility's Controlled Substances and Narcotics Policy dated January 2025 documented that when a resident refuses a controlled substance after it has been poured, the medication must be destroyed with a witness, and the back of the Controlled Drug 24-Hour Administration Record must be completed. The Nursing Supervisor must be notified. Resident #60 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 7/31/2025 and completed on 8/6/2025, the facility did not ensure all drugs and biologicals were stored in locked compartments and only authorized personnel were permitted to have access. This was identified for one (Unit 3 ) of two (2) Units reviewed during the medication storage task and for one (Resident #8) of six (6) residents reviewed for accidents. Specifically, 1) during the medication administration observation on 08/01/2025 at 5:46 AM, an unattended medication cart on Unit 3 was observed to be unlocked in the hallway with an unlocked narcotic box. Additionally, there were two cups containing Resident #60's controlled medications on the medication cart. 2) Resident #8 was observed with a souffle medication cup containing four (4) medication tablets on their overbed table and did not have a Physician's order to self-administer medications. The findings are: 1) The facility's Controlled Substances and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification and abbreviated Survey (Complaint #NY 00327627) initiated on 6/05/2024 and completed on 6/11/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for two (Unit 2 and Unit 3) of three units reviewed during the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 1 2024 from October 1, 2023, through December 31, 2023, indicated excessively low weekend staffing; 2) During the survey 13 of the 26 sampled residents ( Resident # 19, # 72, #45, # 18, # 75, # 16, # 57, # 36, # 39, # 73, # 31, 50 and # 49) complained of staffing shortage causing a delay in staff response to call bells and a delay in attending to the residents' needs; and 3) During observations on the weekend of 6/8/2024 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure an assessment was completed for each resident to accurately reflect a resident's status. This was identified for one (Resident #54) of one resident reviewed for Hospice and End of Life. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect Resident #54 received Hospice care. The finding is: The facility's policy and procedure titled MDS 3.0 Completion dated August 2020 documented residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The facility initially and periodically conducts a comprehensive, accurate, and standardized assessment of each resident's functional capacity. Resident #54 was admitted with diagnoses including Dementia, Protein-Calorie Malnutrition, and Hypothyroidism. The Quarterly Minimum Data Set assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure a comprehensive person-centered care plan was generated for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1) one (Resident #81) of two residents reviewed for skin conditions; 2) one (Resident #73) of two residents reviewed for positioning; and 3) one (Resident #90) of one resident reviewed for language and communication. Specifically, 1) Resident #81 had a history of a chronic skin condition and was currently experiencing symptoms that included pruritis (itching), crusting, and weeping lesions. There was no comprehensive care plan developed for the resident's chronic skin condition; 2) Resident #73 was observed on 6/5/2024 and 6/9/2024 wearing a Miami J Cervical Collar and there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024 the facility did not ensure person-centered comprehensive care plans were reviewed and revised to address each resident's needs. This was identified for 1) one (Resident #80) of one resident reviewed for hydration and 2) one (Resident #37) of one resident reviewed for Dental Services. Specifically, 1) there was no documented evidence that the comprehensive care plans for Resident #80 were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment. 2) For Resident #37, the dental care plan was not reviewed and revised to reflect the resident's dental pain concerns and the need for dental X-rays as recommended by the resident's Dentist. The finding is: A facility policy titled Comprehensive Care Plan, dated 12/2019 documented that the interdisciplinary team should ensure the timeliness of each resident's person-centered comprehensive care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure that each resident's medical care was supervised by a Physician throughout the resident's stay. This was identified for 1) one (Resident #45) of one resident reviewed for anticoagulant medication use and 2) one (Resident #73) of one resident reviewed for positioning/mobility. Specifically, 1) Resident #45's permanent cardiac pacemaker (a device placed in the chest that sends small electrical impulses to the heart muscles for maintaining a suitable heart rate) was supposed to be checked every three months as per the physician's order. The resident's Primary Care Physician did not ensure the pacemaker was monitored as per the physician's order. 2) Resident #73 was observed on multiple occasions wearing a Miami J Collar. The Primary Care Physician was not aware of the use of the Miami J Collar (a neck brace used to prevent head and neck movement) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews during the Recertification Survey and Extended Survey (NY 00312849) initiated on 6/5/2024 and completed on 6/11/2024, the facility did not ensure that each resident received routine dental care. This was identified for one (Resident #37) of two residents reviewed for Pain Management. Specifically, on 3/17/2023, Dentist #1 recommended dental X-rays of the upper left and lower left teeth for Resident #37 due to a complaint of mouth pain. There was no documented evidence that the dental X-rays were ever done. The finding is: The facility's policy titled Dental and Oral Health, dated 1/2021, documented it is the policy of the facility to make routine and 24-hour emergency dental care available to its residents and to ensure the availability of these services. The dental program shall include preventive care, evaluation, and treatment, including extractions, restorative dentistry, and dental prosthetics. Resident #37 was admitted with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Osteoarthritis. The 1/25/2023 Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility failed to establish and maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases. This was identified for six (Resident #77, #57, #50, #9, #43, #32) of seven residents reviewed for respiratory care. Specifically, for six (Resident #77, #57, #50, #9, #43, #32) of six residents receiving nebulizer treatment the facility did not follow their policy and procedures to change or clean the tubing, the mouthpiece, and the mask utilized to provide treatment via the nebulizer to prevent and minimize the risk of infection. Findings include but are not limited to: The Nebulizer Policy revised in May 2022, documented that after completion of nebulizer treatments, the nebulizer mask must be rinsed with normal saline and air dried. The mask can be cleanly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice. This was identified for one (Resident #64) of seven residents reviewed for respiratory care. Specifically, Resident #64 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was not receiving oxygen therapy as per the Physician's order. The finding is: The policy and procedure for oxygen administration dated November 2019 documented to verify there is a Physician's order for the procedure [oxygen administration], assemble equipment needed for the procedure [oxygen administration], and connect the resident tubing to the oxygen source. Resident #64 was admitted with the diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews during the Recertification Survey initiated on 9/6/2022 and completed on 9/13/2022, the facility did not ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs safely, and in a manner that promotes each resident's rights, physical, mental and psychosocial well- being. This was identified for one (Resident #64) of seven residents reviewed for Respiratory care. Specifically, Resident #64 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had a Physician's order to administer oxygen continuously at 3 Liters/minute. The Certified Nursing Assistant (CNA) did not report the resident's refusal to utilize the physician prescribed oxygen to the charge nurse. The finding is: The Policy and Procedure for Oxygen administration dated November 2019 documented to verify there is a Physician's order for the procedure [oxygen administration], assemble equipment needed for the procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.