Central Island Healthcare

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/10/2025 and completed on 6/16/2025, the facility did not develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. This was identified for one (Resident #305) of one resident reviewed for Urinary Catheter. Specifically, Resident #305 was admitted on [DATE] with the use of an indwelling Foley catheter. The baseline care plan, completed on 6/9/2025, did not document the use of the Foley catheter. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/10/2025 and completed on 6/16/2025, the facility did not ensure that a comprehensive person-centered care plan was developed or implemented for each resident to meet a resident's medical and nursing needs. This was identified for one (Resident #93) of four residents reviewed for Skin Conditions Non-Pressure. Specifically, Resident #93 had a Physician's Order to put on a compression bandage wrap in the morning and remove at bedtime, for bilateral (both) lower extremities. Resident #93 was observed multiple times without the compression bandage wrap on the right lower extremity. Additionally, there was no care plan developed to address Resident #93's use of the compression bandage wrap for both lower extremities. The finding is: [...]

Inspectors wrote2) The facility's policy titled Maintenance Book, revised 1/2025, documented that the maintenance books and daily work orders will be inspected and completed by the end of the shift daily unless an outside vendor must be involved. As the Maintenance Technician arrives and starts the assignment, all maintenance books located on all units at the nurse's station will be checked. As work orders are written in the maintenance log books on each unit, Maintenance Technicians are to do daily rounds and check and complete work orders. The Maintenance Technician must sign off on any work orders completed. If unable to complete, report to the [Maintenance] Director for further assistance and direction. Resident #142 was admitted with diagnoses including Cerebrovascular Accident, Heart Failure, and Malnutrition. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure each resident received pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet their needs. This was identified for one (Unit 2 North medication cart) of ten medication carts observed during the Medication Storage Task. Specifically, Licensed Practical Nurse #1 administered the Lantus Insulin to Resident #128 on [DATE] and [DATE] from a a multidose vial that was dated [DATE]. As per the manufacturer's recommendations, the Lantus insulin multidose vial should be discarded after 28 days from opening. The finding is: [...]

Inspectors wrote2) Resident #93 was admitted with diagnoses including Chronic Obstructive Pulmonary Disorder, Congestive Heart Failure, and Sjögren Syndrome (an immune system illness that mainly causes dry eyes and dry mouth). The admission Minimum Data Set assessment, dated [DATE], documented a Brief Interview for Mental Status score of 15, which indicated that Resident #93 had intact cognition. The Minimum Data Set assessment documented that Resident #93 had shortness of breath or trouble breathing when lying flat. A Physician Order dated [DATE] documented Breyna 160 micrograms-4.5 micrograms/actuation aerosol inhaler, inhale 2 puffs by inhalation route every 12 hours for Asthma. A review of Resident #93's Electronic Medical Record indicated Resident #93 did not have a Physician Order and was not assessed to self-administer their medications. A Comprehensive Care Plan titled, Respiratory Disorder: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 6/10/2025 and completed on 6/16/2025, the facility did not ensure that each resident's medical records were in accordance with accepted professional standards and practices and were complete and accurately documented. This was identified for one (Resident #94) of five residents reviewed for Unnecessary Medications. Specifically, Resident #94 had a physician's order for sliding scale insulin (adjusting the insulin dose based on the current blood glucose reading) coverage. Review of the June 2025 medication administration record revealed multiple instances when the insulin was administered based on the sliding scale order; however, the dosage and the injection site were not documented. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 6/10/2025 and completed on 6/16/2025, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #303) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #303 was placed on Contact and Droplet Precautions as per the physician's order for a diagnosis of Bronchitis (inflammation of the lining of the airway) due to Rhinovirus (common cold). Registered Nurse # 1 was observed entering Resident #303's room without wearing appropriate Personal Protective Equipment. The finding is: [...]

Inspectors wroteBased on record review and staff interview during the abbreviated survey (NY00367963) the facility did not ensure that each resident receive an accurate assessment reflective of the resident's status. This was evident for one (Resident #1) resident reviewed for Minimum Data Set (MDS) Accuracy. Specifically, the Minimum Data Assessment Assessments dated 12/16/2024 with a look back period of 12/09/2024 to 12/16/2024 documents the resident had 1 (one) unstageable pressure ulcer due to coverage of wound bed by slough and eschar present on admission and 1 (one) unstageable pressure injuries presenting as deep tissue injury that were present on admission/entry (12/09/2024). The Nursing admission Progress Noted dated 12/10/2024 at 11:58PM documented redness to the sacrum no openings, bilateral heals red and dry.

Inspectors wroteBased on observations, record review and interviews during the Recertification Survey initiated on 1/2/2024 and completed on 1/9/2024 the facility did not ensure that all alleged violations were thoroughly investigated. This was identified for one (Resident #129) of five residents reviewed for Accidents and one (Resident #174) of three residents reviewed for Skin Care (Non-Pressure Related). Specifically, 1) on 10/2/2023 a skin tear to Resident #129's left leg was identified by a Certified Nursing Assistant and reported to the nursing supervisor. There was no documented evidence that the facility initiated an investigation to identify the root cause of the skin tear, an injury of unknown origin, to rule out abuse, neglect, and mistreatment; and 2) Resident #174 had a Physician's order to treat a skin tear to the left lower leg. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/2/2024 and completed on 1/9/2024 the facility did not ensure that a comprehensive person-centered care plan was developed or implemented for each resident to meet a resident's medical and nursing needs. This was identified for one (Resident #62) of two residents reviewed for pressure ulcers and one (Resident #80) of three residents reviewed for Skin Condition. Specifically, 1) Resident #62 had a physician's order and care plan intervention to float heels while the resident was in bed. On multiple occasions the resident was observed in bed with their heels directly on the mattress; and 2) Resident #80 had a physician's order to elevate all extremities and to wear heel booties at all times. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 1/2/2024 and completed on 1/9/2024, the facility did not ensure that all residents were provided the necessary services to ensure that a resident's abilities in activities of daily living do not diminish. This was identified for one (Resident #19) of three residents reviewed for Activities of Daily Living. Specifically, Resident #19 did not receive the nursing Floor Ambulation Program in December 2023 and January 2024 as recommended by the Rehabilitation Department and as indicated on the resident's Comprehensive Care Plan. The finding is: The facility's Floor Ambulation Program policy and procedure dated 9/15/2018 documented that residents with limited abilities in ambulation will be assisted to maintain and/or regain these abilities to the greatest extent possible. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/02/2024 and completed on 1/09/2024, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #152) of five residents reviewed for Accidents. Specifically, Resident #152 sustained a left wrist fracture, was sent to the hospital for evaluation and returned to the facility with recommendations to use a left wrist splint. The facility staff did not obtain physician's orders for the use of the splint, did not refer the resident to the Rehabilitation Therapy department for recommendations related to the wrist fracture. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 1/2/2024 and completed on 1/9/2024 the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #88) of two residents reviewed for Pain Management. Specifically, Resident #88 had a physician's order for Oxycodone (a narcotic pain medication), 10 milligrams (mg) tablet, to be administered six times per day (for a total of 60 milligrams daily); however, the resident was only receiving the medication four times a day (for a total of 40 milligrams daily) due to a discrepancy in how the physician's order was written, which was not identified by the facility staff. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 1/2/2024 and completed on 1/9/2024 the facility did not ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This was identified for one (Resident #138) of three residents reviewed for Mood and Behavioral Symptoms. Specifically, Resident #138 exhibited depressive symptoms and had a Physician's order for psychological counseling one to five times a month. Resident #138 was not provided with psychological counseling as per the Physician's orders. The Finding is: [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 1/02/2024 and completed on 1/09/2024, the facility did not ensure an infection prevention and control program was established to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #523) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #523 had a physician's order for Contact and Droplet precautions for a confirmed positive COVID-19 infection. On 1/4/2024 Certified Nursing Assistant #9 was observed exiting Resident #523's room wearing Personal Protective Equipment (a gown, gloves, and a surgical mask). Certified Nursing Assistant #9 did not remove the Personal Protective Equipment prior to wheeling the resident out of their room to obtain the resident's weight. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint #NY 00262655) completed on 1/4/2022, the facility did not ensure that injuries of unknown origin were reported immediately (no later than 24 hours) to the New York State Department of Health (NYSDOH) for one (Resident #67) of one resident reviewed for Abuse. Specifically, on 7/29/2020 Resident #67 was noted with edema to the right knee and discoloration to the lower right leg. Subsequently, the X-ray report indicated a right knee fracture. The identified injury was of unknown origin and the facility did not report the injury to the NYSDOH. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 1/4/2022, the facility did not ensure that opened medications were discarded according to the manufacturer's recommendation. This was identified in 1 of 3 medication room refrigerators. Specifically, an opened multidose vial of Influenza Vaccine was not discarded within the timeframe specified by the manufacturer. The finding is: The facility policy titled Medication Storage for Injectables documents, All other multiple-dose vials will be discarded according to manufacturer's specifications, and if not specified, shall be maintained no longer than 1 year or the manufacturer's list expiration date on the vial, whichever is shorter. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY#00286283), completed on 1/4/2022, the facility did not ensure non-pharmacological interventions were implemented and documented for each resident who was administered an as-needed (PRN) psychotropic medication for one (Resident #401) of two residents reviewed for Hospitalization. Specifically, Resident #401 received PRN Alprazolam (Xanax-an antianxiety medication) on two occasions with no documented evidence for the need to use the antianxiety medication nor non-pharmacological interventions attempted prior to the administration of the antianxiety medication. The finding is: [...]