Our Island Home

Inspectors wroteBased 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 protection and advocacy system.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a [NAME] Monitor was appointed, and treatment plan approved by the court for one Resident (#13) who was admitted to the facility and administered an antipsychotic medication, from a total sample of 12 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, the facility failed to:1. Ensure a treatment cart was locked when not in direct supervision of a licensed nurse;2. Ensure Resident #10's Albuterol Sulfate HFA inhaler (used to treat shortness of breath) was stored securely; and3. Ensure Resident #25's medications were stored in their original packaging.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:-Ensure staff handled medications in a sanitary manner to prevent potential transmission of infections; and-Ensure staff followed hand hygiene procedures prior to handling medication(s) and after administering medication(s).

Inspectors wroteBased 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.

Inspectors wroteBased on observations, document review, and interviews, the facility failed to follow infection control prevention practices to prevent the transmission of communicable diseases and infections for one Resident (#13) out of one resident on transmission-based precautions, out of a total sample of 13 residents. Specifically, the facility failed to ensure staff wore the appropriate PPE (personal protective equipment) while providing care for Resident #13, who was on droplet and contact precautions.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#10, #5 and #21), out of a sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended Pneumococcal vaccine 20-valent (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed for one Resident (#12), of 12 sampled residents, to maintain their catheter drainage bag below the level of the bladder at all times to prevent potential complications.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility for one Resident (#17), out of a total sample of 12 residents. Specifically, the facility failed to implement enhanced barrier precautions for a Resident who has a tracheostomy stoma and is at high risk for infection.

Inspectors wroteBased on interview, the facility failed to implement and maintain an effective training program for all staff, which included laundry personnel, training on standards, policies, and procedures for the facility's infection prevention and control program as it relates to handling contaminated laundry.