Deficiencies (last 3 years)
Deficiencies (over 3 years)
20.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 13
Apr 30, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at Islands Skilled Nursing & Rehabilitation.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, environmental cleanliness, accurate resident assessments, care planning, medication management, infection control, and safety measures. Specific issues included staff standing over residents during meals, dust buildup on televisions, inaccurate assessments and care plans, failure to act on pharmacist recommendations, improper medication labeling and storage, inadequate infection prevention practices, and failure to maintain dryer lint cleaning records.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to a dignified existence during meal assistance; staff were standing over residents while assisting with meals and urinary catheter bag was not covered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a clean and homelike environment; buildup of dust on the back of ceiling mounted televisions in five rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess one resident's limitations of range of motion, resulting in risk of improper treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a baseline care plan for a resident's hyperglycemia and insulin use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans for two residents, including bed rail use and range of motion interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow care plan and facility protocols for prevention and treatment of pressure ulcers for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an environment free from accident hazards; a resident's bed rail was removed without staff awareness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to act on pharmacist medication regimen review recommendations, putting a resident at risk for medication complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication cart keys were secured and narcotic counts were properly reconciled; expired insulin was administered to a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure ice machine was kept clean and sanitary; buildup of grayish-green residue was observed under the ice dispenser. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to correctly complete a Physician Orders for Life Sustaining Treatment (POLST) form for a resident, including inaccurate designation of healthcare power of attorney. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control measures; urinary catheter bag was resting on the floor and staff failed to perform hand hygiene between glove changes and wear gowns when required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to keep records of dryer lint removal and cleaning, with observation of lint accumulation in dryer traps. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for dignity deficiency: 4
Residents sampled for care plan review: 20
Residents sampled for pressure ulcer review: 3
Residents sampled for medication review: 5
Residents sampled for urinary catheter or UTI: 2
Medication administration dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interim Director of Nursing | Interviewed multiple times regarding deficiencies in dignity, catheter privacy, medication regimen review, care plans, and infection control |
| Certified Nurse Aide 9 | Certified Nurse Aide | Observed assisting resident R9 with meals while standing over resident |
| Certified Nurse Aide 11 | Certified Nurse Aide | Observed assisting residents R13 and R16 with meals while standing over residents |
| Environmental Services Supervisor | Environmental Services Supervisor | Acknowledged dust buildup on televisions and lack of proper cleaning equipment |
| Administrator | Administrator | Interviewed regarding housekeeping schedules, staffing submissions, and medication cart policies |
| Infection Preventionist | Infection Preventionist | Confirmed staff training on hand hygiene and PPE use |
| Registered Nurse 7 | Registered Nurse | Observed leaving medication cart keys unattended and handling expired insulin |
| Social Worker | Social Worker | Interviewed regarding POLST and advance directive issues for resident R18 |
| Kitchen Manager | Kitchen Manager | Observed ice machine condition and cleaning logs |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jul 18, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's inappropriate discharge of a resident (R1) without adequate reason or proper notification, and failure to allow the resident to return post hospitalization despite having the capacity to provide needed care.
Findings
The facility violated federal regulations by initiating a discharge without the resident's representative's consent, failing to provide required discharge documentation and notification, and denying the resident the right to return after hospitalization. Additionally, the facility failed to update the resident's care plan with important preferences, did not provide 24-hour physician availability during an emergency, and nursing staff lacked competency in managing the resident's care, including unauthorized medication administration.
Complaint Details
The complaint involved a resident (R1) who was transferred to a hospital for acute care. The facility initiated a discharge without the resident's representative's consent and failed to notify the representative or ombudsman properly. The facility refused to allow the resident to return post hospitalization despite having the capacity to provide needed care. The resident's representative was not given the opportunity to appeal the discharge decision.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility initiated discharge without adequate reason or proper notification to resident's representative, denying resident the right to return post hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification of transfer/discharge to resident's representative and ombudsman, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to permit resident to return to the facility after hospitalization despite having capacity and capability to provide care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop a complete and updated care plan reflecting resident's specific preferences and interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide or arrange emergency physician care 24 hours a day; nursing staff unable to reach provider during resident's emergency condition. | Level of Harm - Minimal harm or potential for actual harm |
| Nursing staff lacked competency to provide safe care, including unauthorized application of scopolamine patch causing harm. | Level of Harm - Actual harm |
Report Facts
Deficiencies cited: 6
Resident heart rate: 160
Notification dates: May 31, 2024
Notification dates: Jun 5, 2024
Medication order dates: Mar 5, 2022
Medication order dates: Mar 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Director | Admissions Director | Interviewed regarding admission and discharge decisions for resident R1. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and nursing staff competency issues. |
| Administrator | Administrator | Interviewed regarding decision to deny resident return and interactions with family. |
| Respiratory Therapist | Respiratory Therapist | Interviewed regarding resident's respiratory care and behavior on day of transfer. |
| Social Worker | Social Worker | Interviewed regarding transfer/discharge notification process. |
| Physician MD1 | Physician | Interviewed regarding resident's condition and medication orders. |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 16, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and mistreatment involving residents R34 and R10, including failure to timely report suspected abuse and failure to prevent further potential abuse during the investigation.
Findings
The facility failed to timely report allegations of abuse within the required timeframes and did not remove the accused staff member from resident care during the investigation. The investigation found the allegations unsubstantiated. Additionally, the facility failed to report an injury to resident R10 and did not document communication from the dialysis center regarding the injury.
Complaint Details
The complaint involved allegations of physical and verbal abuse by CNA16 towards residents R34 and R10. The Long-Term Care Ombudsman reported the incident on 05/08/24. The facility failed to report the abuse allegation within two hours as required and did not remove the accused staff member during the investigation. The investigation was completed on 05/10/24 and found the allegations unsubstantiated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse or mistreatment to the State Survey Agency within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent further potential abuse by not removing the accused Certified Nurse's Aide (CNA16) from resident care during the investigation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report and document injury to resident R10 and lacked communication from dialysis center regarding the injury. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Dates of incident and reporting: Incident occurred 05/08/24, reported to State Survey Agency on 05/10/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA16 | Certified Nurse's Aide | Accused staff member in abuse allegations involving residents R34 and R10 |
| DON | Director of Nursing | Interviewed regarding investigation and reporting of abuse allegations |
| RN23 | Unit Manager Registered Nurse | Interviewed regarding resident R10's bruise and communication with dialysis center |
| RN83 | Registered Nurse | Assigned nurse to resident R10, interviewed about bruise |
Inspection Report
Routine
Deficiencies: 17
May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, failure to timely report and respond to abuse allegations, inadequate notification of transfers, incomplete and inaccurate care plans, medication errors including improper administration and documentation, inadequate infection prevention and control practices, and failure to maintain accurate facility-wide assessments and staffing information.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure residents were provided privacy and dignity while receiving care, including uncovered urinary catheter bags and inadequate privacy curtains. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the rights of a resident's representative in medical treatment decisions were exercised, specifically regarding tracheostomy cap placement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written Notice of Medicare Non-Coverage (NOMNC) to residents or their representatives as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report allegations of abuse and mistreatment to the State Survey Agency within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent potential further abuse by not removing accused staff from resident care during investigation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely written notification of resident transfer/discharge to resident, representative, and Ombudsman. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to reassess resident for falls quarterly as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to include resident daily preferences in baseline care plan within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide residents with necessary supplies for nutrition, grooming, and hygiene, including shortages of feeding pump tubing, suction toothbrushes, and appropriately sized briefs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident received treatment and care according to physician orders, specifically failure to hold stool softener medication during episodes of loose stools. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post daily nursing staffing information including hours worked and resident census. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure licensed pharmacist documented physician review and response to medication regimen review recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and failed to limit PRN psychotropic medication use to 14 days without documented rationale. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label medications properly, store medications securely, and ensure narcotic counts were signed off each shift. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurses accurately documented medication administration routes and failed to ensure medications were not left unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct, document, and annually review a comprehensive facility-wide assessment reflecting resident needs and resources. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an effective infection prevention and control program, including environmental cleaning, equipment cleaning, and proper use of disposable equipment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 38.36
Residents with tracheostomies: 24
Residents on mechanical ventilators: 15
Supply budget: 18000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN80 | Registered Nurse | Observed administering medications incorrectly to Resident 17. |
| RN23 | Unit Manager Registered Nurse | Interviewed regarding medication administration and care plan deficiencies. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, infection control, and reporting. |
| RT22 | Respiratory Therapist | Interviewed regarding suction cannister change frequency. |
| RTS | Respiratory Therapist Supervisor | Interviewed regarding tracheostomy cap incident and suction cannister. |
| CNA16 | Certified Nurse's Aide | Named in abuse allegation and investigation. |
| FM6 | Family Member | Reported abuse allegation against CNA16. |
| RN79 | Registered Nurse | Interviewed and observed regarding medication administration and feeding pump use. |
| SS | Supply Supervisor | Interviewed regarding supply shortages and ordering. |
| IP | Infection Preventionist | Interviewed regarding infection control program and housekeeping involvement. |
| DOM | Director of Maintenance | Interviewed regarding housekeeping and environmental cleaning. |
Inspection Report
Routine
Deficiencies: 2
Sep 6, 2023
Visit Reason
The inspection was conducted to assess compliance with vaccination policies, specifically pneumococcal and COVID-19 vaccinations, including documentation and education provided to residents and their representatives.
Findings
The facility failed to ensure pneumococcal vaccination was offered to one of six sampled residents, placing the resident at risk. Additionally, the facility failed to properly document COVID-19 vaccination administration or refusal for one resident, and did not document education provided to the resident's representative regarding the vaccine.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure pneumococcal vaccination was offered to one resident at high risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly document COVID-19 vaccination administration or refusal and education provided to resident or representative. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 6
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding pneumococcal vaccine eligibility for resident R3 |
| Infection Preventionist | Infection Preventionist | Interviewed and provided information on vaccination consent and documentation |
Inspection Report
Routine
Deficiencies: 20
May 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication management, staffing, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights regarding communication and self-determination, inadequate care planning, insufficient staffing levels, medication management issues including missing pharmacist reviews and improper medication storage, failure to prevent accidents and falls, inadequate nutritional care, failure to accommodate food allergies, and lapses in infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Deficiencies (20)
| Description | Severity |
|---|---|
| Staff speaking a foreign language around residents, which bothered some residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to identify and support a resident's preference to not be placed in a yellow gown. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post the results of the facility's most recent State survey in an accessible location for residents and family. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to repair damaged linoleum floor and ripped privacy curtains in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely written notice of discharge to residents or representatives and to the State Long-Term Care Ombudsman. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written notice of the facility's bed-hold policy to residents upon transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement person-centered comprehensive care plans for residents, including care plans for gastrostomy tube placement verification and indwelling catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise care plans following falls or to document effectiveness of fall prevention interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care for residents with craniectomy and gastrostomy tubes, including failure to verify proper G-tube placement prior to use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents remained free from accidents due to incomplete fall risk assessments and lack of monitoring and revision of fall prevention interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide nutritional care and services to address significant weight loss, including failure to notify dietitian and physician. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to use infection control precautions for gastrostomy tube care, including improper storage and disposal of syringes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure sufficient nursing staff to meet residents' needs in a timely manner, resulting in long call light response times and staffing ratios below facility assessment recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure monthly drug regimen reviews by a licensed pharmacist, missing medication regimen reviews for multiple months, and failure to act on pharmacist recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement gradual dose reductions and limit PRN psychotropic medication orders, including indefinite PRN orders without rationale and lack of dose reduction attempts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure all medications were securely stored in locked compartments; medication carts were observed unlocked and unattended multiple times. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide food that accommodates resident allergies; a resident was served food containing an allergen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a clean food preparation area; dust was observed on sprinkler pipes above the food prep area. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate medical records; physician progress notes were documented in the wrong resident records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow airborne precautions for a resident on droplet precautions; staff provided care without wearing required gown. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident to CNA ratio: 7
Resident to CNA ratio: 8
Weight loss percentage: 9.24
Weight loss in pounds: 1.6
Missing medication regimen reviews: 4
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