Indian River Center

Inspectors wroteBased on interview, and record review, the facility failed to prevent physical abuse of a vulnerable resident by another resident on the memory care unit, (#1), and failed to prevent neglect of a cognitively impaired resident exhibiting worsening behavior, (#2), for 2 of 6 residents reviewed for abuse/neglect, of a total sample of 6 residents. This failure contributed to resident #1 sustaining a fractured jaw which led to his transfer to an acute care hospital where he died 6 days later. On 12/25/24 at 9:40 PM, Certified Nursing Assistant (CNA) A witnessed resident #2 enter resident #1's room. Shortly after, resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. CNA A said when he got to resident #1's room, resident #2 was coming out with resident #1's sheets in his hands. [...]

Inspectors wroteBased on interview and record review the facility failed to conduct an accurate and thorough investigation related to an allegation of resident to resident physical abuse of a vulnerable, cognitively impaired resident, (#1), failed to investigate an injury of unknown origin for the same event when abuse was not substantiated, including completely and thoroughly documenting investigative findings, to ensure the safety of all vulnerable residents on the memory care unit. This failure contributed to resident #1's injury, transfer to a higher level of care where he died 6 days later. [...]

Inspectors wroteBased on record review, and interview, the facility failed to promote a culture of safety on the locked memory care unit to ensure residents' dementia and/or behaviors were free of abuse/neglect. The facility Administration's lack of active involvement and their deficient behavioral monitoring, reporting and investigative standards contributed to negative resident-to-resident interactions, which ended, at times, with physical fights, battery, and/or life altering injuries for 2 of 6 residents reviewed for abuse, neglect and behaviors of a total sample of 6 residents, (#1, and #2). On 12/25/24 at 9:40 PM, Certified Nursing Assistant (CNA) A witnessed resident #2 enter resident #1's room. Shortly after, resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) Level II Evaluation was completed for 2 of 3 residents, (#2, #4); and failed to complete Level I screen after significant change in condition for 1 of 3 residents, (#2) reviewed for PASARR, of a total sample of 6 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing care was completed as per professional standards, and physician order for 1 of 1 resident of a total sample of 7 residents, (#7).

Inspectors wroteBased on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents on admission and/or failed to make referrals for newly evident or possible mental disorders/diagnoses to evaluate the need for specialized services or alternative placement for 6 of 7 residents reviewed for PASARRs, of a total sample of 57 residents, (#30, #34, #1, #41, #94, and #84).

Inspectors wroteBased on interview, and record review of facility documentation, the facility failed to effectively implement Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring of previously identified areas of concern and adequately track performance to ensure prior improvement measures were realized and sustained.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents courteously, fairly and with dignity by using labels such as feedersto identify them, by standing over residents while assisting with their meals, and by leaving their meal at the bedside for an extended time before they were to be assisted with dining for 2 of 7 residents reviewed for dependent dining, of a total sample of 57 residents, (#130 and #54).

Inspectors wroteBased on interview, and record review, the facility failed to obtain a Level I Preadmission Screening and Resident Review (PASARR) for 1 of 6 residents reviewed for PASARRs, of a total sample of 57 residents, (#5). Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinsonism, dementia, bipolar disorder, depression, insomnia, and dysphagia. Review of the resident's clinical record revealed no Level I or Level II PASARR. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor choice of morning routines and schedules significant to support autonomy for 1 of 6 residents reviewed for choices from a total sample of 55 residents, (#66).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate personal hygiene related to nail care for 1 of 4 dependent residents reviewed for Activities of Daily Living (ADLs) of a total sample of 55 residents, (#91).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatments to prevent further decrease in range of motion for 1 of 5 residents reviewed for positioning and mobility of a total sample of 55 residents, (#112).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care and services for oxygen therapy for 1 of 1 resident reviewed for respiratory care of a total sample of 55 residents, (#105).

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike dining environment on 1 of 2 dining rooms, (Caring Way Secure Dining Room).

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange diabetic shoe services for a diabetic resident who had a history of toe wounds for 1 of 2 residents reviewed for non-pressure wounds in a total of 47 sampled residents, (#50).

Inspectors wroteBased on observation, interview, and record review, the facility failed to label or date food items in 1 of 3 Nourishment rooms, (Key West).