Inverness Rehab

Inspectors wroteBased on interview and record review, the facility failed to follow their change in condition policy by not notifying the provider about a resident's urinary retention and being unable to drain urine through catheterization. This failure has caused 1 of 3 residents (R1) in a sample of 3 reviewed for catheter care to be admitted to the intensive care unit (ICU) for aggressive treatment for sepsis secondary to urinary tract infection (UTI).

Inspectors wroteBased on Observation, interview and record review, the facility failed to ensure food items in the walk-in refrigerator were labeled or dated. This practice has the potential to affect all 116 residents residing in the facility who receives food from the kitchen. The facility also failed to document personal refrigerator temperature logs and discard expired food from the refrigerators for seven residents R23, R28, R43, R30, R43, R65 and R72 reviewed for refrigerator logs in a sample of 24 residents. During an initial tour of the kitchen on 8/19/25 at 10:00am, surveyor and V17(Food service Director) observed in the walk-in freezer a sandwich condiment tray containing coleslaw salad, egg salad, lettuce, tomatoes, and sliced turkey with a use by date of 8/15/25. During an interview, at 10:15 am, V17 stated that the condiments tray should not be in the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures are implemented and prescribed oxygen inhalation was administered for 10 of 10 residents (R7, R14, R15, R23, R36, R45, R60, R63, R86, R98) reviewed for oxygen in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for controlled medications for four of four residents (R42, R63, R87, R98) reviewed for controlled medications in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications are stored securely for two of two residents (R80, R122) reviewed for medication storage in a sample of 14. The facility also failed to label multidose medication with open date which has the potential to affect all 24 residents currently residing in Unit 3, and all potential new admissions in Unit 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures during medication administration procedures for four of four residents (R3, R21, R30, R39) reviewed for medication administration in a sample of 24.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure low air loss mattress device was on the correct weight setting for a resident identified to be high risk in developing pressure ulcers. This deficient practice affects one (R23) of three residents reviewed for pressure injury prevention and treatment in a final sample of 24 residents. Findings Include: R23 is a [AGE] year-old male resident, with diagnoses of but not limited to: paraplegia chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel. On 8/19/25 at 11:10AM, observed R23 in bed, awake and alert on low air loss mattress set on 420 lbs. Per R23, he weighs 314 lbs the last time R23 was weighed. On 8/19/25 at 11:40AM, Observed and confirmed with V4 (ADON) that the low air loss mattress is set on 420 lbs. R23 commented that that is the setting R23 is comfortable with. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to maintain the highest level of mobility for one of six residents (R14) reviewed for mobility in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to reduce accident hazards and risks for one of two resident (R100) reviewed for accidents in a sample of 24.

Inspectors wroteBased on interview and record review the facility failed to provide medication as ordered by the prescriber to meet the needs of the resident, including acquiring medications. This failure affects one of three residents (R2), reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure that blood glucose monitoring for three (R1, R3, R4) of three residents reviewed for blood sugar monitoring were checked before meals per the physician order.

Inspectors wroteBased on interview and record review, the facility failed to investigate the allegation of sexual abuse for one of three residents (R1) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reorder scheduled medication to ensure availability for a resident and failed to pass medication timely, per physician orders. These failures applied to two (R1, R2) of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician order to check urine for presence of ketones for one (R1) of three residents reviewed for diabetic management.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on conducting background checks for four (R52, R103, R105 and R106, ) of 10 residents reviewed for admission screening. This failure has the potential to affect 117 residents currently residing in the facility.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure call lights were answered in a timely manner for two (R44 and R87) of two residents in a sample of 44 reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement effective fall interventions and adequate supervision for a dependent resident assessed as a high risk for falls with diagnoses of Parkinson's disease and Dementia. This failure affected one (R99) of three residents reviewed for falls in the sample of 44. This failure resulted in (R99) experiencing repeated falls that resulted in hospitalizations, sustaining lacerations on two occasions, with one laceration requiring three sutures.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that nursing staff (including agency staff) have the necessary competencies, skill sets, and training required to prevent falls and assure resident safety. This failure applied to 3 (R1, R2, and R3) of 3 residents reviewed for staff competence and has the potential to affect all 117 residents currently in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their fall prevention care plans and have an effective process in place to ensure direct care staff are aware of and educated about care plan interventions for 4 (R1, R3, R4, R6) of 5 residents reviewed for care plans in the sample.

Inspectors wroteBased on interview and record review, the facility failed to provide freedom from inappropriate physical restraint for 1 (R2) of 1 resident reviewed for restraints in the sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by 1. Failing to provide adequate supervision and monitoring of residents at risk for falls and with a history of falls; 2. Failed to implement and follow the plan of care to prevent falls and future falls; 3. Failed to train all staff, including agency staff on fall prevention; 4. Failed to provide staff with necessary information and immediate access for this information of all residents at risk for falls in order to keep residents safe from harm. This failure affects for 4 (R1, R3, R4, R6) of 5 residents reviewed for accident hazards in the sample and has the potential to affect all 117 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and monitoring of residents at risk for falls and with a history of falls for 4 (R1, R3, R4, R6) of 5 residents reviewed for accident hazards in the sample. The facility also failed to follow the plan of care to prevent future falls and failed to train staff (including agency staff) on fall risk interventions.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a resident from being verbally abused by a CNA (Certified Nursing Assistant) for one of two residents (R337) reviewed for abuse in the sample of 45. This failure resulted in R337's psychosocial harm as witnessed by R337's increased anxiety and agitation.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and radiological services in a timely manner, failed to follow the physician order for a STAT/immediate x-ray; failed to follow their diagnostic/labs notification policy and caused a delay in treatment for 1 (R187) of 3 residents reviewed for quality of care from the sample of 45 residents. This failure resulted in R187 waiting over 48 hours to obtain an x-ray that revealed a transverse fracture of the arm causing delayed treatment of the fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the plan of care and procedures for wound care to prevent and heal avoidable facility-acquired pressure ulcers for 2 (R3, R64) of 3 residents reviewed for pressure ulcers in the sample of 45 residents. This failure resulted in R3 and R64 to sustain facility-acquired, clinical stage 4 pressure ulcers that required surgical removal of necrotic tissue.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide effective pain management for a hospice resident with severe cognitive impairment, failed to identify signs and symptoms of pain for 1 (R187) of 5 residents reviewed for pain in the sample of 45 residents. It can be determined that the reasonable person in the resident's position would have experienced pain from the left forearm fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of quality by 1. Failing to prevent the development facility-acquired pressure ulcers, failed to train facility nursing staff including contracted nurses on pressure ulcer prevention and care; 2. Failed to follow a resident's advance directives for DNR status; 3. Failed to coordinate care with contracted hospice agencies, 4. Failed follow physician orders for a stat radiological x-ray; and 5. Failed to identify and treat pain. These failures affect 2 (R3, R64) of 3 residents reviewed for pressure ulcers, 1(R127) of 68 residents reviewed for advance directives, 1 (R187) reviewed for pain and quality of care, 4 residents (R5, R91, R92, R337) reviewed for end-of-life hospice care in the sample of 45 residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all nursing staff possess the necessary skills to provide nursing services to meet the resident's needs that promote each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 135 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their comprehensive care plans for wound care and prevention, hospice care, and fall prevention for 4 (R3, R64, R91, R95) of 6 residents from the sample of 45 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pharmacy medication labeling policy by not noting and implementing open date labels. This applies to 11 of 50 (R16, R20, R21, R28, R31, R66, R73, R86, R92, R93, R122) residents' medications in three of seven medication carts during the medication storage and labeling task. Findings Include: On 04/11/2023 at 12:31 PM Surveyor conducted inspection of medication cart on unit 2. Surveyor observed opened and undated medication for: R66 - Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH - three opened inhalers - no open date. R66 - Lactulose Oral Solution 10 GM/15ML (Lactulose) - no open date. R92 - Breo Ellipta 100-25 MCG/INH Aerosol Powder - no open date. R28 - Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT - no open date. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain consistent hospice communication for 4 of 4 (R5, R91, R92, R337) residents reviewed for hospice care in the sample of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow and implement advanced directives by providing cardiopulmonary resuscitation to one of one resident (R127) reviewed for resident rights compliance. This failure dismissed R127's Do Not Resuscitate and Do Not Intubate wishes and it has a potential to affect 68 residents with current Do Not Resuscitate advanced directives.