Iris Cove Health & Rehabilitation

Inspectors wroteBased on job description review and interview, the facility failed to have a Register Dietitian (RD) or other clinically qualified nutrition professional for 153 of 153 residents residing in the facility.

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to ensure timely notice regarding Medicare eligibility and coverage for 1of 3 (Resident #76) sampled residents.

Inspectors wroteBased on policy review, Director of Nursing (DON) job description review, Registered Dietitian (RD) job description review, medical record review, observation, and interview, the facility failed to assess for and ensure residents maintained acceptable parameters of nutritional status for 1 of 4 ( #173) sampled residents reviewed for nutrition.

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to protect the Residents' right to be free from neglect when they failed to provide necessary care and services to meet the needs of the Residents for 2 of 5 (Resident #3 and #4) sampled residents reviewed for a change in mental status. Resident #3, a vulnerable Resident with severe cognitive impairment, experienced seizure activity on [DATE], and staff failed to perform neurological (neuro) assessments and monitor the Resident after a seizure. On [DATE], Resident #3 experienced a change in condition including vomiting, increased lethargy, changes in speech, gurgling respirations, and subsequently became unresponsive to verbal and tactile stimulation. Resident #3 was hospitalized on [DATE] with diagnosis of an intraparenchymal hemorrhage (a bleed on the brain) and subsequently expired on [DATE]. [...]

Inspectors wroteBased on policy review, job description review, orientation checklists, record review, and interview, the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to detect changes in a resident's condition, perform neurological assessments, and monitor a resident after a change in condition for 1 of 5 (Residents #3) sampled residents.

Inspectors wroteBased on policy review, video camera footage review, medical record review, observation, and interview, the facility neglected to supervise a resident with confusion and periods of hallucinations, and at risk for wandering and elopement for 1 of 6 sampled residents (Resident #338) reviewed for wandering and elopement. Resident #338 exited the facility without staff supervision and staff knowledge and was found off the facility property, sitting on a concrete block at the entrance of a housing community, across the street from a lake, approximately 459 feet and 6 inches from the front entrance of the facility, 0.2 miles from a busy intersection and 172 feet from a busy street that had a 45 miles per hour speed limit. Resident #338 was outside the facility without staff supervision and knowledge and off the facility property for approximately 39 minutes. [...]

Inspectors wroteBased on policy review, facility investigation review, video camera footage review, medical record review, observation, and interview, the facility failed to thoroughly investigate incidents of elopement for 1 of 6 sampled residents (Resident #338) reviewed for wandering and exit-seeking behaviors. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy for Resident #338, a resident with episodes of confusion and hallucinations. Resident #338 exited the facility through the front door without staff supervision or knowledge and was found in front of a town house complex entrance, approximately 459 feet and 6 inches away from the facility. Resident #338 was outside the facility unsupervised for approximately 39 minutes. [...]

Inspectors wroteBased on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to provide adequate supervision for a resident with confusion and periods of hallucinations and failed to place and monitor a Wander Guard (mechanical bracelet device to alert staff of wandering residents that causes the door to alarm when a resident is close to exit door) for function for 2 of 6 sampled residents (Resident #96 and Resident #338) reviewed for wandering behaviors and elopement. Resident #338 exited the facility without staff supervision and knowledge and was found off the facility property, sitting on a concrete block at the entrance into a townhouse community, with a lake across the street. [...]

Inspectors wroteBased on policy review, job description review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that protected residents that wandered and exhibited exit seeking behavior from eloping from the facility. Administration failed to provide oversight to monitor and provide a safe resident environment for a confused resident with periods of hallucinations from exiting the facility without staff knowledge or supervision, failed to thoroughly investigate an incident of elopement, failed to ensure policies related to wandering and elopement were followed, and failed to ensure Wander Guards (mechanical bracelet device to alert staff of wandering residents that would cause the door to alarm when a resident is close to an exit door) were available to use on residents with wandering behaviors. [...]

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure 9 of 22 staff (Licensed Practical Nurse (LPN) #4, #5, Certified Nursing Assistant (CNA) #1, #2, #3, #5, #6, #7, and #11) provided care for a resident in a manner that maintained or enhanced the resident's dignity when the staff did not knock on resident doors prior to entering the room, called residents feeders, and did not address the resident by a courtesy title for 13 of 133 residents (Resident #8, #9, #17, #20, #37, #40, #43, #49, #64, #112, #122, #341 and #342) observed during dining.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services when oxygen tubing was not dated and/or changed weekly for 5 of 6 sampled residents (Resident #62, #63, #101, #123, and #190) reviewed for oxygen therapy.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when undated, open medications and expired medications were observed in 1 of 11 medication storage areas (West Hall Medication Room) and when 1 of 5 nurses (Licensed Practical Nurse (LPN) #2) left medications unattended for 1 of 6 sampled residents (Resident # 343) observed during medication pass.

Inspectors wroteBased on document review and interview, the facility failed to document the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on every shift on the staffing postings and failed to have staffing postings completed and available for 24 of 76 days of staffing postings (12/2/2019, 12/3/2019, 12/4/2019, 12/5/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/9/2019, 12/12/2019, 12/14/2019, 12/15/2019, 12/25/2019, 1/7/2020, 1/8/2020, 2/1/2020, 2/2/2020, 2/3/2020, 2/4/2020, 2/10/2020, 2/11/2020, 2/12/2020, 2/13/2020, 2/14/2020, and 2/17/2020) reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure residents who received psychotropic medications were appropriately monitored for side effects and behaviors for 5 of 7 sampled residents (Resident #27, #100, #104, #111, and #283) reviewed for unnecessary medications.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed in 2 of 3 isolation rooms (Resident #107 and #163) and failed to maintain infection control practices when 2 of 6 nurses (Licensed Practical Nurse [LPN] #3 and #4) failed to perform proper hand hygiene, failed to clean a stethoscope, and failed to protect the feeding tube tip from being contaminated for 2 of 7 sampled residents (Resident #45 and #88) reviewed during medication administration observations.

Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility to complete and transmit an MDS assessment within 14 days of the completion date for 1 of 38 sampled residents (Resident #2) reviewed for Resident Assessment and transmission.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to accurately assess residents for bladder and bowel continence, activities of daily living, cognition, and the use of antipsychotics for 4 of 38 sampled residents (Resident #10, #62, #87, and #104) reviewed.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to implement fall interventions for 2 of 5 sampled residents (Resident #71 and #135) reviewed for falls.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents (Resident #103) reviewed for the use of an indwelling urinary catheters.