Indian River Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. Review of the medical record revealed resident #2, a [AGE] year-old male was admitted to the facility on [DATE] from an in-patient psychiatric hospital with diagnoses that included Alzheimer's Disease, major depressive disorder, recurrent severe, anxiety disorder, cognitive impairment, mild neurocognitive disorder, hypermobility syndrome, and affective mood disorder with other behavioral disturbance. The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) of 12/29/24 noted during the look-back periods, resident #2 was rarely/never understood and unable to complete the Brief Interview for Mental Status (BIMS). Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #7, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included acute cystitis with hematuria, urinary tract infection, and chronic systolic (congestive) heart failure. The resident's hospital Discharge Worksheet dated 1/24/25 read, Your PICC/Midline dressing should be changed routinely every 7 days or sooner if becomes wet, soiled or loose. Review of the resident's admission readmission Nursing Evaluation dated 1/29/25 revealed he was admitted from the hospital on 1/29/25. The resident was alert and oriented to person, place, time and event, and had an intravenous (IV) access via a PICC. A PICC is a catheter (small tube) used to give treatments and to take blood. The catheter is inserted into an arm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: 1. Review of the medical record revealed resident #30, a [AGE] year old female was admitted to the facility from an acute care hospital on 6/26/24 with diagnoses that included history of stroke, metabolic encephalopathy (brain dysfunction), epilepsy, dementia, insomnia, major depressive disorder, generalized anxiety disorder, and psychotic disorder. The Minimum Data Set (MDS) admission assessment with an Assessment Reference Date (ARD) 7/03/24 indicated during the look-back period, resident #30 was rarely/never understood and staff assessed her cognition as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Review of the facility's policy, Quality Assurance/Performance Improvement Plan revealed the following, All employees will participate in ongoing quality assurance and performance improvement efforts which support our mission by striving to provide excellent service for residents. The document indicated the QAPI committee was ultimately responsible to ensure compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. In addition the QAPI committee would implement any Performance Improvement Projects (PIP) topics indicated by data analysis. PIPs were, Implemented in accordance with CMS' protocol for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). Findings: 1. On 9/09/24 at 1:15 PM, Certified Nursing Assistant (CNA) A was observed bringing a meal tray into resident #130's room. She then fed the resident lunch while standing up, leaning over the resident's meal and bedside tray, while she spooned food items into the resident's mouth. CNA A was observed going in and out of several resident's rooms and at 1:26 PM, another resident asked her for assistance to get back to bed. CNA A replied, she had two feeders she needed to help, and she would help him when she finished. CNA A was then observed entering resident #130's room to assist the roommate, resident #54, with their lunch. CNA A also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of resident #5's physician orders revealed Quetiapine Fumarate 600 milligrams (mg) at bedtime for bipolar disorder with a start date of 7/16/24, Donepezil 10 mg at bedtime for dementia on 7/16/24, Mirtazapine Tablet 30 mg at bedtime for depression with a start date of 7/16/24, Lamotrigine 200 mg at bedtime for bipolar disease with a start date of 8/01/24, Lamotrigine 200 mg in the morning for bipolar disease with a start date of 8/1/24 and Aripiprazole 25mg in the morning for bipolar disorder with a start date of 9/03/24. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: A review the medical record revealed resident #66 was admitted to the facility 7/26/2019 with diagnoses including stroke and hemiplegia. Resident #66's Minimum Data Set (MDS) quarterly assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. Activities of daily living (ADL) showed the resident required assistance with transfers from the bed and getting dressed. The MDS admission comprehensive assessment with Assessment Reference Date of 7/28/2022 noted it was very important to the resident to choose what clothes to wear while in the facility. Resident #66's lifestyle and activity assessment evaluation dated 7/27/2022 indicated the resident formerly worked as a fashion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Review of resident #91's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, congestive heart failure, atrial fibrillation, glaucoma, hearing loss, and dementia. Review of resident #91's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/22 revealed he had a Brief Interview for Mental Status score of 12 which indicated he had moderate cognitive impairment. The MDS showed resident #91 required extensive assistance on staff for dressing, and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. Review of the admission readmission Nursing Packet dated 8/9/22 included a Skin Assessment. The assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #112 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction, contracture of right ankle, contracture of left ankle and contracture of muscles of left hand. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/16/22 revealed resident #112 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. She required extensive to total assistance with Activities of Daily Living (ADLs) and did not resist care. The assessment revealed she had limited range of motion (ROM) to one side of her body for upper extremities and both sides of her body for lower extremities. A care plan for ADL assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #105 was admitted to the facility on [DATE] and most recently re-admitted on [DATE]. Her diagnoses included cerebrovascular disease, diabetes mellitus type 2, hypertension, coronary artery disease and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment with assessment reference date 11/23/22 revealed resident #105 was cognitively intact, and had physical or verbal behaviors towards herself or others. Resident #105 was assessed as needing extensive assistance from at least two staff for bed mobility, transfers from surface to surface and dressing. She required extensive assistance from one staff for eating and personal hygiene. Resident #105 was noted to require use of oxygen and received hospice care. Resident #105 had a care plan for altered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide a homelike dining environment on 1 of 2 dining rooms, (Caring Way Secure Dining Room). Findings: On 3/15/21 at 12:20 PM, observations of the secure unit dining room revealed there were no tablecloths or napkins on the tables and lunch served in plastic/disposable dishware and flatware. On 3/15/21 at 12:37 PM, Certified Nursing Assistant (CNA) F served soup and crackers in plastic bowls with disposable plastic spoons. There were no napkins served with the soup. On 3/15/21 at 12:46 PM, resident #471 stood up, walked across the room and asked CNA F for a napkin to use while she ate her soup. CNA F provided the resident with 3 brown paper towels from the handwashing sink. On 3/15/21 at 12:51 PM, resident #36 was observed eating her soup while her nose was dripping. There were no napkins on the table and she wiped her dripping nose on her hand. On 3/15/21 at 1:03 PM, resident #63 had chicken noodle soup and was spitting the chicken out into her hand as there were no napkins on the table. CNA C walked by her and told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, diabetic neuropathy with diminished sensation to her right lower extremity, left above the knee amputation (AKA), and rheumatoid arthritis. The resident's most recent quarterly Minimum Data Set (MDS) assessment revealed her Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated no cognitive impairment. On 3/15/21 at 12:33 PM, the resident was observed with Registered Nurse (RN) E. Resident #50 said she had a wound on her right big toe. She pointed to the tennis shoe on her right foot and said the inside of the tennis shoe had rubbed against her big toe and caused the wound. RN E indicated the resident's toe wound started as a blister,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to label or date food items in 1 of 3 Nourishment rooms, (Key West). Findings: On 3/17/21 at 11:12 AM, the Key [NAME] Nourishment Room freezer was noted with 1 gallon container of lactose free vanilla ice cream and a beef patty. The beef patty and the ice cream did not have names or dates on them. A sign posted on the freezer door read Attention Families and Staff for the safety and wellbeing of our customers everything put into this refrigerator must be 1. Labeled with the customer's name 2. Dated on the day it was put in the refrigerator 3. Items that are without a name or date will be discarded immediately 4. All items will be discarded after 3 days from the date on the item. On 3/17/21 at 11:22 AM, Certified Nursing Assistant, (CNA) B said she did not know who the food in the freezer belonged to. She added she was not aware food in the nourishment fridge/freezer needed to be labeled or dated. On 3/18/21 at 2:02 PM, the Director of Food Services said frozen items were harder to label. She said when food was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.