Indian River Center

In the surveyor’s words

From the most serious findings on record at Indian River Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 15, 2025

  Based 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 [DATE] 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. […]

• Immediate jeopardy, isolatedF610Mar 15, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF835Mar 15, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 16, 2021

  Based on observation, interview and record review, the facility failed to maintain a secure environment in an enclosed courtyard, failed to respond to exit door chimes, and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 8 residents reviewed for elopement, out of a total sample of 9 residents (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, become lost or been hit by a car. On 12/12/21 at approximately 9:11 PM, resident #1 exited the secure memory care unit and entered an enclosed courtyard. […]

• Immediate jeopardy, isolatedF689Sep 21, 2021

  Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility and failed to ensure all staff were knowledgeable of elopement protocols to promote safety for 1 of 34 residents at risk for elopement, (#21). On 9/3/21 at 7:46 PM, the facility failed to prevent a physically and cognitively impaired resident #21, from exiting the facility unsupervised in the dark without shoes. The resident exited the facility by pushing the panic bar on the main entrance doors for 15 seconds which released the magnetic lock. Resident #21 walked along wet sloping sidewalks with grates and drainage ditches with varying depths of 3 to 6 feet. […]