Inverness Rehab

In the surveyor’s words

From the most serious findings on record at Inverness Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 24, 2022

  Based on record review and interview, the facility failed to ensure a resident was free from abuse. A staff member (V7) intimidated a resident and created a hostile environment. The facility also failed to have a staff member (V8) recognize a resident was being abused and failed to intervene immediately to stop the abuse and protect the resident. This applies to 1 of 4 residents (R1) reviewed for abuse. As a result, R1 was subjected to the abusive behavior of V7 (certified nurse aide) who mentally abused R1 by making R1 afraid. The facility's investigation did not include all employees' accounts of the abuse incident leaving V7 on duty to intimidate residents. This was identified as an immediate jeopardy situation which began on 1/27/2022. […]

• Actual harm, isolatedF684Feb 6, 2026

  Based 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).The findings include:R1 is a [AGE] year-old female originally admitted on [DATE], having a slight cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. […]

• Actual harm, isolatedF689Jul 11, 2024

  Based 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 hospitalization s, sustaining lacerations on two occasions, with one laceration requiring three sutures. Findings include: R99 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, dementia, depression, ataxic gait, cognitive communication deficit, urgency of urination and visual hallucinations. […]

• Actual harm, isolatedF600May 19, 2023

  Based on interview and record review the facility neglected to ensure that one resident (R1) of 4 residents reviewed for neglect and abuse, was cleaned thoroughly and free from being intimidated by a member of their staff. This failure resulted in R1 crying and feeling intimidated, so much so that she was afraid to ask again for help and allowed stool to sit on her person for hours until the next shift came so that she would not be confronted by a staff member who refused to clean her thoroughly. Findings include: Review of R1's medical records document the following diagnosis: Morbid obesity, need for assistance with personal care and abnormalities of gait and mobility. […]

• Actual harm, isolatedF600Apr 13, 2023

  Based 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. Findings include: R337 was admitted to the facility on [DATE] with diagnosis including but not limited to Malignant Neoplasm of Endometrium, Polyneuropathy, Osteoarthritis of knee, Essential Hypertension, and Acquired Absence of both Cervix and Uterus. On 04/10/2023 at 01:42 PM Surveyor observed R337 laying the bed, with eyes closed. […]