Iris Cove Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Iris Cove Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 1, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 22, 2021

  Based 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. […]

• Immediate jeopardy, isolatedF610Oct 22, 2021

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 22, 2021

  Based 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. […]

• Immediate jeopardy, isolatedF835Oct 22, 2021

  Based 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… […]