Ave Maria Home

Inspectors wroteBased on policy review, wunderground.com, medical record review, observation and interview, the facility failed to provide adequate supervision and an environment free of accident hazards for cognitively impaired residents and residents at risk of elopement for 2 of 5 (Resident #1 and #5) sampled residents reviewed for elopement and accident hazards. On 6/7/2023, Resident #1, a severely cognitively impaired resident, left the facility around lunch time without staff knowledge in her wheelchair, went down the facility drive, down a hill toward the facility dumpster, and was out of the facility at least 15 minutes. A facility staff member found Resident #1 when the staff member was going towards the dumpster, 360 feet from the facility. [...]

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment and failed to ensure fall risk assessments were completed for 4 of 4 sampled residents (Resident #8, #49, #55, and 239) reviewed for accident hazards and falls.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to complete discharge assessments for 1 of 21 sampled residents (Resident #1) reviewed for completion of the Minimum Data Set (MDS) assessment.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the residents' status for hospice services and Activities of Daily Living (ADL) for 2 or 21 sampled residents (Resident #28 and Resident #71) reviewed for Minimum Data Assessments (MDS).

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 2 of 21 sampled residents (Resident #28) reviewed for Care Plans.

Inspectors wroteBased on medical record review and interview, the facility failed to provide communication from the dialysis center and failed to provide care and services for 1 of 1 sampled resident (Resident #17) reviewed for dialysis.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to revise the care plan to reflect the resident's current status for wounds and the use of a wanderguard 3 of 21 sampled residents (Residents #8, #14, and #44) reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to document treatments for pressure ulcers for 1 of 2 sampled residents (Resident #91) reviewed with pressure ulcers.

Inspectors wroteBased on policy review, monthly temperature chart review, observations and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when refrigerator and freezer temperatures were not documented twice per day in 4 of 9 (Green House (GH) #2, 4, 5 and 8) [NAME] Houses, food was not stored in sealed containers, and open foods were not labeled in 3 of 9 (GH #7, 8 and 9) [NAME] Houses. This had the potential to affect 61 residents that received meals from these [NAME] House kitchens.

Inspectors wroteBased on policy review, abuse investigation review, and interview, the facility failed to report an alleged abuse within the required time allotment for 2 of 4 (Resident #135 and #188) residents involved in an abuse allegation.

Inspectors wroteBased on policy review, disciplinary report review, staff working schedule review, and interview, the facility failed to prevent further potential abuse for 2 of 4 (Resident #135 and #188) residents reviewed for abuse.

Inspectors wroteBased on document review, observation, and interview the facility failed to ensure daily staffing information was posted in a prominent place, readily accessible to residents and visitors in 6 of 9 (Green House (GH) #1, 2, 4, 5, 7, and 8) [NAME] Houses, and failed to document on the staffing postings the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care each shift in 9 of 9 (GH #1, 2, 3, 4, 5, 6, 7, 8, and 9) [NAME] Houses for 94 of 94 days of daily staff postings reviewed.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure medications and biologicals were stored safely and securely when medications were left unattended by 2 of 4 (Staff Development Coordinator and Licensed Practical Nurse (LPN) #3) nurses observed during medication administration.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent infections and cross-contamination when staff failed to keep an indwelling catheter off the floor for 2 of 4 (Resident #3 and #186) sampled residents reviewed for indwelling urinary catheters, staff failed to maintain sterile technique during a catheter bag change, staff failed to perform site care to a peripherally inserted central catheter (PICC) for 1 of 1 (Resident #66) residents with a PICC line, and staff failed to wash a contaminated drinking container for 1 of 12 (Resident #66) residents in [NAME] House #7.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure Resident #40 was treated with respect and dignity when 1 of 18 (Shahbaz , the certified nursing assistant manager of the [NAME] House home, #3) staff referred to a clothing protector as a bib during the dining observation.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS) was completed for activities for 1 of 22 (Resident #17) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to provide timely laboratory services to meet the needs of 1 of 5 (Resident #69) sampled residents.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to document significant changes in the resident's medical condition in the medical record for 1 of 3 (Resident #1) residents reviewed for hospitalization and failed to ensure medical information was kept private and confidential for 1 of 10 (Resident #187) residents in [NAME] House (GH) #8.