Ave Maria Home

In the surveyor’s words

From the most serious findings on record at Ave Maria Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 28, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF689May 12, 2022

  Based 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. The findings include: Review of the facility's policy titled, Fall Prevention Program, revised 2/1/2022, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .The facility utilizes a standardized risk assessment for determining a resident's fall risk .Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes .When any resident experiences… […]

• No harm, potential for more than minimal, isolatedF640May 12, 2022

  Based 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. The findings include: Review of the facility's policy titled, Assessment Frequency/Timeliness, revised on 2/15/2021, revealed .A discharge assessment will be completed within 14 days of the discharge date . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note revealed Resident #1 was discharged home on 1/13/2022. […]

• No harm, potential for more than minimal, isolatedF641May 12, 2022

  Based 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). The findings include: Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Admit to [Named Hospice Facility] .for terminal dx [diagnoses] of Alzheimer's Disease . Review of the significant change MDS assessment dated [DATE], revealed Resident #28 was not assessed for receiving hospice services. […]

• No harm, potential for more than minimal, isolatedF657May 12, 2022

  Based 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. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 2/15/2021, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing .needs that are identified .That comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . […]