Home of the Innocents

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Feb 12, 2023

  Based on observation, interviews, record review, document review, and facility policy review, it was determined the facility failed to ensure the care planned intervention to provide continuous line-of-sight monitoring was consistently implemented for one (1) of twelve (12) sampled residents (Resident #66). The facility developed a care plan that included an intervention for Resident #66 to always be within staff's line of sight when he/she was up in a wheelchair. However, on 12/14/2022, the facility failed to supervise Resident #66. Resident #66 exited the facility through the emergency/fire exit doors located on the Ocean Avenue Unit without staff's knowledge. Immediate Jeopardy (IJ) was identified on 02/10/2023 and determined to exist on 12/14/2022. […]

• Immediate jeopardy, isolatedF689Feb 12, 2023

  Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of three (3) sampled residents reviewed for accidents (Resident #66). The facility assessed Resident #66 to be at risk for elopement and was care planned for him/her to always be within staff's line of sight when up in a wheelchair. However, the resident exited the facility undetected by staff on 12/14/2022 at 7:48 PM and was outside unsupervised for approximately eight (8) minutes. Immediate Jeopardy (IJ) was identified on 02/10/2023. […]

• No harm, potential for more than minimal, patternF607Feb 12, 2023

  Based on interviews, document review, and facility policy review, it was determined the facility failed to ensure its abuse prohibition policy was implemented, by failing to verify and maintain documentation of screening and training, including criminal record checks, for contract agency employees. This had the potential to affect all residents. The findings include: Review of the facility's policy titled, Protecting Residents from Abuse and Neglect, revised October 2022, revealed; Screening 1. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2023

  Based on interviews, document review, and facility policy review, it was determined the facility failed to: Consistently monitor and document temperatures and sanitizer levels for the dishwasher to ensure dishes were thoroughly cleaned and sanitized. The facility failed to consistently monitor and document the refrigerator/freezer temperatures to ensure perishable food items were stored at safe temperatures. The facility also failed to consistently monitor and document the temperature of food on the steam table to ensure food was served at safe temperatures and prevent potential food borne illness for residents who received meals from the kitchen. The findings include: 1. […]

• No harm, potential for more than minimal, patternF656Feb 21, 2022

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure care plans were developed and/or implemented for three (4) of six (6) sampled residents, Resident #1, Resident #2, Resident #3, and Resident #4. Certified Nurse Assistant (CNA) #1 failed to follow the care plan for Residet #1, when she independently transferred the resident to his/her bed. Staff inflated the balloon of Resident #2's supra-pubic catheter with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]