cms_DC: 87
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
87 | SERENITY REHABILITATION AND HEALTH CENTER LLC | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2016-08-18 | 279 | D | 0 | 1 | GZ9J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 35 Stage 2 sampled residents, it was determined that facility staff failed to initiate a care plan with goals and approaches to address one (1) resident ' s impaired vision and one (1) resident's behavioral symptoms. Residents #39 and #160. The findings include: 1. Facility staff failed to initiate a care plan with goals and approaches for Resident #39 who had impaired vision and was diagnosed with [REDACTED]. A review of an Eye Exam Consultation Record dated (MONTH) 28, (YEAR) revealed the following [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) dated (MONTH) 9, (YEAR) revealed that Resident #39 in Section B1000 Vision is coded as Impaired . Section V, Care Area Assessment Summary revealed in care area #4 Visual Function that a check mark was placed in the boxes allocated for Care Area triggered and Care planning decision indicating care plan needed. A review of the clinical record lacked evidence of a care plan with goals and approaches to address Resident #39's impaired vision. A face-to-face interview was conducted on (MONTH) 17, (YEAR) at approximately 11:05 AM with Employee #4 who acknowledged the aforementioned findings. The record was reviewed on (MONTH) 17, (YEAR). 2. Facility staff failed to initiate a care plan with goals and approaches to address Resident #160's behavioral symptoms. A history and physical examination [REDACTED]. Neurological: Poor, uncooperative (with) exam . An admission MDS (Minimum Data Set) dated (MONTH) 26, (YEAR) revealed Section E0800 Behavioral Symptoms (rejection of care) was one of the triggered care areas to be addressed in the care plan. A review of Resident #160 ' s comprehensive care plan lacked evidence of a care plan with goals and approaches to address the resident ' s behavioral symptoms. A face-to-face interview was conducted with Employee #3 on (MONTH) 17, (YEAR) at approximately 11:20 AM. After review of the aforementioned he/she acknowledged the findings. The clinical record was reviewed on (MONTH) 17, (YEAR). | 2020-09-01 |