Mint Hill Senior Living

The facility failed to ensure that 4 out of 5 sampled residents had accurate care plans signed by the assessor upon completion. Specifically, the care plans for Residents #1, #2, #4, and #5 lacked the required signature from the assessor as mandated by the facility's own policy.

The facility failed to ensure that the assessor signed care plans upon completion. A review of sampled residents revealed that 4 out of 5 residents had care plans that lacked the required signature from the assessor.

The facility failed to ensure proper referral and follow-up with physicians for three residents regarding critical health needs. Specifically, staff did not notify physicians about missed medications for anxiety, blood pressure, and a phosphate binder, nor did they communicate medication refusals or follow up on wound clinic orders.

The facility failed to ensure proper referral and follow-up with physicians to meet the health care needs of residents. Specifically, the facility did not notify physicians regarding missed medications for anxiety, blood pressure, and phosphate binders, nor did they report medication refusals or follow up on orders for a wound clinic.

The facility failed to ensure physician notification for a care referral and an EMS call when a resident experienced an acute change in condition. Specifically, for one out of five sampled residents, the facility did not properly notify the physician or EMS during a period of altered mental status and respiratory distress.

The facility failed to ensure physician notification for a resident who experienced a change in baseline function and altered mental status. Specifically, a resident with COPD presented with grogginess, inability to hold a conversation, and respiratory distress, but the physician was not notified of these changes prior to the resident's emergency hospitalization.

The facility failed to ensure that two sampled medication aides were competency validated by a Licensed Health Professional through return demonstration for the monitoring of a non-invasive ventilator. This failure occurred despite a resident requiring continuous NIV therapy due to severe chronic respiratory failure.

The facility failed to ensure that medication aides Staff A and Staff E were competency validated by a Licensed Health Professional via return demonstration for the monitoring of a non-invasive ventilator (NIV). While documentation existed for CPAP/BIPAP tasks, the staff had not been properly validated for the specific NIV equipment required for Resident #4.