Aviata At Englewood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that 1 resident, (Resident #1), was free from physical abuse resulting from a staff member intentionally hitting the resident's right forearm during care. The findings included:Review of the facility Abuse, Neglect, Exploitation & Misappropriation policy (last revised 11/16/22) states, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy further states willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. The policy also states that physical abuse includes hitting, slapping and punching. The policy further states actions, such as striking or kicking a resident, restraining a resident improperly or without authorization, and other such acts which can be seen as causing physical pain to a resident is strictly prohibited.Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff and resident interviews, the facility failed to follow Infection Control measures to prevent a potential outbreak of scabies.The findings included:Review of the facility policy titled, Infection Prevention and Control revised October 2018, revealed an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Outbreak management includes a process that consists of: determining the presence of an outbreak; managing the affected residents; preventing the spread to other residents; documenting information about the outbreak; reporting the information to appropriate public health authorities; educating the staff and the public; monitoring for recurrences and reviewing the care after the outbreak has subsided; and recommending new or revised policies to handle similar events in the future.Review of the clinical record for Resident #1 revealed an admission date of 6/10/25. Diagnoses included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff followed safety precautions to prevent avoidable accidents or potential for accidents for 3 (Residents #892, #66 and #442) of 3 residents reviewed.The findings included:1. Review of Notification of Change in Condition Policies and Procedures effective date 11/30/2014, revision date 12/16/2022 states the Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is change in the status or condition. The nurse to notify the attending physician and Resident Representative when there is a(n) accidents, significant change in the patient/resident's physical, mental, or psychosocial status. Need to alter treatment significantly: new treatment, adverse consequences, acute condition, or exacerbation of a chronic condition. The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Document resident/patient change in condition on 24-hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide infection control standards for 2 (Residents #83 and #893) of 2 residents reviewed with urinary catheters.The findings included:Review of Infection Control Policies and Practices dated 2001, revised 2018 states the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Bullet # 2 states the objectives or our infection control policies are to (a) prevent, detect, investigate, and control infections in the facility. Bullet #4 states All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.Review of Urinary Catheter Policies and Procedures dated 11/30/2014, revised 9/19/2017 states Foley bag to be covered by a privacy bag to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility's policies and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 5 (Resident #7, #10, #24, #55 and #60) of 20 residents reviewed for activities of daily living (ADLs). The findings included: 1. Review of the clinical record revealed Resident #7 had a readmission date of 11/17/22 with diagnoses including dementia, anxiety and muscle weakness. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 11/30/22 documented Resident #7 required extensive assistance for personal hygiene and limited assistance for bathing. The MDS noted Resident #7's cognitive skills for daily decision making were moderately impaired. The care plan initiated on 12/1/21 noted staff were to provide a full bed bath when a shower could not be tolerated and to check nail length, trim…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to ensure 2 (Resident #61 and #67) of 5 sampled residents for change in condition received appropriate care in accordance with professional standards of practice. The findings included: Facility policy and procedures (N-140) revised 3/3/2021 regarding physician orders stated, the center will ensure that physician orders are appropriately and timely documented in the medical report. The Clinical Nurse 1 job description duty and responsibilities listed conduct a thorough evaluation of each residents' medical status upon admission and throughout the resident's course of treatment and assist in the implementation of an individualized treatment plan for each resident assigned. 1. Clinical record review revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included Heart Failure, and renal insufficiency. The physician order dated 11/17/2022 specified to apply knee-hi TED hose (compression stockings) to patients'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide necessary services to prevent a decline in range of motion for 1 (Resident #41) of 2 sampled residents with limited range of motion. On 1/4/23 at 9:40 a.m., Resident #41 was observed in his room sitting in his wheelchair. His right wrist/hand was contracted. The resident was not wearing any positioning device or splinting to the area. Resident #41 said he had a right splint for the contracture, but it was misplaced during the evacuation after Hurricane [NAME] and needs to be remade. He said when he had his splint he wore it daily. Review of the clinical record for Resident #41 revealed the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41's cognition was intact. Resident #41 had a diagnosis of Cerebral Palsy. Review of the physician's orders revealed an active order for a right hand splint to be worn daily for 6 hours as tolerated, restorative was to apply/remove every day shift starting 9/11/20. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview the facility failed to maintain the kitchen, nourishment rooms, and activity kitchen in a clean, safe, and sanitary manner that was in good repair by not having clean surfaces in food storage areas, clean surfaces on food preparation equipment, outdated/unlabeled food items, and not maintaining the ice machines in a manner to prevent potential contamination. The findings included: The facility's policy, Ice Machines and Ice Storage Chests, revised January 2012, stated Ice-making machines, ice storage chest/containers, and ice can all become contaminated by unsanitary manipulation by employees, residents and visitors and to help prevent contamination of ice machines Keep the ice scoop/bin in a covered container when not in use. On 3/21/21 at 10:05 a.m., during the initial kitchen tour the following observations were made: heavy accumulation of dust in ceiling vent at kitchen entrance; hole in wall by pipe in dry storage area; and storeroom ceiling vent dusty. The top of the dish machine was soiled with dry salts and debris, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews, the facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and the public by not having clean surfaces; maintaining resident equipment in a sanitary manner; not repairing damaged shower rooms and pantry walls; and having heavily soiled/stained furniture in day room. Not maintaining a sanitary environment has the potential for cross contamination and biological growth (bio-growth). The findings included: On 3/21/21 at 12:40 p.m., in an interview, Resident #80 said he had osteomyelitis (infection of the bone) in his left foot, had daily dressing changes, and was on antibiotics. The resident said he was concerned about the housekeeping in his bathroom, the shower rooms, and worried about getting an infection in his foot again. On 3/21/21 at 10:49 a.m., 3/21/21 at 2:21 p.m., 3/22/21 at 8:45 a.m., and 9:09 a.m., while touring the facility the following was observed: room [ROOM NUMBER] had three unlabeled, uncovered wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to provide adaptive equipment necessary to promote psychosocial wellbeing for 1 (Resident #7) of 1 resident identified with a hearing deficit. The findings included: On 3/21/21, review of the clinical record showed a quarterly Minimum Data Set (assessment of resident functional capabilities and health needs) completed on 3/16/21. The assessment noted Resident #7 required a hearing device and had moderate difficulty hearing. The plan of care initiated on 3/17/21 documented Resident #7 had a communication problem due to difficulty hearing with interventions to apply a right ear hearing aid. The Certified Nursing Assistant (CNA) resident care [NAME] specified the CNA was to apply the right ear hearing aid. On 3/21/21 at 9:09 a.m., during an initial observation Resident #7 was sitting in a wheelchair in her room, calling out and asking to have her hearing aid put in. On 3/22/21 at 9:16 a.m., during an observation Resident #7 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to properly document and maintain complete and accurate records in the areas of health status and treatments for 3 (Residents #90, #60, #53) of 19 records reviewed. The findings included: The facility's policy and procedure for discharged records (Document MR-135), last revised on [DATE] noted To ensure required discharge documentation in a resident's closed medical record is accurate, complete, dated and signed by the appropriate individuals . Check that the physician's order for discharge, transfer or release of body is written appropriately, signed, and dated. Check the final nurses' note for pertinent resident information which includes but is not limited to date and time of discharge, pronouncement if ceased to breathe/expired . final disposition. Check deceased resident's records for pertinent resident information, which includes but is not limited to notification of resident's family and physician, resident condition and vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.