Adviniacare At Naples

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility's policies and procedure, resident and staff interviews, and record review the facility failed to provide appropriate care and services to 2 (Residents #47 and #48) of 2 residents receiving intravenous antibiotics through peripherally inserted central catheters (PICCs).The findings included:Review of the facility provided policy for PICC Line Dressing Changes last revised on 2/2026 revealed on page 1, #4. When a transparent dressing is applied over a gauze dressing it is considered a gauze dressing and is changed every 48 hours or sooner.Review of the clinical record for Resident #48 revealed an admission date of 5/19/26. Admitting diagnoses included infection following a procedure. On 5/19/26 at 7:47 p.m., Registered Nurse (RN) Staff A documented in a nursing progress note that Resident #48 was admitted to the facility with orders to continue antibiotics until 5/27/26. The note documented that Resident #48 had an existing intravenous site (IV)…

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 and interview, the facility failed to post the nurse staffing data at the beginning of each shift for 3 consecutive days on 5/23/26, 5/24/26, and 5/25/26.The findings included: On Tuesday 5/26/26 at 9:00 a.m., the nurse staffing data was observed displayed behind a plastic stand at the nurse's station. The nurse staffing data was dated 5/22/26 (Friday).Photographic evidence obtainedOn 5/28/26 at 8:51 a.m., in an interview, Registered Nurse (RN) Staff B said the night shift nurse should have changed the nurse staffing data over the weekend and on Monday. She said she worked the day shift over the weekend and did not notice the nurse staffing data was not changed on 5/23/26 (Saturday), 5/24/26 (Sunday), or 5/25/26.On 5/28/26 at 8:54 a.m., in an interview, Medical Records Staff F said she was responsible to post the nurse staffing data Monday through Friday but did not work on Monday or Tuesday. She said that in her absence, the Director of Nursing (DON) completed the nurse staffing data sheets and would have arranged to have it posted.On 5/28/26 at 9:00 a.m., in…

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, facility policy review, resident, family member and staff interviews, the facility failed to ensure dental services were appropriately coordinated for 1 (Resident #39) of 2 residents reviewed for dental services. The facility failed to maintain documentation of dental consultations in the medical record, failed to follow up on recommendations made during a dental consultation and failed to ensure the Resident was informed of financial responsibility and payment options for recommended dental services. These failures have delayed necessary dental care and impeded the Residents ability to make informed decisions regarding treatment and associated costs.The findings included:Review of the facility Dental Services policy (last revised October 2022) noted routine and emergency dental care services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care . Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a licensed dentist that comes to our…

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 interview, the facility failed to have a binding arbitration agreement for 3 (Residents #1, #20 and #28) of 3 residents reviewed that explicitly states that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility. This has the potential to affect all residents residing in the facility.Review of the facility's binding arbitration agreement (not dated) revealed that it did not state that signing this agreement is not a requirement for admission. The signature page of the document states the undersigned acknowledge that each of them has read all six (6) pages of this agreement . that by signing this agreement each has waived his/her rights to a trial, before a judge and/or jury, and that each of them voluntarily consents to all terms of this agreement. Residents #1, #20 and #28 were sampled from the facility provided list of admissions who had signed the arbitration agreement.On 5/27/26 at 1:20 p.m., in an…

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 staff interviews, record review and facility policy review the facility failed to report an incident of possible neglect to the State Survey Agency related to a medication error for a critical medication for 1 (Resident #1) of 3 residents reviewed. The findings included: The facility's policy and procedure for Coumadin Management with a creation date of 10/2022 noted, It is the policy that residents on Coumadin therapy will be monitored to assist in maintaining recommended laboratory parameters as established by the attending physician . Prior to and with each medication administration, the nurse will: a. Review the Medication Administration Record [MAR] to ensure consistency in medication dose orders, b. Document the most recent lab result (PT/INR), c. The physician has been notified of laboratory results, and d. Document the next laboratory draw date is identified. Licensed staff receiving laboratory results are required to update the MAR, notify the physician of results, and adjust dosage orders as necessary. Changes in dosage require the entire medication order to be…

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 staff and resident interview, medical record review, and review of facility policies, the facility failed to have documentation of a thorough investigation for 1 (Resident #243) of 1 resident reviewed for elopement. The findings included: The facility's event investigation guidelines (undated) for suspected neglect noted to include time frame date, shift, and time of report or discovery of the event, including specific individuals involved . Elopement: Investigation should begin immediately. Summarize what was done in the investigative process and your conclusion with supportive evidence to support the root cause of the incident. Include all details of when, what etc. Include facts of evidence obtained. Consistencies in consistencies, effect on resident, staff involved. Review of the clinical record for Resident #243 revealed an admission date of 12/6/23 for Rehabilitation services after a fracture of the right femur (thigh bone). Diagnoses included Transient Ischemic Attacks (TIA), Dementia 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 record review and staff interview, the facility failed to ensure the baseline care plan was developed and implemented for 1(Resident #196) of 6 baseline care plan reviewed to ensure it includes the instructions/interventions needed to provide effective and person-centered plan of care that meet the professional standards of quality of care. The findings included: On 3/4/24 at 11:09 a.m., during an interview with Resident #196, he said he has a displaced fracture of his left ulna, and the orthopedic surgeon told him when he was discharged from the hospital, Resident #196 needed to see him in his office to determine what the next course of action, needed to be taken, to address the left ulna fracture. Resident #196 said since his admission on [DATE], no one had explained to him the plan of care related to his left ulna fracture and why he had not seen the orthopedic surgeon in 3 days after his admission to the facility as he was told by the orthopedic surgeon when he was in the hospital. A review of…

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 interview and record review the facility failed to ensure they had a physician's order for the continuation, flushing and dressing change of an intravenous peripheral catheter (IVPC) for 1 Resident (#197) of 1 resident reviewed with an IVPC as related to facility's policy IVPC care and in accordance with the professional standard of care for IVPC. The findings included: On 3/4/24 at 11:32 a.m., an observation revealed the IVPC dressing located on Resident #197's right forearm was not dated with the time it was inserted or the last time the IVPC site dressing was changed. On 3/4/24 at 11:32 a.m., during an interview with Resident #197, she said a facility nurse inserted the IVPC last week so she could receive a bag of intravenous (IV) fluid due her lab results. She said since the insertion of the IVPC no one had flushed the IVPC until today or changed the IVPC dressing to her right forearm. She said the IVPC site does not hurt but she didn't know why the nurse did not remove the IVPC after she had received the IV fluids ordered by the physician. On 3/4/24 at…

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 facility policy review, employee file review and interview it was determined that the facility failed to ensure infection control management staff had the proper infection prevention education and training as required. The findings include: On review of facility policy titled, Infection Control Program Policy IC-2 last revised 2/2023 indicates that the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Procedure: Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). b. The qualifications and job responsibilities of infection Preventionist are outlined in the infection Preventionist Job Description. During an interview on 3/6/24 at 3:10 p.m., Director of Nursing (DON) acknowledged that she was the infection control nurse for the facility. DON stated that she had not taken any formal education to become the facilities…

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, review of facility's policy and procedure, and staff interview, the facility failed to have documentation of consistent monitoring of weight, meals, and prescribed supplement intake to evaluate the effectiveness of nutritional interventions for 3 (Resident #16, #9, and #174) of 5 sampled residents identified at risk for impaired nutrition and weight loss. The findings included: The facility Policy, Weight Policy (revised 2/7/21) documented, It is the policy of Pointe Group Care that residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the residents clinical condition demonstrates that this is not possible. Weight-Weight can be a useful indicator of nutritional status, when evaluated within the context of the individuals personal history and overall condition . Procedure: 1. Each resident should be weighed on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks and at least monthly…

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 clinical record review, review of facility policy and procedure, and resident and staff interviews, the facility failed to provide the necessary care and services to maintain the urinary catheter for 1 (Resident #323) of 1 resident reviewed for indwelling catheter care. The findings included: The facility policy Indwelling Urinary Catheter Insertion and Maintenance-Male Resident (revised 2/3/33), documented.Assessment: Physician's order for catheterization, type and or specimen collection . Purpose of catheterization. .Urinary Catheter (tube inserted into the bladder to drain urine) Maintenance: .Maintain unobstructed urine flow by: Keeping the catheter and collection tube free from kinking. Keeping the collection bag below the level of the bladder at all times. Emptying the collecting bag regularly using a separate, clean collecting container for each resident. On 7/5/22 at 1:00 p.m., in an interview Resident # 323 said no one takes care of me here. I had to hire an aide to take care of me. Resident # 323 said he has a catheter, but staff do not provide care for it, my…

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, record review, policy review, staff and resident interviews, the facility failed to ensure 1(Resident #323) of 12 residents reviewed for accidents was assessed for alternative interventions prior to the use of grab bars. This had the potential to have grab bars installed when alternatives with less chance of negative consequences could be utilized. The findings included: The facility policy Side Rails (revised 2/10/21) documented, .No matter the purpose for use, bed rails and other bed accessories, although prescribed to improve functional independence with bed mobility and transfers, can increase resident safety risk. Procedure: 1. Resident Assessment a. Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds or accessories. c. Assess the resident to identify appropriate alternative prior to installing bed rails On 7/5/22 at 2:14 p.m., Resident #323 was observed in bed with grab bars raised on both sides of the bed. Resident #323 said he asked for the grab bars to assist with turning himself in…

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 resident and staff interview, the facility failed to honor food preferences for 1 (Resident #177) of 3 residents reviewed. This has the potential for complications if allergies to certain foods are served. The findings included: On 7/7/22 record review revealed documentation Resident #177 had a Gluten allergy. The meal ticket noted allergies, none; dislikes, No Gluten, no Barley, no Bread, no Cake, no Cookies, no Pasta, and no Pies. The bottom of the meal ticket noted, Allergic to gluten. Photographic evidence obtained. On 7/5/22 at 1:00 p.m. and on 7/6/22 at 12:10 p.m., Resident #177 was observed having lunch. He was served bread on both days. On 7/6/22 at 12:10 p.m., Resident #177 said he receives bread with his meals and he is not suppose to have it. Resident #177's spouse was present during the interview and confirmed he shouldn't have bread and receives it with his meals. On 7/7/22 at 11:30 a.m., The Director of Dietary said if residents have an allergy or a dislike for a food item listed on their meal tickets, then they should not be receiving it.

Based on observation, review of policies and procedure and staff interview, the facility failed to ensure the hand washing sink in the kitchenette was functioning for staff use. The failure to maintain the function of the sink had the potential for water borne pathogens to grow in the standing water. The facility failed to properly date and label resident food items stored in the facility kitchenette refrigerator. The failure to date, label and dispose of expired foods placed residents at risk for developing food borne illnesses. The findings included: The facility policy Food Storage-Resident Food (revised 2/2022), documented, Purpose: To ensure food safety and prevent the risk of food borne illness. Policy: .If storage units are provided in community areas, those units shall be equipped with thermometers and shall hold foods which are sealed, labeled and dated. Units shall be routinely cleaned and monitored by the Housekeeping Department with the assistance of the Dietary Manager to maintain sanitary units and to discard expired foods. On 7/5/22 at 9:05 a.m., during a tour 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.