Aviata At The Harbor

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for one resident (#83) out of four residents observed. These errors constituted an 11.43% medication error rate. Findings include: On 7/31/2024 at 9:50 a.m., medication administration observations were made with Staff J, Licensed Practical Nurse (LPN) for Resident # 83. The staff member dispensed the following medications: - MiraLAX powder 17 grams -Tizanidine 4 milligram (mg) one tablet -Ipratropium Bromide 0.5 mg and Albuterol sulfate 3 mg (resident's representative refused) -Modafinil 200 mg (100 mg) two tablets -Lyrica 100 mg one tablet -Aspirin 81 mg chewable -Eliquis 5 mg one tablet -Guaifenesin oral 200mg/5 milliliters (ml) give 5 ml -gave 5ml of 200mg/10ml -Multivitamin one tablet -Levetiracetam oral solution 100 mg/ml, 10 ml measured A review of the physician orders for Resident #83 has an order. dated 11/21/2023. for B12 Active oral tablet chewable…

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, record review, and review of policies and procedures the facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring: 1. cleanliness of 10 resident rooms, (104, 116, 126, 130, 131, 201, 214, 216, 226, 231) were free from dried food, spilled liquids on the floors, buildup of dust, dirt, and debris found under resident beds, broken furniture, 2. air conditioning units were free from bio-growth, dust and debris or leaking water for seven resident rooms (#106, #108 #110 #114, #231, #221, #220), 3. five ceiling vents in the kitchen were free from bio growth dust and debris, 4. two residents (#58 and #33) and in addition one resident room (#227) had sufficient clean bedding or linen. The failed to provide a safe, clean, comfortable, and homelike environment affected two wings (East and West) of two wings for four of four days of survey. Findings included: 1. On 06/27/2022 at 10:30 a.m. the following observations of resident rooms #104, #116, #126,…

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, record reviews, and interviews, the facility failed to implement an effective Infection Control Program in response to COVID-19 as evidenced by: 1. two staff members (O, K) not doffing Personal Protective Equipment (PPE) and not wearing PPE appropriately in two of two COVID positive rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 2. not providing clean and sanitary water cups on a daily basis for three residents (#33, #35 and #407) and in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 3. one staff member (U) not performing hand hygiene during the passing of food trays on one unit (West) of two units; and 4. not maintaining a clean environment in the laundry area used to process facility linen and the residents' personal items with the potential to affect a census of 97 residents. Findings included: 1. On 6/27/22 at 12:15 p.m., an observation was made of Staff O, Restorative Aide, standing in the hallway outside of room [ROOM NUMBER], where a COVID-19 positive resident…

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, record reviews, and interviews the facility failed to assess three residents (#408, #19, and #12) out of 97 admitted residents for self-administration of medications related to the medications left at the bedside. Findings included: 1. An observation was made on 6/27/22 at 10:23 a.m. of a medication cup on the over-bed table of Resident #408. The cup contained a white round tablet imprinted with 12, one oval pill imprinted with 125, and a white capsule printed with IP 101. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed the medication was left at bedside for Resident #408. The ADON/IP stated she did not know when they had been administered and the resident had not received any medications from her and she had yet to be in the resident's room that day. The admission Record revealed Resident #408 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified dementia without behavioral disturbance, unspecified bilateral hearing loss,…

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, record reviews, and interviews the facility failed to implement interventions identified in the comprehensive person-centered care plan for two residents (#35 and #296) related to falls and the refusal of care of a total sample of forty-seven residents. Findings included: 1. A review of the admission Record revealed Resident #35 was admitted on [DATE]. The admission Record included diagnoses not limited to history of falls, Type 2 Diabetes Mellitus without complications, and unspecified bipolar disorder. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. During an interview with Resident #35, on 6/27/22 at 3:34 p.m., the resident's bed was hip-high. The resident reported going to the hospital due to sliding out of bed. The resident has the bed controller in reach and can move the bed up and down. Resident #35 reported not knowing how high the bed was 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 observations, interviews, and record review the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for three residents (#89, #12 and #78) related to: 1. not obtaining a physician's order for use of oxygen for one Resident #89, and 2. not maintaining respiratory equipment in a sanitary manner for two residents (#12 and #78) out of five residents sampled for respiratory care. Findings included: 1. An interview was conducted with Resident #89's family member on 06/27/22 at 10:50 a.m. stating (Resident #89) has had breathing issues. He noted she was supposed to get an appointment to see her pulmonary doctor. He indicated, usually the facility is good at updating him. An observation was made on 06/28/22 at 8:55 a.m. of Resident #89 sleeping comfortably. No signs of shortness of breath or gasping were noted. Observed oxygen tubing placed via nasal cannula and free of kinks. An observation was made on 06/28/22 at 10:37 a.m. of Resident #89…

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 observations, interviews and record review, the facility failed to provide pain management by not ensuring pain medications were administered in a timely manner for one resident (#4) of two residents reviewed for pain management. Findings included: During a facility tour on 06/27/22 at 12:02 p.m., Resident #4 stated she had not received her 9:00 a.m. meds (medications). Resident #4 stated she had also asked for a PRN (as needed) med for pain. Resident #4 confirmed she did not received anything all morning and she did not know why. Resident #4 stated she first asked for her Oxycodone for pain at around 8:30 a.m. Resident #4 said, This happens quite often and sometimes they give me double a dose because they did not administer the first dose on time. This is not the first time. It is not right. Resident #4 was noted grimacing and re-stated she had requested pain meds all morning. Resident #4 stated it was frustrating not to have her medications. An immediate interview was conducted on 06/27/22 at 12:05 p.m. with Staff L, Registered Nurse/Unit Manager (RN/UM). Staff L…

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 observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and six errors were identified for two residents (#100 and #83) of five residents observed. These errors constituted a 23.08% medication error rate. Findings included: 1. On 6/28/22 at 9:03 a.m., an observation of medication administration with Staff E, Registered Nurse (RN), was conducted with Resident #100. The staff member dispensed the following medications: - Amlodipine 2.5 milligram (mg) tablet orally - Pantoprazole Delayed Release (DR) 40 mg tablet orally - Topiramate 100 mg tablet orally - Gabapentin 600 mg - 2 tablets orally - Lisinopril 40 mg tablet orally - Vitamin C 500 mg tablet orally - Vitamin D3 25 microgram (mcg)/ 1000 international unit (iu) tablet orally - Vitamin B 12 500 mcg tablet orally - Duloxetine 60 mg DR caplet orally - Oxycodone-Acetaminophen 7.5-325 mg tablet orally - Zofran 4 mg tablet orally During the dispensing of the above medication, Resident #100 informed…

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 observations, interviews and record review, the facility did not ensure medications stored an inaccessible to unauthorized staff, residents, and visitors for three residents (#40, #90 and #53) for two days (6/27/22, 6/28/22) of a four day survey. Findings included: 1. During a facility tour on 06/27/22 at 10:23 a.m., an observation was made in Resident #40's room of four tablets on the floor between two dressers. A small water glass and a medicine cup were noted on the floor next to the tablets. One tablet was large, white, an oval shaped; one table was small, round, and pink; one tablet was small, round and light orange, another tablet was dark pink and round. On 06/27/22 at 12:03 p.m., a second observation was made of the same tablets on the floor between two dressers in Resident #40's room. During the second observation, it was noted that housekeeping had already cleaned the room. On 06/27/22 at 3:15 p.m., a third observation was made of the four tablets in Resident #40's room. During this observation, an additional small, round, yellow tablet was noted by Resident #40's…

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 effective interventions were in place for prevention of falls for once Resident (#23) with head injury; prevention of falls with a fracture for one Resident (#94); and the prevention of inappropriate behavior for one Resident (#460) out of 47 sampled residents. Findings included: 1. On 03/02/21 at 12:45 p.m. Resident #23 was observed propelling his wheelchair toward the smoking area. He exited into the smoking area. He was wearing shorts, and red abrasions were observed on his legs. On 03/03/21, Emergency Medical Services (EMS) were at the facility in the early morning. The facility reported that they were there to transport Resident #23 to the hospital because he had fallen and sustained injuries. Observation and interview were conducted with Resident #23 on 03/03/21 at 3:06 p.m. in his room. He was seated in his wheelchair. His bed linens were disheveled. The call light was observed on the bed. There was a hole observed in his…

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 that one resident (Resident #67) out of 28 residents receiving respiratory treatments was assessed for self-administration of treatments. Findings Included: On 03/02/21 at 12:20 p.m. Resident #67 was observed in her bed in her room. There was a Bi-Pap machine on her bedside table and an oxygen (O2) concentrator machine which was running and was set at 4 liters per minute (4 L/min). The resident was not connected to any oxygen delivery devices and stated that she was just about to switch from her Bi-Pap machine which she used for her sleep apnea to her nasal cannula. She also revealed a nebulizer treatment delivery device. Regarding respiratory treatments, the resident stated that she mostly manages it all including nebulizer treatments. On 03/04/21 at 8:06 a.m. the resident was observed sleeping with the Bi-Pap machine running and mask in place. On 03/04/21 at 12:00 p.m. the resident was observed asleep with the Bi-Pap machine…

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 reasonable accommodation of preferences related to bathing for one (Resident #67) out of 47 sampled residents. Findings Included: An interview was conducted with Resident #67 on 03/04/21 at 2:33 p.m. She reported that the facility had her scheduled to receive showers in the evenings after she came back to the facility from her hemodialysis treatments. She stated that sometimes she was too tired after her treatments and requested to have her shower the next day but the next day the staff would tell her their schedule was already full and they had no time to give her a shower. The resident reported that she spoke to Staff J, Licensed Practical Nurse (LPN), Unit Manager (UM) about her concern and asked to be switched to a Tuesday/Thursday shower schedule. The resident reported that no changes had been made since she spoke with Staff J about it. She stated that she had not filed a grievance related to the concern because she didn't…

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 investigate and report an alleged sexual abuse, observed and documented by Staff member I, LPN (Licensed Practical Nurse) by one Resident (#460) towards another Resident (#218) of three reviewed. Findings Included: Review of the progress notes dated 1/17/21 at 3:24 a.m. written by Staff member I, LPN, read, Resident refused to be put in bed, resident was in dayroom being watched by staff and while they were attending to other residents they were assigned to, resident left dayroom and was found in another resident room [Resident #218] touching on her feet and had a hand underneath her blanket by resident's leg. Director of Nursing (DON) notified and was told to put resident in bed regardless of his wishes to stay up. Resident has orders in place for one on one watch due to behaviors, but due to staffing resident was not able to be put on these precautions during the night shift. During an interview with the DON on 3/5/21 at 6:03 p.m. the DON…

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 reviews, the facility did not ensure that daily care was provided for 3 (# 52, #44 and #09) of 6 residents sampled for ADL's (Activities of Daily Living) as evidenced by: not providing baths or showers, not providing linens for care and not responding to calls in a timely manner. Findings included: 1. During a facility tour conducted on the East wing on 03/02/21 at 02:14 p.m. and 03/03/21 at 10:16 a.m., Resident #52 was observed in bed, noted with flaky skin and white stuff crusted on face and ears. During an interview at the time, Resident # 52 stated that he had not had a bed bath or shower since moving into the East Wing at the end of January 2021. Resident #52 stated that he is supposed to be assisted to a shower or bath twice a week on Tuesdays, and Fridays. Resident #52 was admitted on [DATE], with a diagnosis to include: chronic obstructive pulmonary disease, muscle weakness, need for assistance with personal care, other specified diabetes, arthropathic, low…

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 resident record, observation, and staff interviews, the facility did not ensure that one resident (#34) of 47 sampled residents benefited from activities designed to meet the interests of the Resident, and provide support for her physical, mental, and psychosocial well-being. Although Resident #34's care plan included activities to include socialization outside of the Resident's room and indicated that Resident #34 was totally dependent on the staff for attending these activities, Resident #34 received only room visits and this did not include the basic need for time out of doors. Findings included: Resident # 34 was admitted to the facility on [DATE] with the primary diagnosis of diffuse traumatic brain injury, other pertinent diagnoses included aphasia, quadriplegia, anoxic brain damage, and major depressive disorder. Evidence of the aphasia is documented in section C, the cognitive pattern section of the Minimum Data Set (MDS) dated [DATE]. A score of zero was documented in answer to the question 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change a Peripherally Inserted Central Catheter (PICC) line dressing according to industry standards for one Resident (#211) of three Residents observed. Findings Included: On 3/2/21 at 3:30 p.m., Resident #211 was observed with a PICC line Intravenous (IV) dressing dated 2/17/21. Resident #211 confirmed the dressing had not been changed and the nurse told him it would be changed today. Resident #211 confirmed the nurses clean the IV and give him medication through the line. On 3/2/21 at 3:40 p.m., Staff member F, Licensed Practical Nurse (LPN) confirmed the dressing was dated 2/17/21 and that it was due to be changed today. Staff member F, LPN confirmed the dressing should be changed every seven days and that the dressing is past the seven days. On 3/2/21 at 4:00 p.m., The Director of Nursing (DON) confirmed the dressing on the PICC line should be changed every seven days. Review of the resident record revealed Resident #211 admitted on…

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 reviews, the facility did not ensure tracheostomy (Trach) care was provided for one Resident (#4) of one resident with a tracheostomy in the East wing. Findings included: Resident #4 was admitted to the facility on [DATE] with an original admission date of 11/06/18 noted. He was admitted with a diagnosis to include: Quadriplegia unspecified, tracheostomy status, pressure ulcer of sacral region, muscle weakness, unspecified neuromuscular dysfunction bladder, hypertension, old myocardial infarction, anxiety disorder, diabetes, history of pulmonary embolism, hyperlipidemia, osteomyelitis unspecified, nasal congestion, major depressive disorder, single episode and other muscle spasm. During a facility tour of the East Wing on 03/03/21 10:30 AM, Resident #4 was observed laying in bed watching TV. Resident #4 reported that the previous night he had waited an hour to receive trach suction care. Resident #4 stated that he called for help for an hour and the evening Nurse did…

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 interview and record review the facility failed to provide care and services consistent with professional standards of practice related communication with the dialysis facility contributing to failure of monitoring resident status post-dialysis treatment for one Resident (#67) out of one resident receiving hemodialysis. Findings Included: Review of the completed document Resident Census and Conditions of Residents (CMS-672) provided by the facility, dated 03/02/21, revealed that there was only one resident in the facility that was receiving hemodialysis treatments; that resident was confirmed as Resident #67 during the survey entrance conference. An interview was conducted with Resident #67 on 03/02/21 at 12:20 p.m. She confirmed that she received hemodialysis treatments at an outpatient center three times a week (Mon, Wed, Fri). A review of the medical record for Resident #67 revealed diagnoses that included type 2 diabetes mellitus with complication, end stage renal disease, and dependence on renal…

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 reviews, the facility did not ensure proper medication storage for one resident, (# 49) out of 26 residents observed. Findings included: During a tour of the East wing on 03/04/21 9:03 a.m., Resident #49 was observed in bed having finished breakfast. An observation was made of the meal tray cart parked outside Resident #49's door. Staff H, Certified Nursing Assistant (CNA) was observed going room to room collecting breakfast trays. Resident #49 started yelling to Staff H, CNA, you took my meds, they were in a cup. Staff H, CNA was observed putting a breakfast tray removed from resident's room in the meal cart. Staff H, CNA told the resident that his glasses were on his side table. Resident #49 continued to shout stating that he was talking about his medications that were in a cup, not his glasses. Staff H, CNA looked through the trays again and could not locate the medications. Staff G, Licensed Practical Nurse (LPN) came out of the room next to Resident #49's room.…

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.