Adviniacare Scallop Shell, LLC

Inspectors wroteBased on record review and staff interview, the facility failed to ensure adequate supervision and timely intervention for Resident ID #9, a resident with documented dysphagia (swallowing difficulties), to prevent accident hazards related to choking. Despite multiple documented episodes of the resident coughing and choking during meal and medication consumption between October 23, 2025, and October 27, 2025, the facility staff failed to implement any immediate, necessary interventions or notify the medical provider of the significant change in condition as required by policy and the resident's care plan. This failure resulted in a severe choking event on October 28, 2025, where the resident was found to be cyanotic (blue in the face) and required staff intervention to manually remove food, placing the resident in Immediate Jeopardy of serious injury, aspiration pneumonia, or death.

Inspectors wroteBased on surveyor observation, record review, and staff interview, the facility failed to ensure that appropriate treatment and services were provided to one resident (Resident ID #70) who was reviewed for fluid management. This failure included missing two physician-ordered doses of Lasix (a medication used to treat excess fluid trapped in the body's tissue) and failing to obtain daily weights as ordered by the physician. As a direct result of these failures, the resident experienced clinical deterioration, including increased shortness of breath and an elevated respiratory rate (30 breaths per minute), requiring an immediate transfer to the hospital for evaluation of potential congestive heart failure exacerbation.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that Registered Nurse, Staff F, was competent to provide nursing services related to acute changes in condition, which resulted in actual harm to Resident ID #9. Despite having been competency-trained and observing the resident choking on food and medication on 10/26 and 10/27/2025, Registered RN, Staff F failed to follow policy and the resident's care plan by neglecting to immediately implement an intervention (such as removing the meal or providing a softer diet option) and failing to notify the resident's provider. [...]

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary medications for 2 of 2 residents reviewed for blood pressure medications with parameters, Resident ID #s 4 and 83 and for 1 of 1 resident reviewed for pain, Resident ID #79.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing them of when changes in coverage are made to items and services covered by Medicare and/or the state Medicaid plan, relative to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form for 3 of 3 residents discharged from Medicare Part A Services that remained in the facility, Resident ID #s 17, 22, and 30.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to not following physician's orders for 1 of 2 residents reviewed for wound care, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan relative to 1 of 1 resident reviewed with a skin graft, Resident ID #24 and 2 of 4 residents reviewed with known skin impairments who lacked weekly skin assessments, Resident ID #s 9 and 257.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that all residents are free from significant medication errors for 1 of 1 resident reviewed relative to heparin (anticoagulant), Resident ID #48.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards of principles that apply to individuals providing services in the facility for 2 of 2 residents reviewed who are receiving hospice services, Resident ID #s 23 and 28.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for failing to place residents on enhanced barrier precautions (EBP; involves using gown and gloves during high-contact resident care activities) for residents that require such for 3 of 5 residents reviewed with wounds, Resident ID #s 24, 28, and 267, and 1 of 2 residents reviewed for a Multi-Drug Resistant Organism (MDRO) infection, Extended Spectrum Beta Lactamase (ESBL), Resident ID #258.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed for Negative-Pressure Wound Therapy, (vacuum assisted closure, a therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote healing in acute or chronic wounds), Resident ID #254.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident was offered the influenza and pneumococcal vaccinations or that they either received or did not receive the influenza or pneumococcal vaccination due to medical contraindications or refusal for 4 of 5 residents reviewed, Residents ID #s 1, 2, 4 and 5.

Inspectors wroteBased on record review, resident and staff interviews it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for adverse medication reactions and following physicians' orders for specialist medical appointments, Resident ID #36 and 1 of 1 resident reviewed for Hospice Services, Resident ID #21.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents reviewed for pain management, Resident ID #s 46 and 257.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed for adverse medication reactions, Resident ID # 36.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality for 1 of 4 residents reviewed relative to wound assessments and following physician orders for skin checks, Resident ID #36.

Inspectors wroteBased on surveyor obseratio, record review, resident and staff interviews, it has been determined that the facility failed to ensure that all licensed nurses have the specific skill sets necessary to care for residents' needs for 4 of 5 residents reviewed, relative to changes in condition, Resident ID #s 257, 46, 21, and 15.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 7 of 8 months reviewed and for 1 of 3 residents reviewed for antibiotic use, Resident ID #36.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received or did not receive the pneumococcal vaccination due to medical contraindications or refusal, for 5 of 8 residents reviewed, Residents ID #'s 14, 15, 21, 30, and 40.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide care in accordance with a resident's comprehensive care plan for 1 of 2 residents, Resident ID #30 relative to aspiration.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for oxygen therapy, Resident ID #15.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that feeding assistants provide dining assistance only for residents who have no complicated feeding problems for 1 of 2 residents observed being assisted by feeding assistants, Resident ID #30.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain medical records in accordance with professional standards and practices for 1 of 1 resident reviewed for adverse medication reactions, Resident ID # 36.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for Methicillin-Resistant Staphylococcus Aureus (MRSA, an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) and Clostridium difficile (C-diff), is a bacterium that is well known for causing serious diarrheal infections), Resident ID #257.