Avantara Aurora

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the building environment and plumbing equipment in good repair by ensuring water pipes connected to resident toilets were free from leaks. This applies to 2 of 3 residents (R1 and R3) reviewed for toilet leaks.

Inspectors wroteBased on interview and record review the facility failed to notify the Long-Term Care Ombudsman facility representative of non-emergent transfer and discharges monthly as the agency requested. This applies to 4 of 4 residents (R9, R12, R88, R89) reviewed for discharge in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming/hygiene for a resident who required assistance for ADL (Activities of Daily Living) care. This applies to 1 of 1 resident (R43) reviewed for ADL care in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary assistance and supervision during toileting, for a resident that had limited ability to sit unsupported, was cognitively impaired, with known impulsivity, and at high risk for falls, to prevent a fall that resulted in injury. This applies to 1 of 2 residents (R9) reviewed for falls in the sample of 23. R9's EMR (Electronic Medical Record) showed R9 was readmitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, kidney transplant status, type 2 diabetes, abnormal posture and hypertensive heart disease. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to perform a nutrition assessment and implement interventions for a resident experiencing poor appetite and oral intake, hyperkalemia, and significant weight loss. This applies to 1 of 1 residents (R1) reviewed for nutrition in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an effective analgesic regimen, reassess a residents unrelieved pain, develop a care plan for pain management or notify the physician of unrelieved pain in accordance with facility policy. This applies to 1 of 1 resident (R94) reviewed for pain management.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow their policy for proper controlled medication documentation, storage, and disposal. This applies to 2 of 4 residents (R40, R98) reviewed for controlled medication storage, labeling, and disposal in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 26 medication opportunities with 2 errors resulting in a 7.69% medication error rate. This applies to 2 of 6 residents (R16, R29) observed for medication administration in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for proper medication storage and labeling. This applies to 2 of 4 residents (R29, R43) reviewed for medication storage and labeling in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve portions of pureed pork in amounts indicated on the planned/approved facility menus. This applies to 2 of 2 residents (R73 and R99) reviewed for pureed diets in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for contact isolation precaution and infection prevention practices during medication administration. This applies to 2 of 7 residents (R83, R93) reviewed for infection control in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their planned menu resulting in lunch entrees being served to residents with inadequate protein. This applies to all 78 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure resident medications. This applies to 5 out of 5 residents (R15, R22, R24, R40, R43) reviewed for medications in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement transmission-based precautions for a resident with an acute contagious gastrointestinal infection and adhere to enhanced-barrier precautions. This applies to 6 out 6 residents (R184, R183, R65, R51, R46, and R40) reviewed for infection control in a sample of 24.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to treat residents with dignity while providing care. This applies to 2 of 2 residents (R183 and R184) reviewed for dignity in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, facility failed to implement measures to prevent re-opening of pressure ulcer for a resident with known skin alterations to the right buttocks and coccyx. The facility also failed to then assess, report, and initiate pressure ulcer treatments. This applies to 1 out of 1 (R40) resident reviewed for pressure ulcer in a sample size of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer enteral feeding as ordered, and failed to change and label enteral feeding tube equipment for residents receiving gastrostomy tube feedings. This applies to 3 out of 4 (R46, R11, and R23) reviewed for enteral feeding in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to change a resident's PICC (Peripherally Inserted Central Catheter) line dressing as ordered. This applies to 1 out of 3 residents (R51) reviewed for central intravenous (IV) lines in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders and weigh a resident weekly. The facility also failed to implement interventions for residents with weight loss. This failure resulted in R76 having a significant weight loss. This applies to 5 of 7 residents (R76, R40, R13, R10, and R53) reviewed for weight loss in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their planned menu/recipes resulting in lunch entrees being served to residents with inadequate protein. This applies to all 66 residents in the facility receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene before and after providing direct care to residents on EBP (enhanced barrier precaution). The facility also failed to implement EBP for residents with implanted medical devices, and during high-contact resident care. This applies to 4 of 20 residents (R18, R25, R60 and R76) reviewed for infection control in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 3 of 3 residents (R12, R60 and R61) reviewed for ADLs (activities of daily living) in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen floor to ensure cleanability. This applies to all 70 residents in the facility receiving oral diets at the facility.