Aviara Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to follow their policy on having a Physician order in place upon admission related to self-catheterization for one of three residents (Resident 1) reviewed for intermittent catheterization. (a technique where a thin tube is inserted into the bladder through the urethra to drain urine). This failure had the potential to cause harm to Resident 1's health. Findings. A review of the facility's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included Flaccid Neuropathic Bladder (a condition where the bladder's nerves are damaged causing losing the ability to empty properly) and Fracture of the Thoracic Vertebra (vertebrae in the middle of the vertebral column). On 12/11/2025 at 11 A.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered care plan for one of three residents (Resident 1) when Resident 1 did not have specific interventions such as an intermittent catheterization. (a technique where a thin tube is inserted into the bladder through the urethra to drain urine)This failure had the potential to cause serious complications and could harm Resident 1's health. Findings. A review of the facility's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included Flaccid Neuropathic Bladder (a condition where the bladder's nerves are damaged causing losing the ability to empty properly) and Fracture of the Thoracic Vertebra (vertebrae in the middle of the vertebral column ). On 12/11/2025 at 11 A.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Advance Directive information was provided to 13 of 27 sampled residents (Resident 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74, 94 ). This failure had the result for Resident 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74 and 94 to not have the opportunity to express wishes for care if capacity for decision making was lost.

Inspectors wroteBased on interviews and record review, the facility failed to identify a system wide issue identified by the survey team for not providing Advanced Directive information for 13 of 27 sampled residents (Resident 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74, 94). This failure had the result for Resident 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74 and 94 to not have the opportunity to express wishes for care if capacity for decision making was lost. On 9/16/25 Resident 7's clinical record was reviewed. Resident 7 was admitted to the facility on [DATE] per the facility's admission Record. A document titled Physician Orders for Life-Sustaining Treatment (POLST) dated 2/20/23 was reviewed. Section D Advance Directives information was blank. There was no documentation that the facility provided Resident 7 with Advance Directive information. On 9/16/25 Resident 8's clinical record was reviewed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility's policy and procedure for infection control were implemented for seven of seven residents (103,15,113,82,10,140, 4), when:1. Resident 103 was not tested for Covid-19 after exposure to a positive roommate according to facility policy. 2. Licensed Nurse (LN) 35 did not use a precaution gown when administering medications via gastrostomy tube (G-tube, a tube is inserted into the stomach to provide medications and nutrients) to Resident 15 on Enhanced Barrier Precautions (EBP, a precaution that requires usage of gowns and gloves during specific, high-contact care activities).3. LN 36 used her own personal blood pressure device (BP, a fabric blood pressure machine that cannot be properly sanitized) on two residents (Resident 113, 82) and did not clean the BP cuff in between the residents' use.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained prior to administering psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) for one of 24 sampled residents (Resident 67). This failure resulted in Resident 67 not informed of the potential adverse consequences associated with the use of these psychotropic medications which could be detrimental to the resident's well-being prior to administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and protect privacy for one resident (Resident 15) during medication administration. This failure had the potential to negatively affect Resident 15's feelings of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 24 sampled residents (Residents 67) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Nonpharmacological intervention was not implemented; side effects and behaviors were not monitored for Resident 67's risperidone & oxcarbazepine.2. Resident 67's psychotropic medications were not evaluated on admission for potential dose reduction or discontinuation. These failures resulted in unnecessary psychotropic medications for Resident 67, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide proper vision treatment and assistive devices for one resident (Resident 18) in a timely manner. This failure had the potential for the resident to not receive timely vision treatment and glasses to maintain his highest practicable physical well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tap water temperatures were kept within a safe temperature range for one of six resident rooms (Resident 76's room). In addition, the facility failed to check the function of a wanderguard (a wearable wristband, that uses sensors and alarms to prevent residents at risk of wandering, like those with dementia, from leaving a designated safe area in a facility) for one sampled resident (67) per the manufacturer's guideline. This failure had the potential to have unsafe tap water temperature hot enough to scald Resident 7 and to put Resident 67's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to manage the care related to intravenous (IV- delivery of fluids, medications, or nutrients into the body's bloodstream, usually through a needle or catheter inserted into a vein) therapy for three sampled residents (90, 124, 4) when:1. A peripherally inserted central catheter (PICC - a long, thin, flexible tube inserted into a vein in the arm and threaded into a large vein near the heart) line dressing was not assessed and changed per the facility's policy for Resident 90 and 124.2. The IV fluid intake was not documented per the facility's policy for Resident 4. This failure had the potential for medical complications related to the residents' IV therapy.1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the controlled drug records (CDR, records that are kept for drugs with high abuse potential) reconciled with the electronic medication administration record (EMAR) for four sampled residents (Resident 62, 92, 88, and 142). In addition, a controlled medication prescribed to Resident 62 could not be accounted for when it was wasted without a second nurse signature. This failure had the potential for the residents' (Resident 62, 92, 88, and 142) controlled drugs to be diverted (when a medication is taken for use by someone other than whom it is prescribed).

Inspectors wroteBased on interview and record review, the facility failed to ensure the provider responded to the interim medication regimen review recommendations by the pharmacist for one (Resident 67) of 24 sampled residents. This failure resulted in unnecessary medications and inappropriately monitored medications for the Resident 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15.5 percent. Five (5) medication errors were observed, a total of 33 opportunities, during the medication administration process for three (3) of eleven randomly observed residents (Resident 113, 10, and 140). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored according to acceptable standards of practice in four of eleven sampled medication carts when:1. A crash cart (a cart filled with supplies and medication used during a health emergency) did not contain sterile water, ky jelly, and alcohol swabs.2. A treatment cart contained an expired bottle of Derma Pak -its iodoform packing strip (medicated pieces of cloth used to pack inside of wounds to promote healing) and Clotrimazole cream (a medicated cream used to treat fungal infections of the skin) for Resident 57 without an active order.3. A medication cart contained Assure Dose glucometer drops with an open date of [DATE]. This failure had the potential for medication to have reduced effectiveness and/or medication misuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccine was offered to one of five residents (Resident 124). This failure had the potential to put Resident 124 at greater risk in developing pneumococcal due to their comorbidities.

Inspectors wroteBased on interview and record review, the facility failed to ensure Covid-19 immunization was offered to one of five residents (Resident 124). This failure had the potential to put Resident 124 at greater risk in developing Covid-19 due to their comorbidities.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: A. Staff did not tie plastic trash bags while transporting to the utility room, did not cover the trash bins, and trash bins were overflowing causing a foul smell in the utility room, B. a Licensed Nurse (LN) 2 did not wear a gown for Resident 6 with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds]) during a wound treatment observation, and, C. Newly admitted residents were not tested for tuberculosis (TB, infectious lung disease) testing upon admission. These failures had the potential for cross contamination and spread of infection between residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan related to behaviors for one of three sampled residents (Resident 1). As a result, Resident 1's needs, goals and interventions were not addressed or communicated to staff members for continuity of care.

Inspectors wroteBased on interview and facility documents review, the facility failed to take the resident (Resident 1) back after Resident 1 signed out for an out on pass (OOP, leave of absence) with a physician ' s order, for one of three sampled residents reviewed for residents discharged against medical advice (AMA, when a patient checks himself out against the advice of his doctor). As a result, Resident 1 was discharged against medical advice on 2/8/25. This failure was an unsafe discharge and had the potential to compromise Resident 1 ' s health, safety and well-being. Cross Reference F 655 and F 689.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of three sampled residents related to a resident ' s (Resident 1) multiple episodes of leaving the facility and non-compliance to the ordered duration of hours while out on pass (OOP, therapeutic leave of absence). This failure had the potential for Resident 1 to not be educated on the risk and benefits of leaving the facility, and his non-compliance with the ordered duration of hours while OOP was not addressed. Cross Reference F 622 and F 689.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their policy related to signing residents out (out on pass- OOP, leave of absence) for one of three sampled residents (Resident 1) when staff did not consistently obtain a physician ' s order for an out on pass, assessed, and documented in his clinical record the time Resident 1 returned from out on pass and, consistently signed the OOP form. This failure had the potential to compromise Resident 1 ' s health, safety and well- being. Cross Reference F 622 and F 655.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four licensed nurses (LN 1 and LN 4) who administered medications to residents were verified as competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to perform medication administration/medication management. This deficient practice had the potential for medications to be administered to Resident 1 and other residents in an unsafe manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received his routine pain medication as ordered. This failure had the potential for Resident 1 to experience pain.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for anticoagulant use (a medication that thins the blood, in order to prevent blood clots from forming or becoming larger) for one of three residents, (Resident 1) reviewed for comprehensive care plans. This failure had the potential for staff to provide inconsistent care, and to put Resident 1 at a higher risk of bleeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respect and dignity was provided to a resident (Resident 1) when Certified Nursing Assistant (CNA) 1 did not render Resident 1's request of a clean bowl for her breakfast cereals and pointed at Resident 1 to have thrown cereals into bathroom toilet bowl. As a result, Resident 1 felt disrespected and was upset with the incident. In addition, this failure had the potential for Resident 1 to feel low self-esteem. Cross Reference to F 812.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met while preparing and distributing food for a resident (Resident 1), when Certified Nursing Assistant (CNA) 1 discarded cereals into the toilet bowl and did not flush the toilet bowl in Resident 1's bathroom. This finding had the potential to expose Resident 1 and her roommate to unsafe and unsanitary food practices that could lead to illness and infection. Cross Reference to F 550.

Inspectors wroteBased on observation, interview and record review, that facility failed to maintain required temperature range between 71 to 81 Fahrenheit (°F) with resident rooms in 44 of 68 random rooms inspected. Based on observation, interview, and record review, the facility failed to ensure resident room temperatures were kept at a comfortable and homelike level for 44 of 68 rooms inspected. This deficient practice had the potential for residents to feel uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed ensure a Peripherally Inserted Central Line catheter ( PICC- a long ,flexible tube inserted into a vein the arm use to deliver medications, fluid, blood directly to the heart) was kept flushed (pushing any residual medication or fluid through the intravenous line) for one of two sampled residents (Resident 1) for intravenous therapy. This failure had the potential for Resident 1 to have a clogged Picc line and an infection that would affect Resident 1 ' s health condition and or decline.

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement care plans for two of two residents reviewed for care plans (Residents 1 and 2). This failure had the potential for staff to not be aware of the care needs for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff provided and documented treatment of wounds for two of two residents reviewed for wound care (Residents 1 and 2). As a result, Residents 1 and 2 were at risk for worsening skin conditions.

Inspectors wroteBased on interview, and record review, the facility ' s Licensed Nurses (LNs) failed to complete a neurological examination (neuro check, evaluation of a patient ' s central nervous system that may include the use of lights, reflex hammers, and an example is checking the blood pressure) for Resident 1 after a Certified Nursing Assistant (CNA) 1 witnessed another resident (Resident 2) incurred physical assault to Resident 1. This failure resulted to incomplete monitoring of Resident 1 and the potential of Resident 1 ' s decline after he was physically assaulted.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was provided care and treatment in accordance with professional standards of practice for one of three sampled residents (Resident 1), identified as high fall risk when; 1. staff failed to implement fall preventions for Resident 1, 2. a Licensed Nurse (LN 1) failed to complete a neurological examination (neuro check, evaluation of a patient ' s central nervous system that may include the use of lights and reflex hammers) for Resident 1 after an unwitnessed fall, and failed to communicate to the incoming shift nurse about Resident 1 ' s fall, and 3. LN 1 failed to notify Resident 1 ' s responsible party (RP) of fall incident. These failures resulted to Resident 1 ' s fall, incomplete monitoring of Resident 1, and the resident ' s RP was not made aware of Resident 1 ' s fall.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to complete a new preadmission screening and resident review (PASARR) when a resident received a new mental illness diagnosis for 2 (Resident #11 and Resident #35) of 4 sampled residents reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a person-centered care plan for 2 (Resident #16 and Resident #38) of 4 sampled residents reviewed for accidents and respiratory care. Specifically, the facility failed to care plan the use of bed rails and supplemental oxygen use for Resident #16 and failed to care plan the use of bed rails for Resident #38.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have physician orders for the use of supplemental oxygen for 1 (Resident #16) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an assessment was completed and informed consent and a physician order was obtained for the use of bed rails for 1 (Resident #16) of 3 sampled residents reviewed for accidents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure routine, scheduled pain medication was available in the facility for administration for 1 (Resident #73) of 2 sampled residents reviewed for pain management.

Inspectors wroteBased on observation, interview, record review, manufacturer guideline review, and facility policy review, the facility failed to have a medication error rate less than 5%. The facility had 3 medication errors out of 30 opportunities, which yielded a medication error rate of 10% for 2 (Resident #30 and Resident #71) of 5 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow infection control procedures for the storage of respiratory equipment for 1 (Resident #16) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on record review, interview, facility policy review, the facility failed to ensure the influenza vaccine was offered to 1 (Resident #69) of 5 sampled residents reviewed for immunizations.

Inspectors wroteBased on observation, inteview and record review, the facility failed to develop care plans for two residents (1,2) following a resident-resident altercation. This failure had the potential for increased risk of abuse for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was answered in a timely manner for one of one Resident ' s (1). This failure had the potential for Resident 1 ' s needs to not be accommodated.

Inspectors wroteBased on observation, interview, record review the facility failed to prevent cross contamination of the resident ice scoops stored at the water/ice stations for two of twnursing stations, when the ice scoops were not covered or contained from the environment. As a result, residents were at risk of ingesting contaminated ice, which had the potential of causing gastrointestinal infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Resident 1 received only medications prescribed for him. This failure had the potential for Resident 1 to have an adverse reaction to the incorrect medications administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physicians orders related to hypertension (blood pressure) management for one of three Residents (1). This failure had the potential for Resident 1 to have elevated blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan related to cardiac pacemaker incision site for one of three residents (Resident 1). This failure had the potential to cause harm and affect the resident ' s well - being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff monitored and provide care to cardiac pacemaker (small device to regulate heart rate implanted under the skin of the chest) incision site for one of three sample residents (Resident 1). This failure had the potential to compromise Resident 1 ' s health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was revised/updated for one of 17 sampled residents (24) who sustained multiple falls. This failure had the potential for Resident 24 to continue falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thorough fall investigations were conducted and resident-specific fall interventions were developed to prevent further incidents of fall for one of three residents (24) reviewed for accidents. These failures had the potential to increase the risk of injuries due to falls for Resident 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to answer call lights in a timely manner for four of four sampled residents (39,174,176, 280) and six of six confidential residents (CR- 1, 2, 3, 4, 5, 6). This failure had the potential for residents needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for storing and labeling of house supply medications for one of one treatment cart (1) and two of four medication carts (1, 2) when: 1. Resident 280's medication was not labeled in medication cart # 1; 2. Multiple wound dressing and treatment items were not labeled with an opened date in treatment cart #1; 3. House supply medications in medication cart # 2 had no opened dates and medications of discharged residents were not removed upon discharge from the facility. These failures had the potential for medication error(s) and administration of expired medication(s) to residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications and medical supplies were discarded from the medication storage room for one of one medication storage room reviewed. This failure had the potential for administration of expired medications and supplies to be given and used on residents. On 6/8/21, at 3:44 P.M., a joint observation of the medication storage room and interview was conducted with licensed nurse (LN) 70. LN 70 stated, only the LN's had access to the medication storage room. The following expired medications were found: 1. Five (5) unopened bottles of Strawberry Ensure (liquid supplement) with an expiration date of 5/1/21. 2. One hundred sterile starswab II culture tubes (specimen collection swab) with an expiration date of 3/13/21. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed when serving meal trays to residents. This failure had the potential to transmit infectious organisms to frail residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 17 sampled residents (19) with dignity and respect when Licensed Nurse (LN 2) shoved a spoonful of crushed medication with applesauce into Resident 19's mouth. This failure had the potential to affect Resident 19's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform an accurate assessment to reflect a resident's status for one of four residents (42) reviewed for falls. This failure had the potential to cause Resident 42 harm when the resident's level of consciousness deteriorated after a recent fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail trimming assistance in a timely manner for one of three residents (29) reviewed for ADL assistance. This failure had the potential to cause discomfort and injury to Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor and document the side effects of a medication for one of one resident (42) reviewed for anti-anxiety medications (medication used to manage anxiety disorder). This failure had the potential to cause Resident 42 harm because of inaccurate assessments of medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide preventative skin measures for one of two residents (29) reviewed for pressure ulcer (An area of damaged skin caused by staying in one position for too long) when: - Resident 29 was not turned or repositioned every two hours - Resident 29's pressure relieving mattress was not programmed in accordance to the physician's order. These failures had the potential for Resident 29 to develop pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed nurse (LN) followed the facility's policy and procedure prior to administering via gastric tube (G-tube- a gastric tube inserted through the belly directly into the stomach for administration of liquid nourishment, fluids and medications) medications for two of two residents (29, 701) observed for tube feeding. This failure had the potential for residents to further developed medical complications.