Aviata at Central Park

Inspectors wroteBased on record reviews and interviews the facility failed to ensure physician orders were followed by administering medications outside parameters without notifying the physician and the IDT (Interdisciplinary) team for one resident (#1) of three residents reviewed.

Inspectors wroteBased on interviews and record review the facility failed to ensure baseline care plans for code status were in place for three residents (#1, #2, and #3) of three residents sampled. Resident #1 was readmitted on [DATE] with diagnoses to include but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, altered mental status, generalized muscle weakness, dysphagia, obstructive sleep apnea, stage III chronic kidney disease, hypertension, anemia, sepsis, pneumonia, metabolic encephalopathy, congestive heart failure (CHF), and dependence on supplemental oxygen. Review of Resident #1's physician order dated 9/8/25 showed resident was a full code. Review of Resident #1's Care Plan revealed no care plan for a code status. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff had the skills, knowledge and certification necessary to provide cardiopulmonary resuscitation (CPR) services for one resident (#1) of three residents sampled. Review of Resident #1's admission record revealed a readmission date of [DATE] with diagnoses to include but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, altered mental status, generalized muscle weakness, dysphagia, obstructive sleep apnea, stage III chronic kidney disease, hypertension, anemia, sepsis, pneumonia, metabolic encephalopathy, congestive heart failure (CHF), and dependence on supplemental oxygen. Review of Resident #1's physician order dated [DATE] showed the resident was a full code. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure four residents (Resident #5, Resident #6, Resident #7, and Resident #8) of five residents observed requiring assistance with eating, were provided a dignified dining experience.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #2, Resident #3, Resident #4) of three residents sampled for care plans.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents received necessary treatment and services consistent with profession standards of practice related to pressure wounds/ ulcers for two residents (Resident #2 and Resident #3) of three residents sampled for pressure wounds/ ulcers.

Inspectors wroteBased on observation, interview, and policy and procedure review the facility failed to label and store all medications in accordance with professional standards of practice for 3 of 4 medication carts, and failed to ensure all medications were stored to permit only authorized personnel access.

Inspectors wroteBased on interview and record review the facility failed to promptly notify the ordering physician of urine culture results requiring a change in treatment for 2 of 3 residents, Residents #31 and #84, in a total sample of 39 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided a clean and homelike environment (Photographic evidence obtained).

Inspectors wroteBased on observation and interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary care and services related to nail care, for 3 (Resident #48, #66, #88) of 8 residents out of a total sample of 39 residents.

Inspectors wroteBased on observation, interview, record review and policy and procedure review the facility failed to provide care for peripherally inserted central catheters in accordance with professional standards of practice for 1 out of 2 residents, Resident #88, out of a total sample of 39 residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to administer oxygen per physician's orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care (Resident #5 and #27) out of a total sample of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection during medication administration for 2 of 6 observations.

Inspectors wroteBased on interviews and record review, the facility failed to respond and resolve a grievance through to a conclusion for one resident (#1) out of three residents sampled for grievances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate supervision to mitigate the risk of a fall with major injury for one resident (#1) out of three residents sampled for falls.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide nursing and related services to assure one resident (#1) out of three residents sampled, attained and maintained the highest practicable physical, mental, and psychosocial well-being related to 1) not identifying a change in condition in a timely manner, 2) not notifying provider and resident representative of change in condition, 3) not being prepared for wound care, and 4) not ensuring pain was managed adequately.

Inspectors wroteBased on interviews, and record review the facility failed to respond to a pharmacist recommendation in a timely manner for one resident (#1) out of three resident sampled.

Inspectors wroteBased on observations, interviews and policy review, the facility did not ensure a clean and sanitary environment was provided during four of four days (10/10/21 - 10/13/21) related to the ice machine not being clean, nine resident rooms (#50, #51, #52, #53, #55, #56, #57, #59 and #61)) not swept or mopped, ceiling vents were filled with dirt, debris and bio-growth in six resident rooms (#53, #55, #56, #57, #59 and #61), and privacy curtains and linens stained and soiled in six resident rooms (#52, #53, #55, #56, #57 and #65) in one hall (Ground Floor - Hall A) out of six halls.

Inspectors wroteBased on observations, interviews and policy review the facility did not ensure that foods were served from clean and sanitary dishware during two of two lunch meal service observations, in two (lower-level dining and main level dining) of two dining rooms.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the results of the most recent state or federal surveys were readily accessible to residents, or visitors to examine the survey results without having to ask staff to see them.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to honor resident rights, by not ensuring 1. the facility had a system in place for residents to promptly receive mail on the day that it was delivered by the US Postal Service to include weekends, and 2. the privacy for all residents in a confidential and private manner related to having residents wear a colored wrist band to identify who had or had not been vaccinated for COVID-19.

Inspectors wroteBased on record review, observations, and interviews the facility did not ensure the care plan was implemented for falls related to floor mats for one resident (#55) of four residents sampled for falls, and for not ensuring partial dentures were provided for one resident (#55) of thirty-six sampled residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide appropriate treatment and services for enternal feeding by not ensuring the physician's order for the tube feeding rate was followed for one resident (#195) of six residents with tube feedings.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and three errors were identified for two (Resident #41 and #48) of four residents observed. These errors constituted a medication error rate of 12 percent.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure one medication was stored and locked up for one day (10/12/2021) of four days of the survey and failed to follow their policy to secure medications appropriately in three (First Floor-B Hall, First Floor - A Hall, Ground Floor - A Hall) of five medication carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 5 (#11, #68, #10, #113, #35) of 33 sampled residents related to Resident #11 by failing to disinfect the glucometer and performing hand hygiene after touching the glucometer; the facility failed to ensure Resident #68 was placed on contact precautions after observation of watery odorous stool started on 1/23/20; the facility failed to ensure eye drops were administered for Resident #10 without contaminating the bottles; the facility failed to ensure staff entering Resident #113's room donned PPE and did not take in reusable equipment, and the facility failed to ensure medical waste for Resident #35 was disposed of according to their policy. Findings Included: 1. [...]

Inspectors wroteBased on interviews, record review and observations, the facility failed to offer or arrange for outside activities for 4 (#69, #14, #46, and #100) of the 33 residents sampled, including but not limited to, going out of doors in the fresh air when weather permitted and making periodic shopping trips for those who would enjoy them.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure assistive services were provided in a timely manner for one (#18) of thirty-three residents related to concerns with hearing.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide necessary treatment and services to promote wound healing for one (Resident #54) of three sampled residents for wound care.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the medication error rate was below 5% for one (#10) of 5 sampled residents who were administered medications. This resulted in 5 errors from 26 medication administration opportunities, for a medication error rate of 19.23%. Findings Included: During medication administration on 1/30/20 at 9:35 a.m. with Staff Member J, RN, she prepared Resident #10's medication: Staff Member J, RN, observed the computer screen and removed one 400 mg tablet of guaifenesin from the over the counter medications and placed it in the medicine cup. One tablet of Depakote delayed release 125 mg's and placed in the medicine cup. One tablet of Amlodipine 10 mg tablet and placed in the medicine cup. Staff Member J, RN, stated she was finished with the pills for Resident #10. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain drugs and biologicals used in the facility in a safe and secure manner in one (ground floor) of two medication storage rooms and one (C) of six medication carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and ensure timeliness of laboratory results for one (#68) of 3 residents sampled related to stool samples for Clostridium Difficile on 4 different days. Findings Included: During observation of Resident #68's medication administration with Staff Member I, RN, on 1/30/20 at 9:02 a.m. revealed the resident turned to her right side with white bed sheets observed up to her chest. Resident #68 turned back toward Staff Member I, RN, and looked at her as brown, watery, odorous stool oozed through the white sheets. Resident #68 used her left hand to pull the sheet away from her by placing her left hand in the watery stool and lifting the white sheet. Staff Member I, RN, observed the resident moving the sheets, and walked back to the door and asked the CNA in the hall to get the resident changed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 3 of 6 (top middle, top right, and bottom middle) burners on the stove.