Aviata at Colonial Lakes

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to privacy for 2 of 2 residents reviewed for privacy, out of a total sample of 52, (#90 and #159).

Inspectors wroteBased on observations interviews and record review, the facility failed to administer medication as ordered by the physician for 1 out of 3 residents sampled for pain management of a total sample of 52 (#104).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure licensed nurses were knowledgeable and demonstrated competency to provide care and services per standards of care for a medication administration for 1 of 6 resident reviewed during observation of medication administration, out of a total sample of 52 residents (186).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for mood and behavior, of a total sample 52 residents, (#31).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Midline Intravenous (IV) dressing care was completed as per professional standards for 1 of 1 resident of a total sample of 4 residents, (#1). Resident #1, an [AGE] year-old female was readmitted to the facility on [DATE]. Her diagnoses included abscess left great toe, cerebral infarction (stroke), type 2 diabetes, heart failure, peripheral vascular disease, elevated white blood cell count and lymphedema. A Midline Catheter is a thin, flexible tube placed into a vein in the arm. The catheter is 8-10 centimeters long and can stay in the arm for up to 29 days. This allows patients to get IV (intravenous) medicines and have blood samples drawn. The catheter is placed by a trained nurse. (retrieved on 10/4/25 at 3:57 PM from https://patient.uwhealth.org/healthfacts). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure prescribed therapeutic diet of dysphagia mechanical soft consistency was followed for 1 of 8 sampled residents, (#1). This failure resulted in resident #1 consuming the wrong consistency snack, causing her to choke, and turn blue until she was transferred and admitted to the hospital Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by Certified Nursing Assistant (CNA) A. The CNA was aware resident #1 was on a mechanical soft diet but allowed the resident to eat the sandwich because she had seen her eat bread in the past. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had the knowledge, skill sets, and competencies to provide foods/snacks to residents in accordance with their plan of care and physician orders for 1 of 8 sampled residents, (#1). This failure resulted in the resident being allowed to consume the wrong consistency snack which resulted in the resident choking and being transferred to a higher level of care where she was admitted to the Intensive Care Unit (ICU) and treated for acute respiratory failure with hypoxia. On 12/20/24 at 11:00 AM, resident #1, who was on a mechanical soft consistency diet, was allowed to consume a peanut butter and jelly (PB&J) sandwich from a tray of snacks left on a table in the dayroom by CNA A. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable goals and interventions for a vulnerable resident with behaviors that posed a risk to their safety, (#1).

Inspectors wroteBased on interview, and record review, the facility failed to appropriately document, investigate, follow up, and promptly resolve grievances for 1 of 3 sampled residents, (#1).

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with professional standards of practice for 1 of 3 sampled residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential spread of infection by not ensuring Enhanced Barrier Precautions (EBP) were followed by not wearing personal protective equipment (PPE) for 1 of 5 residents reviewed for urinary catheter (#3), failed to identify the type of precaution staff needed to follow for EBP for 2 of 5 residents, (#3 and #12) and failed to follow manufacturer's guidelines for cleaning and disinfection of shared glucose meters for 1 of 5 residents reviewed for blood sugar monitoring (#11) of a total sample of 20 residents.

Inspectors wroteBased on interview, and record review, the facility failed to make transportation arrangements for a resident to a specialty medical care appointment, for 1 of 6 sampled residents, (#1). Review of resident #1's record revealed an admission date of 06/14/24. His diagnoses included: cardiomyopathy, type 2 diabetes mellitus with diabetic neuropathy, idiopathic progressive neuropathy, chronic pain syndrome, and acquired absence of left leg below the knee. Review of resident #1's Minimum Data Set Significant Change in Condition assessment dated [DATE] indicated his Brief Interview for Mental Status Summary Score was 15, the highest score value, which suggested the resident is cognitively intact. Review of Resident #1's medical record under Order Details revealed an order dated 07/23/24 at 2:41 PM, which read resident #1 had a neurology appointment scheduled for 09/04/24 at 1:00 PM. [...]

Inspectors wroteBased on observation and interview, the facility failed to store raw foods (e.g., produce) in a manner to reduce the risk of contamination of ready-to-eat foods and failed to store other food items by sealing, labeling and dating when opened. The facility also failed to ensure dishes and flatware were cleaned and stored under sanitary conditions and equipment was clean and in safe working order. These issues had the potential to negatively affect the health of 154 of the 166 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in safe operating condition for all mechanical and electrical equipment. This issue had the potential to negatively affect the health of 154 of the 166 residents in the facility who received food and nutrition by mouth.

Inspectors wroteBased on observation and interview the facility failed to maintain clean and soiled utility rooms to ensure proper storage of contaminated and clean linens, and failed to maintain adequate handwashing supplies on 2 of 2 units, out of a total of 3 units, to prevent cross contamination, and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, out of a total sample of 59 residents, (#321).

Inspectors wroteBased on observation, interview, and record review, the facility failed to review or revise the individualized fall plan of care to include a new intervention after every fall for 1 out of 3 residents reviewed for care plans, from a total sample of 59 residents, (#62).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had a timely appointment for vision care and services for 1 out of 2 residents reviewed for vision and hearing, of a total sample of 59 residents, (#156).

Inspectors wroteBased on interview, and record review, the facility failed to provide proof of consent, refusal, or medical contraindication for Pneumococcal vaccine for 2 of 5 residents reviewed for immunizations, (#5, and #129).

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were accessible on weekends for 1 of 3 residents reviewed for personal funds of a total sample of 68 residents, (#32).

Inspectors wroteBased on record review and interview, the facility failed to obtain physician orders upon admission to address wound care for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 68 residents, (#343).

Inspectors wroteBased on observation and interview, the facility failed to ensure potentially hazardous foods were at a cold holding temperature of 41 degrees Fahrenheit, or below, to prevent foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and complete the Minimum Data Set (MDS) assessment Section F-preferences for customary routine and activities for 1 of 4 residents reviewed for activities of a total sample of 68 residents, (#138).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed for 1 of 3 residents reviewed for PASRR of a total sample of 68 residents, (#36).

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered baseline care plan, that addressed care and services, and failed to provide a summary to the resident and resident representative within 48 hours for 2 of 4 newly admitted residents reviewed for baseline careplans of a total sample of 68 residents, (#108, #343).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for activities for 1 of 4 residents reviewed for activities, (#138), and failed to update a care plan to reflect the residents' preferences and choices for 1 of 4 residents reviewed for choices in a total sample of 68 residents, (#121).

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed, revised, and individualized, for falls for 1 of 4 residents reviewed for falls out of a total sample of 68 residents, (#108).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care for 1 of 4 residents reviewed for Activities of Daily Living (ADL) of a total sample of 68 residents, (#12).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician's orders were implemented for compression stockings for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide bilateral palm guards and left elbow brace per physician orders to prevent further decrease in range of motion (ROM) for 1 of 5 residents reviewed for limited ROM of a total sample of 68 residents, (#139).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ongoing communication, coordination and collaboration between the nursing home and the dialysis center for 1 of 1 resident reviewed for dialysis of a total sample of 68 residents, (#136).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the accurate dosage of insulin was administered as per physician's orders, and failed to ensure the medication was administered as scheduled to 1 of 7 residents observed for medication administration observation of a total sample of 68 residents, (#9).

Inspectors wroteBased on interview and record review, the facility failed to accurately document physician's order for thigh high compression hose for 1 of 1 resident reviewed for edema, of a total sample of 68 residents, (#114).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control practices to prevent cross contamination during wound care for 1 of 3 residents reviewed for pressure ulcers of a total sample of 68 residents, (#129).