Aviata at Grand Oaks

Inspectors wroteBased on record review, interview, and facility policy and procedure review, the facility failed to ensure residents' refunds were refunded within 30 days after discharge for 1 (Resident #1) of 4 residents sampled for timely discharge refunds.

Inspectors wroteBased on resident and staff interviews, review of facility and resident records, and a review of the manufacturer's instructions for Resident #1's rolling walker, the facility failed to ensure that Resident #1 received adequate supervision and sufficient safeguards to prevent an avoidable accident. Staff failed to understand the proper use of the resident's rollator which resulted in Resident #1, one of seven residents reviewed for accidents, falling backwards and striking his head on the cement sidewalk. This failure resulted in a traumatic subarachnoid hemorrhage requiring three days of monitoring in the Intensive Care Unit (ICU) at an acute care hospital. [...]

Inspectors wroteBased on interviews, record review, and a review of the facility's policies and procedures, the facility failed to implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system for its current census of 103 residents. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. [...]

Inspectors wroteBased on record review, interviews, and a review of facility policies and procedures, the facility failed to ensure that residents with mental disorders were appropriately assessed on admission or as needed to determine the need for specialized services for four (Residents #21, #32, #89, and #42) of five residents reviewed for Preadmission Screening and Resident Review (PASRR).

Inspectors wroteBased on a review of resident records, facility reports, staff interviews, and the facility's policies and procedures titled Advance Directives and Florida Cardiopulmonary Resuscitation (CPR), the facility failed to act in accordance with the resident's Advance Directives and his Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to honor Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:34 p.m. on [DATE]. On [DATE], at 7:35 a.m., Immediate Jeopardy began. [...]

Inspectors wroteBased on a review of resident records, facility reports, staff interviews, and the facility's policy and procedure titled Florida Cardiopulmonary Resuscitation (CPR), the facility failed to provide CPR for one resident who was a Full Code status (the desire to be resuscitated in the event of cardiac/respiratory arrest) after finding him unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to provide CPR according to Resident #1's Advance Directives deprived him of potentially lifesaving measures. Resident #1 was not revived and expired in the facility. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 1:34 p.m. on [DATE]. On [DATE], at 7:35 a.m., Immediate Jeopardy began. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy and procedure review, the facility failed to equip corridors with firmly secured and intact handrails. The facility staff failed to report/service the handrails outside of resident rooms #205 and #511, handrails next to the clean utility linen closet located on the 200 hallways, and handrails located around the 400 hallways' nursing station. Handrails in these locations were observed with jagged ends and sharp edges, posing a risk of injury to residents, staff and other building occupants. Daily facility rounds are important to ensure handrails are firmly secured and in good condition to prevent resident injury.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's Maintenance policy and procedure, the facility failed to ensure maintenance was provided to maintain a safe, clean, and comfortable environment for two (Rooms #502 and #508) of 70 rooms in the facility. The air conditioners' electrical covers were broken, and parts of the covers were missing and had become detached from the units in these two rooms.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every three months for three (Residents #11, #68, and #226) of three residents reviewed, from 34 residents in the total sample. Failure to complete resident minimum data set (MDS) assessments could result in a failure to provide needed care, contributing to residents' inability to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, record review, interviews, and a review of the facility's Oxygen Therapy policy and procedure, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for one (Resident #54) of one resident reviewed for oxygen therapy from a total of 34 residents in the sample.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and a review of facility policies and procedures, the facility failed to maintain and implement its infection control program to prevent the development and transmission of communicable diseases and infections, when three employees (Employees C, E, and F) were observed failing to use personal protective equipment (PPE) in transmission base precaution (TBP)/isolation rooms. Supplies for hand hygiene were not provided in the soiled utility room, PPE was not readily available and convenient to the staff for use in TBP rooms, and employees failed to perform hand hygiene when leaving a TBP room. Failure to follow infection control protocols and procedures could leave vulnerable nursing home residents at risk of contracting infections that could be detrimental to their health.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure wet nesting did not occur, 2) Maintain safe food temperatures, 3) Label and date food items in the [NAME] Wing nourishment room refrigerator/freezer, 4) Dispose of outdated and unlabeled/undated foods items properly, 5) Maintain thermometers in the East and [NAME] Wing nourishment room freezers, 6) Ensure hot water was available in the kitchen handwashing sinks, and 7) Ensure the kitchen trashcan pedal, which opened the trashcan lid, was functional. These failures had the potential to negatively impact all residents who received food from the facility kitchen and nourishment rooms.

Inspectors wroteBased on observations during four of four days, record reviews, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for eleven (Residents #14, #65, #57, #100, #30, #1, #7, #27, #32, #45, and #252) of 46 residents in the sample. Specifically, the facility failed to maintain housekeeping and maintenance services in resident rooms and common areas.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to treat one (Resident #1) of 46 sampled residents with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, by failing to ensure the resident's urinary drainage bag was covered for privacy.

Inspectors wroteBased on a review of resident records and interviews with staff, the facility failed to obtain a Level 2 Preadmission Screening and Resident Review (PASARR) in order to determine appropriateness of placement in a nursing facility and to provide the most appropriate setting and support for one (Resident #34) of five residents identified with serious mental disorders requiring a Level 2 screen, from a total of 45 residents in the sample.

Inspectors wroteBased on observations and interviews, the facility failed to provide personal grooming for one (Resident #30) of a sample of 46 residents. Resident #30 was dependent on staff for care, and his fingernails were long with a thick black substance underneath, which could have resulted in scratches and a potential infection.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure provision of care and treatment in accordance with professional standards of practice for one (Resident #256) of 46 residents reviewed, by failing to obtain orders for the care and monitoring of a peripherally inserted central catheter (PICC) line. Resident #256 was admitted from the hospital with a PICC line for antibiotic therapy to treat a urinary tract infection (UTI). The facility was administering intravenous (IV) antibiotics and flushing the PICC line without a physician's order. There was no physician's order for PICC line dressing changes, and no dressing change occurred for 11 days, despite the facility's policy for catheter site dressing regimens.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #89) resident reviewed, out of 14 residents with contractures, from a total of 46 residents in the sample. Specifically, the facility failed to apply and remove Resident #89's left wrist splint as ordered, which could result in the worsening of her contracture.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice, for two (Residents #354 and #53) of six residents receiving respiratory treatment, from a total of 46 residents in the sample, by failing to administer oxygen at the flow rate ordered by the physician.

Inspectors wroteBased on observations, interviews, medical record review, and facility policy review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #41) sampled from a total sample of 46 residents.

Inspectors wroteBased on observation, interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for two (Residents #39 and #94) residents reviewed from a total sample of 46 residents. A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel consistent with state and federal requirements and professional standards of practice.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to dispose of garbage and refuse properly.