Aviata at Harts Harbor

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatment and supports for daily living safely for 14 (Residents #17, #22, #29, #75, #89, #59, #48, #23, #53, #1, #71, #34, #101 and #67) residents in 11 (Rooms #1, #2, #3, #4, #6, #8, #9, #10, #11, #15 and #21) of 65 resident rooms currently in use, and in both of the hallways (East and South) in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an environment free from physical restraints for one (Resident #10) of one resident observed in a Geri Chair (reclining chair).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #59) of five residents reviewed for accident hazards from a total survey sample of 21 residents. A staff member was observed transferring a dependent resident using a mechanical lift without the assistance of a second staff member. The resident was observed swinging from side to side in the lift as the staff member attempted to lower the resident onto a shower bed. This action could have resulted in serious harm to the resident.

Inspectors wroteBased on observations, record review, interviews and on a review of the facility's policy titled Oxygen Therapy, the facility failed to ensure that a resident who required 0respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #74) of four residents reviewed for oxygen therapy from a total survey sample of 21 residents.

Inspectors wroteBased on record review, interviews, and facility policy and procedure review, the facility failed to provide adequate supervision to prevent the elopement for one (Resident #1) of 12 residents identified as at risk for elopement and failed to provide staff training on the facility's Leave of Absences (LOA) process. Resident #1 was allowed to sign himself out of the facility despite being evaluated as an elopement risk. Review of the medical record for Resident #1 revealed an admission date of 3/17/23 and re- entry on 7/7/24. His diagnoses included metabolic encephalopathy, obesity, major depressive disorder, alcohol abuse, insomnia, tobacco use and anxiety disorder. Review of Resident #1's Care plan initiated on 11/15/23 indicated he may go out on LOA with meds and escort. Resident/family members must sign out every LOA. [...]

Inspectors wroteBased on record review, interviews, and facility policy and procedure review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies related to elopement. Facility staff permitted Resident #1 who was an elopement risk to sign out of the facility without an escort. The facility did not implement the corrective action noted in their Performance Improvement Plan (PIP). There was a total of 12 residents at risk for elopement. Review of the medical record for Resident #1 revealed an admission date of 3/17/23 and re- entry on 7/7/24. His diagnoses included metabolic encephalopathy, obesity, major depressive disorder, alcohol abuse, insomnia, tobacco use and anxiety disorder. Review of Resident #1's Care plan initiated on 11/15/23 indicated he may go out on LOA with meds and escort. Resident/family members must sign out every LOA. [...]

Inspectors wroteBased on observations, staff interviews, a staff cleaning schedule review, and facility policy and procedure review, the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable living environment, by keeping resident care equipment and rooms clean for four (Residents #109, #32, #10, and #46) of five residents who received enteral feedings, from 33 residents sampled for the survey, and a facility census of 117 residents. Failure to maintain a clean living environment can impact residents' enjoyment of their living space due to unsanitary and uncomfortable living conditions. It could also affect their ability to attain/maintain their highest practicable physical, mental, and social well-being.

Inspectors wroteBased on record review, staff interview, and facility policy and procedure review, the facility failed to ensure Quarterly Minimum Data Set (MDS) Assessments were completed timely for seven (Residents #83, #105, #87, #76, #28, #59, and #60) of 33 residents sampled for the survey.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility staff training curriculum and employee handbook review, the facility failed to provide reasonable accommodation of needs for one (Resident #109) of 33 residents sampled for the survey, by failing to ensure that residents capable of using the call light had access to the call light at all times.

Inspectors wroteBased on record review and interview, the facility failed to obtain a Level II Pre-admission Screening and Resident Review (PASARR) preventing the ability of the facility to incorporate the recommendations from the PASARR Level II into the resident's assessment, care planning, and transitions of care for one (Resident #87) of three residents whose PASARRs were reviewed, from a total of 33 residents sampled for the survey.

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and facility policy and procedure review, the facility failed to revise the care plan for one (Resident #24) of one resident reviewed for dialysis treatment, out of two residents receiving dialysis, from a total of 33 residents sampled for the survey. Resident #24's dialysis port site was changed; however, his care plan was not revised to reflect the new port site. Failure to update the care plan timely could result in unmet resident needs and negatively impact the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (Residents #24 and #59) of three residents sampled for review of ADL care, from a total of 33 residents sampled for the survey. Failure to provide care and services to meet residents' ADL needs can potentially have a negative outcome to the residents' health.

Inspectors wroteBased on observations, medical record review, staff interviews and facility policy and procedure review, the facility failed to ensure that residents requiring respiratory care, received such care, consistent with professional standards of practice, by failing to follow physicians' orders for two (Residents #109 and #18) of three residents sampled for review of respiratory therapy, from a total of 33 residents sampled for the survey. Failure to provide needed respiratory care for residents could negatively impact their medical status and functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (Resident #64) of a total of 33 residents sampled for the survey.

Inspectors wroteBased on observation, record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. There were 25 opportunities for error with two errors identified, resulting in an error rate of 8% and involving one (Resident #75) of six residents observed during medication administration, from a total of 33 residents sampled for the survey.

Inspectors wroteBased on record review and interview, the facility, licensed for 180 beds, failed to employ a qualified social worker on a full-time basis.

Inspectors wroteBased on observations, interviews, and facility policy and procedure review, the facility failed to help prevent the development and transmission of diseases and infections by failing to properly clean and disinfect a glucometer for one (Resident #59) of six residents observed during medication administration, from a total of 33 residents sampled for the survey.

Inspectors wroteBased on observation, resident and staff interviews, facility pest control management documentation, and facility policy and procedure, the facility failed to ensure the pest control service was effective when cockroaches and flying insects were observed in resident rooms and the activities room. Ineffective pest control could lead to transmission of disease and infection.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure the bathroom shared by two (Residents #1 and #4) residents, out of three resident bathrooms observed were maintained in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure an adequate system to prevent the misappropriation/drug diversion of controlled medications for 8 (Residents #1, #3, #4, #5, #6, #7, #8, and #9) of 9 sampled residents, with the potential to affect all residents prescribed controlled drugs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to promote and facilitate the residents' right to self-determination for two (Residents #103 and #57) of 42 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one (Resident #103) of 42 sampled residents received treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of the resident. Clinical staff failed to complete dressing changes as ordered.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #103) of 42 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to assist one (Resident #37) of 42 sampled residents in obtaining routine and 24-hour emergency dental care. The facility also failed to assist the resident In making appointments, and arranging for transportation to and from the dental services locations if necessary or if requested.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records for each resident that were accurately documented for one (Resident #103) of 42 sampled residents.