Aviata at Oakfield

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident accessible water temperatures were maintained at safe and comfortable levels, not to exceed the required temperature of 105 - 115 degrees Fahrenheit (F) in two units (100,300) of three units, affecting three rooms (204, 315 and 113).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and 16 errors were identified for three resident (#6, 138 and 95) out of seven residents observed. These errors constituted a 38.1% medication error rate.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control policies and procedures were followed related to the use of PPE (Personal Protective Equipment) and Hand Hygiene (HH), for three residents (#16, #85 and #6) out of three residents sampled for contact precautions.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to accommodate a resident's right to communicate in the language of their choice for one resident (#18) of one observed, and failed to provide a resident with a bed that met his height,comfort and furnishings requirements for one resident (#5) of one resident observed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to notify the physician and family of a change in condition after a new skin condition was identified for one resident (#2) out of one resident observed.

Inspectors wroteBased on observation, interview and review of the facility's housekeeping procedures, the facility failed to ensure shower rooms were maintained in a sanitary manner in one shower room (Zone One East) out of two shower rooms observed.

Inspectors wroteBased on interview, records and policy review, the facility failed to ensure the level I Preadmission Screening and Resident Reviews (PASRRs) were completed accurately for two residents (#17 and #18) out of eight residents sampled.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement the care plan related to fall interventions for one residents (#16) of two observed and failed to follow the resident's care plan for protective heel boots for one resident (#108) of one observed.

Inspectors wroteBased on record review and interviews, the facility failed to review, revise and update interventions for a fall care plan to ensure safety and prevent accidents for one Resident (#18) out of five residents sampled.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to document and plan the discharge process, for one of three residents sampled (Resident #1). Findings Included:During an interview on 01/05/26 at 12:47 PM, Resident #1's representative stated the resident was discharged home without supplies and the home health care company did not show up. During an interview on 01/05/26 at 01:22 PM, with Staff B, Social Services Worker (SSW), and the Social Services Director, SSD. Staff B, SSW stated the home health care provider had not been confirmed for Resident #1, prior to discharge on [DATE]. Staff B, stated no supplies were provided to Resident #1 at discharge. Staff B, stated Resident #1 was not reached out to post discharge from the facility. Staff B, stated being made aware the home health care provider had declined to admit Resident #1. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure treatment and care in accordance with professional standards of practice by failing to implement post fall evaluations, for one (Resident #1) of three residents reviewed for falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure urostomy and nephrostomy tubes care was provided and was consistent with professional standards of practice for one (Resident #1) out of three residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to notify the physician of a non-functioning wound vac and neglected to provide wound care per physician orders for one (#1) of three residents sampled for surgical wounds.

Inspectors wroteBased on interviews and record review, the facility failed to provide necessary treatment to promote healing and prevent infection for an identified pressure ulcer for one (#5) of three residents reviewed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the resident's right to be free from neglect by not providing supervision for one resident (#1) out of four residents sampled for elopement. At approximately 12:15 p.m. on 12/20/23, Resident #1 was able to exit the facility through a door with a wander monitoring device alarm, walk into the facility lobby area, and speak with two facility staff members. One staff member held the door open for Resident #1 to enter the lobby, and the other staff member asked Resident #1 to sign out on the visitor log. Resident #1 signed the visitor log and exited out another door with a wander monitoring device alarm. Resident #1 walked approximately 0.2 miles down a heavily trafficked road, he crossed four lanes of traffic, and called his family member to pick him up. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one resident (#1) out of four residents sampled for elopement. Resident #1 had diagnoses to include metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, and a history of falling. Resident #1 was assessed to be at high risk for elopement with a physician's order to have a wander monitoring device in place. Review of Resident #1's medical record revealed Resident #1 did not have a wander monitoring device in place on 12/12/23, 12/13/23, 12/16/23, and 12/19/23. A wander monitoring device could not be located by nursing staff to place on Resident #1 and there was no evidence of an increase in supervision for Resident #1. At approximately 12:15 p.m. [...]

Inspectors wroteBased on interviews and record review the facility failed to implement and develop a comprehensive care plan for one resident (#1) out of 4 residents reviewed who were at high risk for elopement.

Inspectors wroteBased on interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP), when the facility staff failed to prevent accidents and hazards related to the supervision of residents at risk for elopement for one resident (#1) out of four residents reviewed for elopement. Ongoing non-compliance was identified during the complaint survey on 1/16/24 through 1/19/24 related to the supervision of residents and a process to ensure staff have the necessary wander monitoring devices and wander monitoring device checkers accessible and available to them.

Inspectors wroteBased on record review, observations, and interviews the facility 1) failed to hold scheduled interdisciplinary care conferences and notify resident representatives of care conferences within a time frame adopted by the facility's policy for five residents/representatives (#9, #33, #42, #51, and #62) out of 34 sampled residents, and 2) failed to revise the care plan for one resident (#33) out of 34 sampled residents related to the discontinuation of oxygen therapy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1) One of one Dish Washing machines were operating per final rinse requirements during two of four days observed, on 7/24/2023 and 7/25/2023; and 2) One of one rental walk in freezer unit observed with heavy ice build up inside the unit during two of four days observed, on 7/24/2023 and 7/25/2023.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a grievance was filed for one (#33) out of thirty-three sampled residents related to the temperature and noise of the residents' room.

Inspectors wroteBased on record review and interviews the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four residents (#17, #2, #79, and #90) of four residents sampled for PASRR.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a baseline care plan was completed for one resident (#311) of three residents reviewed for care plans.

Inspectors wroteBased on observations, interviews, and record review the facility failed to offer and provide individualized activities and assist one resident (#83) of thirty-three sampled residents to group activities during three of four days observed, 7/24/2023, 7/25/2023, and 7/26/2023. Findings Included: On 7/24/2023 at 8:20 a.m., the 100/300 unit station area was observed with Resident #83 reclined in a Geri chair, positioned out in the hallway between the nurse station and the 100/300 lounge room. Resident #83 was noted with his head tilted and slumped forward with a head pillow not placed correctly behind him. A white linen sheet was observed covering him from his feet to his neck. Resident #83 was observed resting with his eyes closed and not otherwise presenting with any behaviors, pain or discomfort. Resident #83 was observed in the same position in his Geri Chair from 8:20 a.m. [...]

Inspectors wroteBased on observations, interviews and records review, the facility did not ensure a bedfast resident with limited mobility received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to ensure restorative services were provided for one resident (#89) of three residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure a catheter was anchored to prevent excessive tension, secured to facilitate flow of urine, and ensure it was positioned below the level of the bladder for one resident (#17) out of 13 residents sampled during 3 of 4 days of survey.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and two errors were identified for two residents (#30 and #4 ) of five residents observed. These errors constituted a 6.67% medication error rate.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure appropriate coordination of Hospice services for one resident (Resident #8) of three residents sampled.

Inspectors wroteBased on observations, interviews, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection prevention and control program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) as evidenced by 1. failed to ensure multi-resident equipment (mechanical lift) was cleaned with an approved disinfectant, 2. failed to ensure 18 out of 52 staff members were screened at the beginning of their shift on 8/16/21. Failing to implement an infection prevention and control program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) consistently had the potential to expose a total of 112 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dignity was maintained related to not ensuring a privacy bag was provided for a catheter bag for one resident (#113) out of a sample of five residents with indwelling or external catheters for three of three days observed.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure one shower room (West Unit) of two shower rooms and three resident rooms (111, 306 and 316) out of 38 resident rooms were maintained in a safe and sanitary manner for 3 out of 4 days of survey (08/16/21, 08/17/21 and 08/18/21.)

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide treatment and care in accordance with professional standards of practice as evidenced by not ensuring a medication was reconciled and confirmed by the physician upon readmission from the hospital resulting in the medication not being administered for one resident (#29) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one resident's (#29) drug regimen of five residents sampled for unnecessary medications was free of unnecessary medications related to behavioral and side effect monitoring of psychotropic medications.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to store drugs and biologicals in a secure manner by leaving one medication unattended, with no facility staff near on the 300 Hall medication cart; and failed to appropriately store medications in three (300 Hall, 300 [NAME] Hall Cart #1 and Cart #2), of a sample of five medications carts.