Aviata at the Harbor

Inspectors wroteBased on record review and interviews, the facility failed to ensure the rights of a resident representative, appointed as the Guardian Advocate and authorized to consent to medical treatment, were honored related to communication of health status for one resident (#1) of five sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the legally appointed Guardian Advocate was notified of and involved in health care decisions, including the use of psychotropic medications, for one resident (#1) of five sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a baseline care plan within 48 hours of admission to address Advance Directives and person-centered care for one resident (#1) of five sampled residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to develop and implement a comprehensive, person centered care plan addressing hearing impairment and hearing aid management for one resident (#2) out of five residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure temperature logs were completed daily, the microwave in the nutritional room was kept clean and sanitary, and the kitchen reach-in refrigerator was not over packed with food items to keep cold foods at an appropriate safe temperature.

Inspectors wroteBased on observations, interviews, and record review the facility 1) failed to ensure oxygen was delivered according to physician orders for one resident (#91) with a tracheostomy tube out of two sampled residents with a tracheostomy tube, and 2) failed to ensure emergency tracheostomy supplies were readily available at the resident's bedside according to standards of practice for two residents (#91 and #83) out of two residents sampled with a tracheostomy tube.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure medication was stored safely for one out two medication rooms, two out of three medication carts, one treatment out of two treatment carts and medication properly stored for one resident (#38) out of forty residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve food at an appetizing temperature for five residents ( #90, #95, #29, #51 and #18) of five residents sampled for food services.

Inspectors wroteBased on observations, interviews, and record review, the facility 1) failed to ensure an effective infection control program related to Enhanced Barrier Precautions (EBPs) for three residents (#206, #202, and #203) out of four residents observed, and 2) failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care for four residents (#206, #202, #203 and #83) out of four residents observed.

Inspectors wroteBased on interviews and observations, the facility failed to ensure a safe environment, free from potential accidents/hazards for residents in one smoking area out of one smoking area in the facility

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for one resident (#83) out of four residents observed. These errors constituted an 11.43% medication error rate.

Inspectors wroteBased on observations, interviews, record review, and review of policies and procedures the facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring: 1. cleanliness of 10 resident rooms, (104, 116, 126, 130, 131, 201, 214, 216, 226, 231) were free from dried food, spilled liquids on the floors, buildup of dust, dirt, and debris found under resident beds, broken furniture, 2. air conditioning units were free from bio-growth, dust and debris or leaking water for seven resident rooms (#106, #108 #110 #114, #231, #221, #220), 3. five ceiling vents in the kitchen were free from bio growth dust and debris, 4. two residents (#58 and #33) and in addition one resident room (#227) had sufficient clean bedding or linen. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control Program in response to COVID-19 as evidenced by: 1. two staff members (O, K) not doffing Personal Protective Equipment (PPE) and not wearing PPE appropriately in two of two COVID positive rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 2. not providing clean and sanitary water cups on a daily basis for three residents (#33, #35 and #407) and in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 3. one staff member (U) not performing hand hygiene during the passing of food trays on one unit (West) of two units; and 4. not maintaining a clean environment in the laundry area used to process facility linen and the residents' personal items with the potential to affect a census of 97 residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to assess three residents (#408, #19, and #12) out of 97 admitted residents for self-administration of medications related to the medications left at the bedside.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement interventions identified in the comprehensive person-centered care plan for two residents (#35 and #296) related to falls and the refusal of care of a total sample of forty-seven residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for three residents (#89, #12 and #78) related to: 1. not obtaining a physician's order for use of oxygen for one Resident #89, and 2. not maintaining respiratory equipment in a sanitary manner for two residents (#12 and #78) out of five residents sampled for respiratory care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pain management by not ensuring pain medications were administered in a timely manner for one resident (#4) of two residents reviewed for pain management.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and six errors were identified for two residents (#100 and #83) of five residents observed. These errors constituted a 23.08% medication error rate.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure medications stored an inaccessible to unauthorized staff, residents, and visitors for three residents (#40, #90 and #53) for two days (6/27/22, 6/28/22) of a four day survey.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective interventions were in place for prevention of falls for once Resident (#23) with head injury; prevention of falls with a fracture for one Resident (#94); and the prevention of inappropriate behavior for one Resident (#460) out of 47 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (Resident #67) out of 28 residents receiving respiratory treatments was assessed for self-administration of treatments. Findings Included: On 03/02/21 at 12:20 p.m. Resident #67 was observed in her bed in her room. There was a Bi-Pap machine on her bedside table and an oxygen (O2) concentrator machine which was running and was set at 4 liters per minute (4 L/min). The resident was not connected to any oxygen delivery devices and stated that she was just about to switch from her Bi-Pap machine which she used for her sleep apnea to her nasal cannula. She also revealed a nebulizer treatment delivery device. Regarding respiratory treatments, the resident stated that she mostly manages it all including nebulizer treatments. On 03/04/21 at 8:06 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of preferences related to bathing for one (Resident #67) out of 47 sampled residents. Findings Included: An interview was conducted with Resident #67 on 03/04/21 at 2:33 p.m. She reported that the facility had her scheduled to receive showers in the evenings after she came back to the facility from her hemodialysis treatments. She stated that sometimes she was too tired after her treatments and requested to have her shower the next day but the next day the staff would tell her their schedule was already full and they had no time to give her a shower. The resident reported that she spoke to Staff J, Licensed Practical Nurse (LPN), Unit Manager (UM) about her concern and asked to be switched to a Tuesday/Thursday shower schedule. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to investigate and report an alleged sexual abuse, observed and documented by Staff member I, LPN (Licensed Practical Nurse) by one Resident (#460) towards another Resident (#218) of three reviewed. Findings Included: Review of the progress notes dated 1/17/21 at 3:24 a.m. written by Staff member I, LPN, read, Resident refused to be put in bed, resident was in dayroom being watched by staff and while they were attending to other residents they were assigned to, resident left dayroom and was found in another resident room [Resident #218] touching on her feet and had a hand underneath her blanket by resident's leg. Director of Nursing (DON) notified and was told to put resident in bed regardless of his wishes to stay up. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure that daily care was provided for 3 (# 52, #44 and #09) of 6 residents sampled for ADL's (Activities of Daily Living) as evidenced by: not providing baths or showers, not providing linens for care and not responding to calls in a timely manner.

Inspectors wroteBased on resident record, observation, and staff interviews, the facility did not ensure that one resident (#34) of 47 sampled residents benefited from activities designed to meet the interests of the Resident, and provide support for her physical, mental, and psychosocial well-being. Although Resident #34's care plan included activities to include socialization outside of the Resident's room and indicated that Resident #34 was totally dependent on the staff for attending these activities, Resident #34 received only room visits and this did not include the basic need for time out of doors.

Inspectors wroteBased on observation, interview and record review, the facility failed to change a Peripherally Inserted Central Catheter (PICC) line dressing according to industry standards for one Resident (#211) of three Residents observed. Findings Included: On 3/2/21 at 3:30 p.m., Resident #211 was observed with a PICC line Intravenous (IV) dressing dated 2/17/21. Resident #211 confirmed the dressing had not been changed and the nurse told him it would be changed today. Resident #211 confirmed the nurses clean the IV and give him medication through the line. On 3/2/21 at 3:40 p.m., Staff member F, Licensed Practical Nurse (LPN) confirmed the dressing was dated 2/17/21 and that it was due to be changed today. Staff member F, LPN confirmed the dressing should be changed every seven days and that the dressing is past the seven days. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure tracheostomy (Trach) care was provided for one Resident (#4) of one resident with a tracheostomy in the East wing.

Inspectors wroteBased on interview and record review the facility failed to provide care and services consistent with professional standards of practice related communication with the dialysis facility contributing to failure of monitoring resident status post-dialysis treatment for one Resident (#67) out of one resident receiving hemodialysis. Findings Included: Review of the completed document Resident Census and Conditions of Residents (CMS-672) provided by the facility, dated 03/02/21, revealed that there was only one resident in the facility that was receiving hemodialysis treatments; that resident was confirmed as Resident #67 during the survey entrance conference. An interview was conducted with Resident #67 on 03/02/21 at 12:20 p.m. She confirmed that she received hemodialysis treatments at an outpatient center three times a week (Mon, Wed, Fri). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure proper medication storage for one resident, (# 49) out of 26 residents observed.