Aviata at the Sea - Harbor Beach

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions, and to prevent foodborne illnesses, during 2 of 2 tours in the central kitchen.

Inspectors wroteBased on observation, interviews, and records review, the facility failed to ensure call lights were within reach for 3 of 25 sample residents (Resident #1, Resident #17 and Resident #22).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their own policy regarding grooming for Activities of Daily Living (ADL) for 1 of 21 sampled residents (Resident #40).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow fall interventions and failed to complete a post-fall assessment for 1 of 5 sampled residents (Resident #23).

Inspectors wroteBased on observations, interviews, and record review the facility failed to attain weekly weights and identify significant weight loss in a timely manner for 1 of 3 sampled residents (Resident #55).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the professional standards for gastrotomy tube (G-tube) care and management for 2 out of 2 sampled residents (Resident #22 and Resident #52).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the professional standards of tracheostomy care and management for 1 of 1 sampled resident (Resident # 22).

Inspectors wroteBased on observations, interviews and record reviews, the facility also failed to follow a physician order for a seizure medication and failed to follow the professional standards of nursing practice related to the rights of medication administration: the right time for 1 of 25 sampled residents (Resident # 26).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the professional standards of practice related to keeping the medication storage room free of facility staff's personal belongings. The facility also failed to ensure medications and supplies are properly stored for 1 of 21 sampled residents (Resident #53).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the menus and preferences of 3 out of 3 residents observed during dining observations (Resident #34, Resident #1, and Resident #10).

Inspectors wroteBased on observations, interviews, and chart review, the facility failed to provide food in a form to meet the needs of 2 of 2 residents on the Dysphagia advanced diet (Resident #55 and Resident #10). This has the potential to affect three residents on a Dysphagia advanced diet.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to dispose of garbage and refuse properly in 2 of 2 observations.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) for 2 of 15 EBP residents (Resident #4 and Resident #22).

Inspectors wroteBased on review of policy and procedure, record review and interview, the facility failed to ensure that it followed physician's order for Intravenous (IV) antibiotic administration for 1 of 3 sampled residents observed, Resident #1.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 16 of 28 resident rooms, 1 of 2 community shower rooms, main dining room, ice machine room, and 1 of 1 clean linen storage rooms.

Inspectors wroteBased on observations and interviews, 5 of 14 sampled residents (Resident #4, Resident #14, Resident #19, Resident # 30, and Resident # 33) were noted to be treated in an undignified manner by the facility.

Inspectors wroteBased on records review and interviews, the facility failed to investigate an incident in which 1 of 1 sampled resident (Resident #15) sustained injuries of unknown origin.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide assistance and supervision to maintain independent eating abilities for 2 (Resident #5 and #13) of 6 sampled residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and treat a resident with Diabetes for 1 of 1 resident reviewed for insulin (Resident #17).

Inspectors wroteBased on observations, records review, and interviews, the facility failed to provide physician's ordered left hand splint to 1 of 1 sampled resident (Resident #14).

Inspectors wroteBased on record review and interview, the facility Physician failed to identify and treat a resident with Diabetes for 1 of 1 resident reviewed for insulin (Resident #17) and failed to address a critical lab result for 1 of 1 sampled resident (Resident #157).

Inspectors wroteBased on record review and interview, the facility Physician failed to document visits in a timely manner for 2 of 2 sampled residents (Resident #17 and Resident #157).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods by methods that conserve nutritive, value, flavor, and appearance for 4 (Residents #5, #7, #19, and #30) of 4 residents with physician ordered Pureed Diet with Pureed Fortified Foods.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain the hot water temperature at an acceptable level for the safety of the residents observed during an Environmental tour for 7 rooms out of 20 rooms occupied.

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it properly kept a resident covered in a dignified manner, 2) failed to ensure that it referred to a resident in a dignified manner, 3) failed to ensure that it promptly provided feeding assistance to a dependent resident during the lunch meal, 4) failed to ensure that it maintained the resident's Foley catheter in a dignified manner, 5) failed to provide meal trays to all residents at the same time ; and, 6) failed to sit at eye level during dining assistance. This deficient practice affected 5 of 19 sampled residents reviewed for dignity. (Resident #3, Resident #10, Resident #36, Resident #7 and Resident #23).

Inspectors wroteBased on observation and interviews, the facility failed to provide wound care consistent with professional standards of practice to prevent infection and to follow physician's order for wound care for 1 of 1 sampled residents reviewed for pressure ulcers (Resident #6).

Inspectors wroteBased on interviews, and record review, the facility failed to provide nutritional intervention and assessment in a timely manner for 1 of 3 sampled residents reviewed for nutrition (Resident #35).

Inspectors wroteBased on observations, interview and record review, the facility failed to monitor and to follow the physician orders for Tube feeding for 1 of 1 sampled residents reviewed for Tube Feeding (Resident #21).

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) cream medication for 2 sampled residents observed, Resident #3 and Resident #37. 2) failed to ensure that it promptly secured the facility's Emergency medication box (E-kit) after use, during a Medication Administration Observation, for 1 of 1 Medication Storage Rooms, 3) failed to ensure that it discarded two expired stock OTC betadine swab stick packages in the facility's Medication Treatment Cart, 4) failed to ensure that it secured the facility's Treatment Medication Cart during Wound Care Observation; and 5) failed to secure routine medication during Medication Administration Observation, Resident #21.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for three residents during dining observations (Resident #7, Resident #3, and Resident #13).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide fortified foods for three residents during meal observation (Resident #7, Resident #1, and Resident #14). This has the potential to affect ten residents that are on fortified food diet orders.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store, prepare, serve, and distribute food in accordance with professional standards for food safety that, include not keeping cold foods at the correct temperature of 41 degrees Fahrenheit and below, keeping personal items in the food production area, and practicing hand hygiene while handling food.