Aviata at the Sea - Pompano Beach

Inspectors wroteBased on record review and interviews, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) Level I was completed for a resident with mental disorders who was [NAME] Act to the hospital due to a crisis state of violent/aggressive behaviors and then was readmitted to the facility for 1 of 1 sampled resident (Resident #2).

Inspectors wroteBased on interviews, and record reviews, the facility failed to revise the care plan for a resident with recent increased violent/aggressive behaviors towards other residents and staff for 1 of 1 sample resident reviewed for mental disorders (Resident #2).

Inspectors wroteBased on observation, interview and record review, the facility failed to keep food safety requirements in accordance with professional standard of food service safety, for 1 of 2 visits to the main kitchen.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of refuse in a sanitary manner.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide eating assistance in a dignified manner for 1 of 22 residents observed during in-room dining (Resident #51) and failed to provide privacy during personal care for 1 of 22 residents observed during the initial tour (Resident #26).

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 8 out of 39 rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to address catheter care in the baseline care plan for 1 of 2 sampled residents (Resident #182).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to initiate a personalized Care Plan for 4 out of 22 sampled residents (Resident #48, Resident #74, Resident #2, Resident #31).

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide incontinence care in a timely manner for 1 of 1 sampled resident for incontinence care (Resident #65) and failed to obtain a physician order for hospice services for 1 of 1 sampled resident (Resident #71).

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify a severe weight loss in a timely manner, provide adequate nutritional supplements to prevent further severe weight loss and follow weight policy for 3 out of 4 residents sampled for nutrition (Resident #36, Resident #13 and Resident #9).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow the physician's orders for tube feeding and the facility's policy regarding weights, resulting in weight loss for 1 of 1 resident sampled for tube feeding (Resident #5).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the correct fluid restrictions as per the Physician ' s order for 1 of 1 sampled Resident on Dialysis (Resident #27).

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staffing to 4 of 22 sampled residents (Resident #2, #6, #36 and #52) as evidenced by failure to provide two nursing staff to provide assistance with repositioning/ turning a total dependent care resident (Resident #2); failure to provide personal care in a timely manner (Resident #6); failure to provide incontinent care in a timely manner (Resident #36) and failure to assist a resident during dining in a timely manner (Resident #52). This had the potential to affect 75 residents in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to monitor the side effects and behavior of a resident on psychotropic medication (Resident #9), failed to have a written clinical rational note on the pharmacist recommendations for Resident #9 and Resident #2, and failed to monitor side effect for a resident on anticoagulant medication (Resident #2) for 2 of 5 residents sampled for Unnecessary Medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow its own menu portions for a Regular diet. This has the potential to affect 39 out of 75 residents currently on a Regular diet.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, for 2 out of 65 sampled residents observed during dining. (Resident #78, Resident #77)

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were conducted quarterly, and that the necessary staff members attended those meetings for 3 of 6 months reviewed during QAPI review.

Inspectors wroteBased on observation, interviews and record review; the facility failed to follow infection control guidelines by failing to wear a disposable gown during personal care and wound care for Resident #36, failing to have PPE (Personal Protective Equipent) readily accessible for residents on Enhanced Barrier Precautions, failing to wear a disposable gown during medication administration to a resident on Enhanced Barrier Precaution for Resident #71, and failing to provide contact precautions per Physician order for Resident #31. This had the potential to affect 12 residents on Enhanced Barrier Precautions and 1 resident on Contact Precautions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet infection control standards of practice related to a midline catheter used for intravenous (IV) antibiotics or fluids, for 2 of 2 observed residents (Residents #2 and #3).

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a discharge plan for 3 out of 3 residents sampled for discharge to the community (Residents #3, #7 and #8).

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to have Level II Preadmission Screening and Resident Reviews (PASARR) completed for 2 of 19 sampled residents (Resident #15 & Resident #20).

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to employ sufficient dietary staff safely and effectively carry out the functions of the food and nutrition service that include; preparation of food to ensure nutritional value, appearance, and palatability, serve meals in a timely manner, ensure sanitation regulations are followed, and ensure physician ordered therapeutic and mechanically altered diets are followed.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior for 14 of 21 resident rooms, 1 of 1 common areas on the first floor, 1 of 1 common areas on the second floor, and in the laundry area.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to initiate a grievance for 1 of 1 sampled resident (Resident #151) who reported the loss of his personal property (cell phone) at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 3 of 19 sampled residents (Residents #7, Resident #15 and Resident #45).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for necessary adaptive eating equipment for 1 of 7 sampled residents reviewed for Nutrition (Resident #28).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a resident receives wound care consistent with professional standards of practice for 1 of 2 sampled residents reviewed for wound care (Resident #200) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders to provide care to a Central/Midline venous access catheter for 1 of 1 sampled resident reviewed for Catheter Care (Resident #200).

Inspectors wroteBased on observation, interview, and record review, it was determined the medication error rate was 12 percent. Three medication errors were identified while observing a total of 25 opportunities, affecting Resident #200, #37 and #12.

Inspectors wroteBased on observation, interview and review of policy and procedure, the facility failed to: 1) ensure that residents medications and biologicals were properly stored as evidenced by medications and biologicals being left on the resident's night stand for 2 of 2 sampled residents (Resident #5 and #12); and 2) to ensure that it secured the Medication cart #1 (second floor unit) and Treatment Cart (second floor unit).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 66 of 69 residents with foods that were prepared by methods that conserve nutritive value, flavor, appearance, and is palatable, attractive, and appetizing.

Inspectors wroteBased on observation, interview, and record review, The facility failed to ensure pureed foods were prepared in a form to meet the needs of 4 of 4 sampled residents (Resident #6, #16, #20, and #31) with physician ordered pureed diets.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that physician ordered therapeutic diets (Fluid Restriction) were not followed for 1 of 7 sampled residents reviewed for nutrition (Resident #28).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that potentially affected 66 of the facility's 69 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the residents were offered eligible immunizations annually as evidenced by the lack of written consents for declination or acceptance of immunizations for 3 of 5 sampled residents reviewed for immunization review (Resident #5, #21 and #200).

Inspectors wroteBased on observations, interviews and record review, the facility failed to safeguard residents' protected health information for 5 of 5 residents' names with Protected Health Information (PHI) posted in public area, Residents #7, #20, #25, #37 and #107. The census at the time of the survey was 55.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide appropriate assessment and treatment related to mental health concerns; failed to ensure a physician signature on the order for a [NAME] Act; and failed to ensure correct documentation on a [NAME] Act Form for one of one resident, Resident #25.

Inspectors wroteBased on observation, interview, and record review, the medication error rate was 12 percent (%). Three (3) medication errors were identified while observing a total of (25) opportunities, affecting 2 of 8 residents observed, Residents #54 and #29.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' medications were properly supervised / stored as evidenced by over the counter medications being left unattended on the resident's bedside table for Resident #22 and #24 and as evidenced by residents' insulin (pens) medications being left on top of the medication cart unattended and unsecured for Resident #106 and #108.

Inspectors wroteBased on observation, interviews, policy review and record review, the facility failed to provide physical therapy as ordered by the physicians for 2 of 3 sampled residents (Residents #14 and #36).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that the residents medications were documented as administered for prescribed medications for 2 of 8 sampled residents, Resident # 24, and Resident #54 during medication administration observation.