Aviata at Venice

Inspectors wroteBased on observation, record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to provide assistance with showers, personal hygiene and incontinent care as outlined in the resident's care plan and according to residents' preferences for 3 (Residents #6, #13 and #57) of 5 dependent residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide resident centered activities to meet the interests of 2 (Residents #43 and #6) of 3 residents reviewed for activities.

Inspectors wroteBased on record review, review of facility policy and facility staff interview, the facility failed to report an allegation of neglect to the proper authorities within the required timeframe for 1 (Resident #80) of 3 residents reviewed with an allegation of neglect.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide appropriate care in accordance with current standards of care to prevent complications of tube feeding for 1 (Resident #81) of 3 residents reviewed with feeding tubes (tube inserted directly in the stomach to deliver liquid nutrition, fluids, and medications).

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the irregularities identified during the pharmacy consultant's drug regimen review were acted upon for 1 (Resident #13) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, review of facility's policy and procedure, staff and resident interviews, the facility failed to ensure the safe storage of medications for 3 (Residents #37, #70, and #74) of 3 residents observed with unsecured medications at the bedside.

Inspectors wroteBased on observation, review of clinical records and staff interviews the facility failed to provide the necessary care and services to maintain urinary catheters in a safe and sanitary manner for 3 (Resident #900, #899 and #800) of 4 residents reviewed with indwelling urinary catheters.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to ensure adequate supervision to prevent the elopement of 1 (Resident #2) of 1 sampled resident who left the facility without staff knowledge.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to sufficient nursing staffing to ensure timely response to request for assistance for 3 (Residents #5, #6 and #7) of 3 sampled residents.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect the residents' right to be free from neglect by failure to ensure staff used the appropriate mechanical lift, and failure to follow safety protocol when using a mechanical lift to transfer 2 (Residents #1 and #2) of 3 sampled residents who use mechanical lifts for transfers.

Inspectors wroteBased on observation, record review, residents and staff interviews, review of facility's policy and procedure, the facility failed to ensure ongoing monitoring of staff competency for use of mechanical lifts to ensure the safety of residents during transfers for 2 (Residents #1 and #2) of 3 sampled residents of 16 residents who use mechanical lifts for transfers.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 4 (Staff A, Staff E, Staff F, Staff G) of 4 sampled Certified Nursing Assistants (CNAs) were knowledgeable and competent to ensure the safe use of mechanical lifts to transfer residents.

Inspectors wroteBased on observations, review of the clinical record, review of the facility policies and procedures, and staff interviews the facility failed to develop and implement a program of meaningful activities to meet the needs of 6 of 16 residents in the memory care unit. The facility failed to implement meaningful individualized activities to meet the interest and wellbeing of 1 (Resident #58) of 1 resident in the memory unit sampled for individualized activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration.

Inspectors wroteBased on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders for 2 (Residents #18 and #30) of 4 residents observed for medication administration. Three licensed nurses on the morning shift with 29 opportunities were observed. Two medication errors were observed resulting in a 6.9% error rate.

Inspectors wroteBased on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure medications were appropriately labeled in 3 (Carts #1, #2, and #3) of 3 medications carts reviewed. Without an open date on the medication there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The facility also failed to secure medication and treatment carts were secured when not in view of the licensed nurse.

Inspectors wroteBased on observations, record review and staff interview the facility failed to ensure they applied and removed an AFO (ankle-foot orthosis) device for 1 (Resident #66) of 1 out of 6 residents coded as having an AFO. The use of an AFO is to improve standing, transfers, and/or walking patterns by reducing, preventing, or limiting the movement of the lower leg and foot and by supporting weak muscles.

Inspectors wroteBased on observation, review of the clinical record, review of facility policies and procedures, and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #19, and #68) of 3 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide care and services to prevent reduction in range of motion (ROM) for 1 (Resident #78) of 2 residents reviewed for limitation in ROM.

Inspectors wroteBased on record review, and staff interviews the facility failed to ensure they maintained communication between the nursing facility and the dialysis center related to the ongoing assessment of dialysis resident before and after each dialysis treatment for 2 (Residents #7 and #24) of 2 residents receiving dialysis.

Inspectors wroteBased on observation, record review and interview, the facility failed to have documentation of alternatives attempted prior to use of side rails, review the risks and benefits of side rails, and obtain consent prior to the use of side rails for 1 (Resident #44) of 1 resident observed with side rails on the bed.

Inspectors wroteBased on staff interviews and staff record reviews, the facility failed to ensure 3 Certified Nursing Assistants (CNA) (Staff A, H, and I) of 3 sampled records reviewed had a performance review completed at least once every 12 months. The facility failed to ensure staff had in-service education based on the outcome of the employee annual performance/competency evaluations.

Inspectors wroteBased on record review, review of facility's policy and procedure, and staff interview the facility failed to ensure the baseline care plan was developed within 48 hours of admission for 1(Resident #283) of 3 newly admitted residents reviewed.

Inspectors wroteBased on staff interview, and record review, the facility failed to ensure 1 (Resident #282) of 5 sampled residents was free of significant medication errors. Medications not given as ordered can have a significant impact on resident health and welfare.

Inspectors wroteBased on staff interview, and record review, the facility failed to maintain clinical records that were complete and accurate for 1 (Residents #282) of 2 resident records reviewed. Incomplete or inaccurate clinical records could result in residents receiving improper care.

Inspectors wroteBased on observation, and staff interview, the facility failed to maintain the kitchen in a clean and sanitary manner and in good repair by having openings into the ceiling with potential contamination of the food areas; uncleanable surfaces in food storage and preparation areas, and outdated food items.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to provide pharmacy services to ensure 3 (Resident #52, #24, and #37) of 7 residents medication administration records reviewed received medication in accordance with physician orders.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records contained accurately documented information for the administration of medications for 6 (24, #37, #52, #48, #53, #86) of 7 residents medication administration records reviewed.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure the MDS (Minimum data set) assessment accurately reflected falls and fractures for 1 (Resident #37) of 4 sampled residents with falls. Inaccurate MDS assessments can result in a resident not receiving appropriate health care.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement an individualized, person-centered care plan for 1 (#24) of 4 residents reviewed for care planning. Failure to develop and implement a comprehensive care plan can lead to the resident's medical, physical, mental, and psychosocial needs not being met.

Inspectors wroteBased on observation and staff interview the facility failed to ensure proper storage of medications in 1 (Nurses station #2) of 2 medication storage rooms. This has the potential for expired medications to be administered to residents.

Inspectors wroteBased on record review, review of the facility's policy and procedure, staff and resident interview, the facility failed to administer the influenza vaccine as requested to 1 (Resident #56) of 6 sampled residents reviewed for immunization.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain/store resident personal care items in a sanitary manner to prevent potential cross contamination for 9 (Residents #11, #39, #48, #77, #86, #91, #24, #37, and #52) of 20 sampled residents. In addition, the resident chairs in the Memory care unit were in disrepair.