Aviata At Grand Oaks

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and sufficient safeguards to prevent an avoidable accident when a resident was allowed to be pushed while seated on his four-wheeled walker during a community outing. The resident had an admission date of 05/29/2024 and diagnoses including traumatic subarachnoid hemorrhage, type II diabetes, dementia, muscle weakness, hypertension, and generalized anxiety disorder. His care plan identified him as being at risk for falls related to gait and balance problems and general weakness, and his MDS showed he used a rolling walker for mobility and required supervision or touching assistance while walking. During a nature walk outing, the resident became tired and sat on the seat of his rollator. The Social Services Director, who had not received training on resident safety or the proper use of mobility devices, began pushing him down the sidewalk while he remained seated on the walker facing her. The walker wheels caught on a gap in the sidewalk, the walker stopped abruptly, and the resident fell backwards and struck the back of his head on the cement sidewalk. Nursing documentation noted a fall with a hematoma to the back of the head and transfer to the emergency room for a CT scan. The resident was later found to have a subarachnoid hemorrhage and was hospitalized from 04/06/2026 through 04/09/2026, including monitoring in the ICU for neurological deterioration. Interviews showed that non-clinical staff who volunteered for outings, including Social Services, Human Resources, Business Office, and management staff, had not been trained on resident safety, mobility assistance, or safe use of walkers during community outings. The Activities Director, DON, Administrator, AIT, and other staff stated that no one had coordinated resident care needs before the outing, no one had walked the route beforehand, and there was no facility policy available for resident supervision or mobility assistance during community outings. The manufacturer’s instructions for the rollator stated it was not to be used as a wheelchair and that the seat should not be used to transport people.

Penalty

Inspection fine: $15,646

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's Advance Directives and Full Code status, which led to the resident not receiving potentially lifesaving measures. The resident, who had a Full Code status indicating the desire to be resuscitated in the event of cardiac or respiratory arrest, was found unresponsive, pulseless, and apneic. Despite this, the facility's nursing staff did not perform cardiopulmonary resuscitation (CPR) as required by the resident's code status and facility policy. The resident was not revived and was pronounced deceased in the facility. The incident involved multiple staff members, including a Registered Nurse (RN) who was in training and had not received proper orientation. The RN assessed the resident as deceased and did not initiate CPR, despite the resident's Full Code status. Other staff members, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), were present but did not perform CPR. There were discrepancies in the staff's statements, with some admitting that CPR was never performed, while others initially claimed it was. The RN turned away Emergency Medical Services (EMS) upon their first arrival, mistakenly believing she could pronounce the resident's death. The facility's policies on Advance Directives and CPR were not followed, leading to a failure to provide the necessary emergency response. The staff's actions and inactions, including the RN's decision not to perform CPR and the subsequent false documentation, contributed to the deficiency. The facility's investigation substantiated the allegation of neglect, highlighting the lack of adherence to established protocols and the failure to provide appropriate care to the resident.

Removal Plan

• All resident code statuses were checked and found to be accurate.
• The initiation of the Code Blue response was deemed correct.
• An Ad Hoc QAPI meeting was conducted and a PIP was developed.
• Staff were re-educated on insubordination and following directives.
• Staff were trained on Advance Directives and situations during which they should be honored.
• Staff were trained in the facility's CPR policy, including when to start CPR.
• An audit of CPR certifications for nurses was performed and all nurses were American Heart Association (AHA) certified.
• Abuse and neglect training was provided building wide.
• Scheduled deviations were covered since RN A had effectively removed herself from facility orientation.
• A second QAPI was conducted about the corporate compliance program with a focus on staff notification of non-compliance and filing concerns without fear of retaliation.
• Code blue drills were conducted with all licensed staff participating.
• Staff were retrained or received information packets on Code Blue response and drills.
• Weekly Advance Directive audits were being conducted.
• The facility would continue reviewing nurses' CPR status and licensure.
• Classroom training for new nurses would be audited to ensure completion.
• CPR tests were provided to validate the nurses' understanding of policies with 100% of nurses passing.

Penalty

Inspection fine: $15,646

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide CPR to a resident who was a Full Code status after being found unresponsive with no respirations. The resident, who had been admitted for short-term skilled care with an expected discharge home, had multiple diagnoses including acute systolic congestive heart failure, chronic respiratory failure with hypercapnia, acute pulmonary edema, chronic obstructive pulmonary disease, and atherosclerotic heart disease. Despite the resident's Full Code status, CPR was not performed, and the resident was pronounced deceased in the facility. The incident involved several staff members, including a Registered Nurse (RN) who was in training and had not received proper orientation. The RN assessed the resident as pulseless, apneic, unresponsive, and cool to the touch, with blue digits, but did not initiate CPR. Instead, the RN pronounced the resident deceased and turned away Emergency Medical Services (EMS) when they first arrived. The RN and other staff members later admitted that CPR was never performed, despite initial false statements indicating otherwise. The facility's policy required CPR to be performed on residents without a Do Not Resuscitate order, but this was not followed. The RN, who was the highest licensed position in the building at the time, acted independently and did not follow the facility's protocol. The incident was further complicated by false documentation and statements made by staff, which were later corrected during the facility's investigation.

Removal Plan

• All resident code statuses were checked and found to be accurate.
• Initiation of the Code Blue response was deemed correct.
• Another Ad Hoc QAPI meeting was conducted.
• A separate plan was developed to focus on ethics and compliance; how to address unethical behavior and staff response.
• Staff were re-educated on insubordination and following directives.
• Staff were trained on Advance Directives and situations during which Advance Directives should be honored.
• Staff were trained in the facility's CPR policy, including when to start CPR.
• An audit of CPR certifications for nurses was performed and all nurses were American Heart Association certified.
• Abuse and neglect training was provided building wide.
• Scheduled deviations were covered.
• Focus on policing themselves resulted in a root cause analysis and evaluation of processes.
• Second QAPI was conducted about the corporate compliance program with a focus on staff notification of non-compliance and filing concerns without fear of retaliation.
• Code blue drills were conducted with all licensed staff participating.
• Staff had been retrained, or received the information packet, on Code Blue response and drills.
• Weekly Advance Directive audits were conducted.
• Facility would continue reviewing nurses' CPR status and licensure.
• This was added to the orientation process.
• Classroom training for new nurses would be audited to ensure completion.
• CPR tests were provided to validate the nurses' understanding of policies with 100% of nurses passing.