Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Oakfield during CMS and state inspections, most recent first.
Resident bathroom sink water temperatures were found above the acceptable range in multiple rooms, with readings of 121 to 124 degrees Fahrenheit. The DOM said he had no audit plan for testing individual room sinks, had no documented temperature checks, and used an infrared thermometer instead of the facility’s required calibrated dial stem thermometer. He later identified another water heater supplying resident areas that was set at 127 degrees Fahrenheit and had no temperature log, while the NHA confirmed the facility had plumbing issues and no prior work orders related to the problem.
Medication administration errors exceeded the allowed rate, with multiple observed errors involving an RN and an LPN. One resident’s nebulizer medications were combined and the mouth was not rinsed, another resident’s extended-release and other medications were crushed together and given via G-tube with a missed specialty medication dose, and a third resident experienced delayed administration while staff addressed blood pressure concerns and an antibiotic due on the hallway.
Failure to follow PPE and HH requirements for residents on contact precautions and EBP. An LPN/UM entered a resident’s room without PPE, assisted the resident out of the room, and handled belongings without performing HH. Separate observations showed CNAs entering another resident’s room without gowns or gloves despite contact precautions, and an RN entering a third resident’s room twice without gown and gloves while giving IV medication. The residents had orders for ESBL, C. diff, MRSA, wounds, a foley catheter, and other isolation-related conditions.
Failure to accommodate communication and bed needs: A resident who spoke Arabic was observed relying on gestures, while staff gave inconsistent accounts of his language and the facility’s language line was not working, despite the care plan identifying interpreter needs. Another resident, who was cognitively able to make his own decisions and was receiving Hospice services, was repeatedly observed in a bariatric bed that was too short for his height, with his feet pressed against the foot board; staff and the DON confirmed the bed was wide but not long enough.
Failure to notify the physician and family of a resident’s skin change. Weekly skin assessments documented bilateral lower arm bruising/discoloration, but progress notes did not show notification to the MD, family, or administration. Staff later stated the resident had chronic itchy skin and rubbed his arms on the bed rail, but the behavior was not found in the care plan documentation.
Shower Room Not Maintained in Sanitary Condition: A shower room in Zone One East was observed with black biological growth on the grout of the shower walls and floor. The housekeeping/laundry manager stated housekeeping was responsible for cleaning and sanitizing shower rooms, including walls, floors, and equipment, and for verifying cleanliness each morning. The DOM also observed the growth and stated it should be cleaned and removed by housekeeping.
Incomplete PASRR Screening for Two Residents: Two residents had inaccurate Level I PASRRs that did not reflect documented mental health diagnoses. One resident with bipolar disorder, MDD, anxiety, and Parkinson's disease had only bipolar disorder checked, while another resident with MDD, anxiety, and insomnia had a blank PASRR with no mental illnesses checked. The SSD stated she did not review these PASRRs or notify the IDT, and the DON stated all Level I PASRRs were expected to be reviewed and completed accurately by the IDT.
A resident with a history of falls, osteoporosis, and moderate cognitive impairment was repeatedly observed in bed with the call light out of reach and a fall mat folded away from the bedside, despite a care plan requiring the call light within reach and bilateral floor mats. Another resident with CVA-related weakness, foot drop, and impaired cognition was repeatedly observed in bed without ordered heel boots, which were found in the closet even though staff stated the boots were expected to be on while the resident was in bed.
A resident with significant mobility impairment and a history of repeated falls had a fall care plan that was not accurately revised after new fall events and IDT discussions. The record showed multiple falls, including being found on the floor near the bed or wheelchair and sliding from the wheelchair, while the care plan continued to list broad interventions such as frequent rounding and medication review without clear documentation of specific changes discussed by the IDT. Interviews with the LPN/MDS coordinator and DON confirmed the care plan was not updated to reflect the resident’s chair changes or medication-related discussion after falls.
A resident with multiple complex conditions, including a stage 3 pressure injury requiring daily wound care, was discharged home without a documented discharge plan, without confirmation of home health services, and without needed supplies. Progress notes and the care plan lacked evidence of discharge planning discussions with the resident or representative, and there was no nursing documentation of discharge education or supplies provided. Social services documented that home health was expected, but later learned after discharge that the initial home health agency had not agreed to accept the resident, and the resident’s family reported that no home health visit occurred and no supplies were sent home, contrary to facility discharge planning policy.
A resident with sepsis, muscle weakness, and gait abnormalities, who required extensive assistance with ADLs and used a walker or wheelchair, was found on the floor beside the bed after an unwitnessed fall. The nurse documented a red mark on the forehead and a skin tear on the left elbow and used a mechanical lift with a CNA to return the resident to bed, but the medical record contained no neurological checks or other required post-fall assessments. During interviews, the ADON and DON acknowledged that the fall was unwitnessed, that the cause of the forehead mark was not clarified, and that no neuro checks were completed, despite the facility’s Fall Management policy requiring neuro checks, comprehensive post-fall evaluation, documentation, and care plan updates after a fall.
A resident admitted with a colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes had these devices clearly documented on the Medicaid certification form, MDS, care plan, and NP/physician progress notes, which called for daily assessment and meticulous stoma and nephrostomy care. However, the facility’s admission data collection only recorded a colostomy and omitted the urostomy and nephrostomy tubes, and the physician orders contained detailed instructions only for colostomy appliance changes and peristomal skin care, with no orders for urostomy or nephrostomy care. The DON stated that admission orders should have addressed these devices and that nurses are expected to reconcile hospital discharge orders and enter all orders into the EMR, while staff reported they follow physician orders and document ostomy care on the TAR. This disconnect between documented clinical needs and the absence of corresponding urostomy/nephrostomy orders and TAR entries resulted in a failure to provide ostomy-related care consistent with professional standards of practice.
A resident with a history of dementia and other health issues developed a stage 3 pressure ulcer, but the facility failed to provide necessary treatment and documentation. Despite having orders for wound care, treatment was documented only once over several days. The facility's policies required regular skin evaluations and documentation, which were not consistently followed, leading to the deficiency.
Resident Sink Water Temperatures Exceeded Safe Limits
Penalty
Summary
The facility failed to ensure resident-accessible water temperatures were maintained at safe and comfortable levels and did not exceed the required range of 105 to 115 degrees Fahrenheit in two units, affecting resident room bathrooms in rooms 204, 315, and 113. During the initial tour, water flow temperatures in resident bathroom sinks were observed to be too hot to hold the back of the hand under the water. The surveyor and Director of Maintenance later tested multiple resident room sinks and found temperatures of 121 degrees Fahrenheit in room 204, 121 degrees Fahrenheit in room 315, and 124 degrees Fahrenheit in room 113. The Director of Maintenance stated he had been in the role for four months and did not have an audit plan for testing water temperatures at individual resident room sinks. He said he set the facility water heaters at around 110 to 115 degrees Fahrenheit and was not sure how many water heaters were in the building. He confirmed there were at least three water heaters for resident rooms and shower rooms, plus a separate booster for the kitchen and laundry room, but he did not know the settings for those units. He also confirmed he had no documented evidence of testing hot water temperatures in resident rooms and did not know that was required. During the tour, the Director of Maintenance used a digital infrared thermometer to test the water and stated he did not need to calibrate it. The facility policy provided later required daily hot water checks using a calibrated dial stem thermometer, with resident rooms, shower rooms, and common areas kept below state requirements. The Director of Maintenance later remembered another bank of water heaters in a locked courtyard area that supplied resident spaces, including community shower rooms and resident room bathroom sinks; that heater was reading 127 degrees Fahrenheit and had no temperature log. The Nursing Home Administrator stated the facility had plumbing issues and needed parts to regulate the temperature in one of the water heaters, and confirmed there were no work orders available before the surveyor identified the errant temperatures.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5.00%, with 16 medication errors identified during 42 observed medication administration opportunities, resulting in a 38.1% error rate. The errors involved three residents and included improper administration of nebulizer medications, crushing and administering medications through an enteral tube in a manner inconsistent with the medication’s formulation, and delays and omissions in medication administration during the medication pass. For one resident receiving nebulizer treatments, an RN administered ipratropium bromide/albuterol and budesonide together in the same nebulizer treatment. The RN stated she combined the medications to save time and did not think there was a policy or contraindication against doing so. The resident’s mouth was not rinsed after the treatment. The pharmacist stated the budesonide and albuterol treatments should be given separately, with a three-to-five-minute interval, and the Medical Director stated it was best practice to separate the medications because budesonide can become foamy in the chamber and may affect absorption. For another resident with an enteral tube, an LPN crushed venlafaxine ER, empagliflozin, and acetaminophen together, mixed them in one cup, and administered them through the gastrostomy tube in repeated portions because medication remained in the cup. The LPN stated she had been told it was okay to crush all medications together and also reported that the resident’s prescribed Nerlynx had not been given because it was unavailable. For a third resident, staff did not initially recognize that an antibiotic was due because it had not been discussed in report, and medication administration on the hallway was delayed while staff obtained blood pressure readings and a manual cuff. The RN held blood pressure medications after obtaining a low blood pressure reading, later administered clopidogrel, and both assigned nurses acknowledged they had not started medication administration for the hallway at the time of the observation.
Failure to Follow PPE and Hand Hygiene Requirements
Penalty
Summary
The facility failed to ensure infection control policies and procedures were followed for residents on contact precautions and enhanced barrier precautions. On 04/15/2026, Staff M, an LPN/Unit Manager, was observed entering Resident #16’s room without any PPE, walking into the room, assisting the resident out of the room in a wheelchair, and then returning into the room to remove the bedside table and place it next to the resident outside the room. Staff M was not observed performing hand hygiene before or after contact with the resident or the resident’s belongings. Resident #16 was admitted on 3/3/2026 and had diagnoses including ESBL, resistance to multiple antibiotics, and unspecified E. coli. The resident’s summary report dated 4/16/2026 showed active isolation orders for enhanced barrier precautions related to a history of ESBL and wounds. The care plan initiated on 2/16/2026 identified a focus for enhanced barrier precautions related to known MDRO infection/colonization as evidenced by ESBL/urine, C. diff, and wounds, with interventions requiring staff to wear enhanced barrier precaution PPE during high-contact direct care activities. The care plan also included contact isolation interventions for C. diff, including wearing gowns and masks when changing contaminated linens and disinfecting equipment before it left the room. Additional observations showed similar infection control failures for other residents. On 4/13/2026 and 4/14/2026, unidentified CNAs entered Resident #85’s room without gowns or gloves even though a contact precautions sign was posted outside the door; the DON observed one of these events and stated the CNA should have been gowned and gloved. Resident #85 had an order for contact precautions for ESBL/urine. On 4/16/2026, Staff G, RN entered Resident #6’s room twice without a gown and gloves while administering IV medication, despite an enhanced barrier precautions sign on the door; Staff G later agreed she should have worn a gown when administering the IV antibiotic. Resident #6 had orders for enhanced barrier precautions for MRSA, a foley catheter, a wound, and a midline.
Failure to Accommodate Communication Needs and Bed Size Requirements
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need to communicate in the language of his choice. Resident #18, who was admitted with diagnoses including cerebral infarction with left-sided hemiparesis and difficulty walking, was observed in bed pointing and using hand gestures to communicate while a family member stated he did not speak English and spoke Arabic. No signs were posted to direct others to his preferred communication method. The care plan identified Arabic as his primary language and included interpreter needs, but staff interviews showed inconsistent understanding of his language needs, with staff identifying him as speaking Arabic, Egyptian Arabic, or Hindi. Staff also reported relying on gestures or a translation app, and the facility’s communication line was not operable when staff attempted to use it. Interviews with nursing staff and the DON showed the facility’s main source of communication for residents with limited English proficiency was the communication line, but staff were unable to use it because it was out of service. One LPN stated the resident used gestures because he did not understand English, while another stated the resident understood English and the language line would be used if needed. The DON stated the facility also coordinated with therapy for a communication board and confirmed she was not aware the communication line numbers were not working. The facility policy required effective communication services for limited English proficiency individuals, including oral communication through bilingual staff or interpreting. The facility also failed to provide Resident #5 with a bed that met his height, comfort, and furnishings needs. Resident #5, who had diagnoses including orthopedic aftercare, low back pain, diabetes mellitus type II, muscle wasting, gait abnormalities, and anxiety, was repeatedly observed lying in a bariatric bed with his feet pressed against the foot board and the foot board extended beyond the mattress. He stated Hospice had provided the bed at his request for a larger bed, but he needed a longer mattress rather than a wider one. He reported telling multiple staff members that the bed was not long enough, and his family member also stated the bed was not appropriate for his height. Staff confirmed the bed was wide but not long enough, and the NHA and DON acknowledged the facility did not have a longer bed and should have obtained one from Hospice.
Failure to Notify Physician and Family of Resident Skin Change
Penalty
Summary
The facility failed to notify the physician and family of a change in condition after a new skin condition was identified for one resident. Weekly Skin Integrity Assessments dated 3/13/2026 and 3/19/2026 documented bilateral lower arm bruises for the resident, but the progress notes did not show notification to the family, physician, or administration about those bruises. The resident’s record showed diagnoses including NSTEMI myocardial infarction, dementia, depression, PTSD, and chronic kidney disease. During observation and interviews, staff stated they were unaware of the discoloration until 4/15/2026, and one LPN said they had not completed the assessment because they had been away for the past month. A unit manager stated that discoloration is normally reported to the physician and family and entered into the health system as a change in condition, but the manager could not find documentation of the behavior that staff said caused the arm discoloration. Administration stated the red discoloration was from the resident rubbing his arms on the bed rail due to chronic itchy skin and self-inflicted scratches, but no care plan documentation supporting that behavior was provided.
Shower Room Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure shower rooms were maintained in a sanitary manner in one shower room in Zone One East. On 04/16/2026 at 2:48 p.m., the shower room was observed to have black biological growth on the grout between the tiles on the shower walls and on the grout between the tiles on the shower floor. The growth was seen on the shower walls and floor upon entering the shower area, including the floor perpendicular to the wall observed. Photographic evidence was obtained. During interviews, the housekeeping/laundry manager stated housekeeping staff were responsible for maintaining the cleanliness and sanitization of shower rooms, including disinfecting shower equipment, cleaning walls and floors, and removing trash. The manager described a cleaning process that included sweeping, spraying disinfectant on walls, floors, and equipment, allowing it to remain for at least five minutes, and then removing the chemical from equipment and walls with a cloth, with the floors mopped using the same disinfecting chemical. The manager also stated housekeeping was responsible for verifying the cleanliness and sanitization of each shower room every morning, but during the tour the manager confirmed the black biological growth and was uncertain which department was responsible for preventing it, believing it may have been maintenance. The Director of Maintenance also observed the growth and stated it should be cleaned and removed by housekeeping. Facility policy and the housekeeping job classification both identified housekeeping as responsible for cleaning and maintaining the shower room.
Incomplete PASRR Screening for Two Residents
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for two residents sampled. Resident #17 was admitted with diagnoses including bipolar disorder, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode manic without psychotic features, and Parkinson's disease. Review of the resident's Level I PASRR dated 12/17/2025 showed that only bipolar disorder was checked in section A, with no other mental illnesses checked. The review found the Level I PASRR was incomplete and that a Level II was not submitted for consideration. Resident #18 was admitted with diagnoses including major depressive disorder, recurrent, moderate, other specified anxiety disorders, and primary insomnia. Review of the resident's Level I PASRR showed a blank PASRR with no date and no mental illnesses checked in section A. The review found this Level I PASRR was incomplete and that a Level II was not submitted for consideration. During interview, the SSD stated she did not complete PASRRs because she did not have a master's degree in social work, that PASRRs were completed by an RN, and that she did not review these two residents' PASRRs or notify the IDT that they needed to be updated. The DON stated she expected all Level I PASRRs to be reviewed, updated, and completed accurately by the IDT. The facility policy stated the center would assure that all SMI and intellectually disabled residents receive appropriate pre-admission screening and that Social Services would be responsible for coordinating significant change updates.
Care Plan Not Followed for Fall Interventions and Heel Boots
Penalty
Summary
Failure to implement the care plan for fall interventions was identified for Resident #16. The resident had diagnoses including age-related osteoporosis, a prior fracture of the lower end of the right radius, muscle wasting, gait abnormalities, cognitive communication deficit, history of falls, anxiety, and major depression. The most current MDS showed a BIMS score of 9 out of 15, indicating moderate impairment. The care plan included interventions to keep the bed in low position, use bilateral floor mats, and ensure the call light was within reach and encourage use of it. During observations on multiple occasions, Resident #16 was found lying in bed with the call light placed out of reach, including on the back left side of the pillow and hanging over the back of the bed. The resident confirmed she could not reach it and attempted to reach for it without success. Staff B, a CNA, and Staff A, an LPN, both confirmed the call light was not within the resident's reach while she was in bed. The right-side fall mat was also observed folded and positioned against the wall away from the bed, rather than placed at bedside as documented in the care plan. Failure to follow the care plan for protective heel boots was identified for Resident #108. The resident had diagnoses including adjustment disorder with mixed anxiety and depressed mood, generalized muscle weakness, and bilateral foot drop, with a care plan focus related to ADL self-care performance deficit after a CVA with left-sided weakness, impaired cognition, impaired communication, and foot drop. The care plan directed staff to don and doff bilateral ankle flexion boots for contracture management as ordered, but during repeated observations the resident was in bed without heel boots on and the boots were found inside the closet. Staff interviews confirmed the resident was expected to have the boots on while in bed, and staff stated the boots were not being applied.
Fall Care Plan Not Updated After Repeated Falls
Penalty
Summary
The facility failed to review, revise, and update the fall care plan for one resident after multiple falls and changes in condition. The resident had diagnoses including cerebral infarction due to thrombosis of the right anterior cerebral artery, muscle wasting and atrophy, difficulty walking, and generalized muscle weakness. The record showed repeated falls and fall-related events, including being found on the floor near the bed and wheelchair, sliding out of the wheelchair, and attempting to ambulate while a family member was present. The resident’s focus care plan documented numerous fall-related incidents and included interventions such as frequent rounding while in bed, frequent rounding while in the wheelchair in the resident’s room, and medication review. The care plan was initiated on 07/15/2025 and revised on 02/03/2026, with later revisions noted for frequent rounding in the wheelchair and medication review. However, the documentation reviewed did not show that the interventions were consistently updated to reflect the specific fall events or the changes discussed by the interdisciplinary team. Interviews with the LPN/MDS coordinator and the DON showed that the interdisciplinary team met after falls and discussed the resident, but the care plan was not accurately updated to reflect those discussions. The DON stated the team had discussed changes to the resident’s chair after one fall and anxiety medications after another fall, but she could not verify that those changes were documented in the care plan or medication record. Facility policy required the care plan to be updated with new interventions as appropriate and revised based on changing needs and after each MDS assessment.
Failure to Plan and Document Safe Discharge With Confirmed Home Health and Supplies
Penalty
Summary
The deficiency involves the facility’s failure to document and plan the discharge process for one resident, resulting in a discharge that did not ensure needed services and supplies were in place. The resident was admitted with multiple serious diagnoses, including sepsis, osteomyelitis of the femur, COPD, muscle weakness, malignant neoplasm of the rectum, a colostomy, chronic kidney disease, and a female genital tract fistula, and had physician orders for daily wound care to a stage three pressure injury on the coccyx. Record review showed the resident’s care plan did not include a discharge plan, and progress notes lacked documentation of discharge planning discussions with the resident or the resident’s representative. A nursing progress note documented that the resident went home via stretcher, and a social service discharge note stated the resident was to receive home health, but there was no documentation of nursing discharge responsibilities, including education or supplies provided at discharge. Interviews and documentation further showed that the home health provider had not been confirmed prior to discharge, and no supplies were provided to the resident at the time of discharge. The resident’s representative reported the resident was discharged home without supplies and that the home health company did not show up. Social services later learned, through a post-discharge contact with the family, that the initial home health company had not agreed to care for the resident, and the resident had to obtain a different home health provider. Staff confirmed there was no documentation of the nurse’s role in the discharge and acknowledged that documentation should have included education and supplies given. Review of the facility’s Discharge Planning policy showed requirements for early discharge planning, completion of a discharge planning record, provision of discharge summaries and instructions, and post-discharge follow-up, which were not reflected in the resident’s record.
Failure to Implement Required Post-Fall Evaluations After Unwitnessed Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not implementing required post-fall evaluations for one resident. The resident was admitted with diagnoses including sepsis, muscle weakness, and gait and mobility abnormalities, and required substantial to maximal assistance with multiple ADLs, including transfers and positioning. A fall risk assessment indicated the resident was a low fall risk, cognitively intact, and used a walker or wheelchair. A progress note documented that during room checks on 12/18/2025 at 1:05 PM, a nurse found the resident on the floor beside the bed after the resident reported slipping while trying to push herself back into bed. The nurse documented a head-to-toe assessment noting a red mark on the forehead and a skin tear on the left elbow, and that a mechanical lift was used with a CNA to return the resident to bed. Record review showed no neurological checks or other fall-related assessments following this unwitnessed fall, despite the presence of a red mark on the resident’s forehead and a skin tear. During interviews, the ADON, DON, and NHA acknowledged the fall was unwitnessed and that the facility did not ask the resident if the red mark on the forehead was due to a head injury, instead accepting the resident’s explanation. The ADON stated they did not know the cause of the red mark and confirmed that no neuro checks were found in the record. The DON stated that unwitnessed falls require monitoring, neuro checks, complete skin assessments, treatment for possible skin care, frequent monitoring, and range of motion assessments, and acknowledged these required post-fall steps were not completed. Review of the facility’s Fall Management policy showed that post-fall strategies must include resident evaluation, initiation of neurological checks, physician and representative notification, post-fall evaluation, care plan updates, 72-hour post-fall documentation, IDT review with root cause analysis, and weekly review, which were not implemented for this resident after the fall.
Failure to Establish and Implement Urostomy/Nephrostomy Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy and nephrostomy tube care consistent with professional standards of practice for one resident who required such services. The resident was admitted with multiple significant diagnoses, including sepsis, acute osteomyelitis, COPD, chronic kidney disease, artificial openings of the urinary tract, female genital tract fistula, history of malignant neoplasm of the large intestine, colostomy status, and DVT. Admission documentation (the Medicaid 3008 form) identified the presence of a urostomy, bilateral nephrostomy tubes, and a colostomy. However, the facility’s admission/readmission data collection only documented a colostomy under gastrointestinal status and did not document the presence of a urostomy or nephrostomy tubes under genitourinary status. The resident’s MDS admission assessment did identify nephrostomy tubes and ostomies (including urostomy and colostomy), and subsequent NP and physician progress notes documented that the resident had a permanent colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes, with all appliances intact on exam. These notes directed staff to continue daily assessment for leakage, obstruction, decreased output, skin breakdown, hematuria, foul odor, catheter-related pain, and signs of infection, and to maintain meticulous stoma and nephrostomy care. The resident’s care plan also referenced skin excoriation on the sacrum and coccyx related to an ileal conduit, ostomy, and nephrostomy tubes. Despite this, the physician orders in the record only contained a detailed order for colostomy appliance changes and associated skin care, with no corresponding orders for urostomy or nephrostomy tube care. During interviews, the DON stated that at admission, batch or standing orders are generated based on hospital discharge orders and that nurses are expected to reconcile hospital discharge orders with the physician, with all orders entered into the electronic medical record. The DON acknowledged that at the time of this resident’s admission, the orders should have addressed urostomy and nephrostomy tube care but could not explain the missing orders. Staff reported that ostomy care is to be provided every shift and as needed, with care orders reflected on the TAR and documented there, and that nurses follow physician orders when caring for residents with ostomies. Facility policies required individualized care plans, monitoring of treatment effectiveness, and incorporation of identified needs (such as ostomies and nephrostomy tubes) into the care plan and CNA Kardex. The lack of specific physician orders and corresponding TAR entries for urostomy and nephrostomy care, despite clear documentation of these devices in assessments and progress notes, led to the cited deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment to promote healing and prevent infection for a resident with a stage 3 pressure ulcer. The resident, who had a history of a left femur fracture, muscle weakness, muscle wasting, and dementia, developed a stage 3 pressure ulcer on the sacrum on November 19, 2024. Despite having orders for wound care, including the use of a low air loss mattress and specific dressing changes, the treatment was documented as completed only once between November 19 and November 23, 2024. The resident's medical records indicated that the pressure ulcer was identified on November 6, 2024, but there were no documented pressure wound care orders at that time. The Director of Nursing confirmed that there should have been orders documented when the wounds were identified. Additionally, the facility's policies required weekly skin evaluations and documentation of any skin impairments, but the records showed inconsistencies in the documentation and follow-up of the resident's skin condition. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that there was a lack of adherence to the facility's policies regarding pressure ulcer care and documentation. The facility's policies outlined the need for timely documentation of physician orders and regular skin evaluations, which were not consistently followed in this case. This failure to provide appropriate care and documentation contributed to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Center For Rehabilitation And Healing Of | 0.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Central Park | 0.9 mi | ★★★★★ | 3 | 0 |
| Victoria Crossing Rehabilitation Center | 1.1 mi | ★★★★★ | 11 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 8.9 mi | ★★★★★ | 10 | 0 |
| Whispering Oaks | 9.1 mi | ★★★★★ | 11 | 0 |
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