AdviniaCare Scallop Shell, LLC

In the surveyor’s words

From the most serious findings on record at AdviniaCare Scallop Shell, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 20, 2025

  Based on record review and staff interview, the facility failed to ensure adequate supervision and timely intervention for Resident ID #9, a resident with documented dysphagia (swallowing difficulties), to prevent accident hazards related to choking. Despite multiple documented episodes of the resident coughing and choking during meal and medication consumption between October 23, 2025, and October 27, 2025, the facility staff failed to implement any immediate, necessary interventions or notify the medical provider of the significant change in condition as required by policy and the resident's care plan. […]

• Actual harm, patternF684Sep 22, 2023

  Based on record review, resident and staff interviews it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for adverse medication reactions and following physicians' orders for specialist medical appointments, Resident ID #36 and 1 of 1 resident reviewed for Hospice Services, Resident ID #21. Findings are as follows: 1a. […]

• Actual harm, patternF697Sep 22, 2023

  46715 Based on surveyor observation, record review, resident, and staff interviews, it has been determined that the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents reviewed for pain management, Resident ID #s 46 and 257. Findings are as follows: Per the American Nurses Association (ANA) Statement The Ethical Responsibility to Manage Pain and the Suffering It Causes (2018): Nurses have an ethical responsibility to relieve pain and the suffering it causes; Nurses should provide individualized nursing interventions; The nursing process should guide the nurse's actions to improve… […]

• Actual harm, isolatedF684Nov 20, 2025

  Based on surveyor observation, record review, and staff interview, the facility failed to ensure that appropriate treatment and services were provided to one resident (Resident ID #70) who was reviewed for fluid management. This failure included missing two physician-ordered doses of Lasix (a medication used to treat excess fluid trapped in the body's tissue) and failing to obtain daily weights as ordered by the physician. As a direct result of these failures, the resident experienced clinical deterioration, including increased shortness of breath and an elevated respiratory rate (30 breaths per minute), requiring an immediate transfer to the hospital for evaluation of potential congestive heart failure exacerbation.Findings are as follows:Review of a policy titled Electronic Physicians… […]

• Actual harm, isolatedF726Nov 20, 2025

  Based on record review and staff interview, the facility failed to ensure that Registered Nurse, Staff F, was competent to provide nursing services related to acute changes in condition, which resulted in actual harm to Resident ID #9. Despite having been competency-trained and observing the resident choking on food and medication on 10/26 and 10/27/2025, Registered RN, Staff F failed to follow policy and the resident's care plan by neglecting to immediately implement an intervention (such as removing the meal or providing a softer diet option) and failing to notify the resident's provider. […]