Aviata at Arbor Springs

In the surveyor’s words

From the most serious findings on record at Aviata at Arbor Springs, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jul 30, 2026

  Based on record review, interview, and policy and procedure review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate (DNR) for 1 of 3 reviewed residents, Resident #6, when found unresponsive and absent of life. This has the potential to affect 42 residents with advance directives of Do Not Resuscitate.Findings include:Review of Resident #6's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include acute embolism and thrombosis of right subclavian vein, acute embolism and thrombosis of right internal jugular vein, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess… […]

• Actual harm, isolatedF627Apr 16, 2026

  Based on record review and interview, the facility failed to ensure residents were provided sufficient orientation for safe and orderly transfer/discharge, failed to ensure an effective discharge plan was developed and implemented, and failed to ensure attempts to meet the specific resident needs at the facility as the basis for transfer for 1 of 3 residents reviewed for discharge (Resident #2). The facility discharged Resident #2 to a receiving facility located at a significant distance from the resident's family members and identified support system, resulting in Resident #2 experiencing emotional distress, increased social isolation, and decreased access to family support.Findings include: Review of Resident #2's admission record showed the resident was initially admitted to the… […]

• No harm, potential for more than minimal, widespreadF880May 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, failed to ensure enhanced barrier precautions were followed and failed to ensure staff performed hand hygiene and followed infection control standards during wound care to prevent possible spread of infection and communicable diseases. Findings include: 1. During an observation on 5/21/2024 at 5:00 AM, Staff A, Registered Nurse (RN), unlocked the medication cart and obtained a blood glucose monitoring machine, blood glucose strips and alcohol wipe without performing hand hygiene. Staff A entered Resident #140's room, donned gloves without performing hand hygiene and obtained the blood glucose sample for testing. […]

• No harm, potential for more than minimal, widespreadF582Jan 20, 2023

  Based on record review and interview, the facility failed to ensure 2 of 2 residents (Resident #21 and Resident #80) received a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form 10055) as required. Findings include: 1. Review of the Notice of Medicare Non-Coverage form for Resident #21 revealed the skilled nursing services would end on 10/10/2022. Review of the Beneficiary Protection Notification Review form completed by the Social Services Director revealed the facility/provider initiated Resident #21's discharge from Medicare Part A Services when his benefit days were not exhausted. […]

• No harm, potential for more than minimal, widespreadF570Jul 15, 2021

  Based on interview and record review, the facility failed to have a surety bond with the amount equal to the current total amount of resident funds. Findings: Review of the Trial Balance for resident funds dated 7/15/2021 revealed a balance of $106,525.71. Review of the Patient Surety Bond and the rider dated 12/22/2020 revealed a bond for $100,000.00. During an interview on 7/15/2021 at 10:32 AM, the Regional Business Office Manager stated that she knew the amount of the residents' personal funds exceeded the amount of the Surety Bond.