Aviata at Oakfield

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 19, 2024

  Based on observations, interviews, and record review the facility failed to protect the resident's right to be free from neglect by not providing supervision for one resident (#1) out of four residents sampled for elopement. At approximately 12:15 p.m. on 12/20/23, Resident #1 was able to exit the facility through a door with a wander monitoring device alarm, walk into the facility lobby area, and speak with two facility staff members. One staff member held the door open for Resident #1 to enter the lobby, and the other staff member asked Resident #1 to sign out on the visitor log. Resident #1 signed the visitor log and exited out another door with a wander monitoring device alarm. […]

• Immediate jeopardy, isolatedF689Jan 19, 2024

  Based on observations, interviews, and record review the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one resident (#1) out of four residents sampled for elopement. Resident #1 had diagnoses to include metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, and a history of falling. Resident #1 was assessed to be at high risk for elopement with a physician's order to have a wander monitoring device in place. Review of Resident #1's medical record revealed Resident #1 did not have a wander monitoring device in place on 12/12/23, 12/13/23, 12/16/23, and 12/19/23. […]

• No harm, potential for more than minimal, patternF689Apr 16, 2026

  Based on observations, record review and interviews, the facility failed to ensure resident accessible water temperatures were maintained at safe and comfortable levels, not to exceed the required temperature of 105 - 115 degrees Fahrenheit (F) in two units (100,300) of three units, affecting three rooms (204, 315 and 113). Findings included: On 4/13/2026 at 9:10 a.m. during an initial tour of resident rooms revealed water flow temperatures too hot to hold the back of the hand under in the resident bathroom sinks in rooms [ROOM NUMBER].On 4/13/2026 at 11:00 a.m. during an interview with the Director of Maintenance (DOM), he stated he had been the DOM at the facility for four months and did not have an audit plan to include water temperature testing at individual resident room sinks. […]

• No harm, potential for more than minimal, patternF759Apr 16, 2026

  Based on observations, interviews and record review the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and 16 errors were identified for three resident (#6, 138 and 95) out of seven residents observed. These errors constituted a 38.1% medication error rate.Findings included: On 4/15/2026 at 8:26 a.m., during medication administration for Resident #95, an observation was made of Staff D, Registered Nurse (RN) who pulled the following medications: Ipratropium bromide and albuterol 0.5mg/3 ml (milligrams /milliliters ) and Budesonide 0.25mg/2 ml. […]

• No harm, potential for more than minimal, patternF880Apr 16, 2026

  Based on observation, record review and interview, the facility failed to ensure infection control policies and procedures were followed related to the use of PPE (Personal Protective Equipment) and Hand Hygiene (HH), for three residents (#16, #85 and #6) out of three residents sampled for contact precautions.Findings included: On 04/15/2026 at 11:07 AM, Staff M, Licensed Practical Nurse (LPN)/ Unit Manager (UM), was observed entering the room of Resident #16 without wearing any personal protection equipment (PPE). Staff M walked about three feet into Resident #16's room, assisted Resident #16 out of her room via wheelchair, and positioned the resident on the outside of the room door, across from the nurse's station. […]