Aviata at San Jose

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Mar 4, 2022

  Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to 1) Clarify residents' diet orders on admission, 2) Provide residents with cognitive and functional limitations assistance with meals, and 3) Appropriately assess a resident's respiratory status, perform finger sweeps and the [MEDICATION(S)] maneuver, following a choking incident for one (Resident #2) of two residents reviewed for dysphagia, from a total of four residents in the sample. These failures contributed to Resident #2's admission to an acute-care hospital's intensive care unit due to respiratory arrest following aspiration. […]

• Immediate jeopardy, isolatedF726Mar 4, 2022

  Based on interviews and record reviews, the facility failed to ensure licensed nurses had specific competencies and skills sets necessary to care for residents' needs and ensure resident safety for one (Resident #2) of two residents reviewed with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. He was ordered a pureed/nectar-thick diet and was to have been assisted with his meal. […]

• Immediate jeopardy, isolatedF805Mar 4, 2022

  Based on interviews and record reviews, the facility failed to ensure that one (Resident #2) of two residents reviewed for dysphagia, from a total sample of four residents, received a diet texture designed to meet his individual needs. This failure contributed to the resident's emergent transfer to an acute-care hospital where he suffered respiratory arrest upon admission following the aspiration of a regular-textured dinner meal at the nursing home. On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. He had been given a regular-textured dinner meal and was attempting to eat it alone in his private room. […]

• Immediate jeopardy, isolatedF867Mar 4, 2022

  Based on interviews, record reviews, and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to Resident #2's admission to an acute-care hospital's intensive care unit due to respiratory arrest following aspiration. On [DATE] at 6:00 p.m., Licensed Practical Nurse (LPN) A heard Resident #2, diagnosed with dysphagia, coughing. When she entered his room, he could not speak and struggled to breathe. […]

• Immediate jeopardy, isolatedF578Mar 13, 2021

  Based on a review of resident and facility records and interviews with staff, the facility failed to: 1) Honor a resident's Do Not Resuscitate Order (DNRO) when he was discovered to be unresponsive and without a pulse or respirations and, 2) Ensure that a resident's DNRO was filed in the resident's medical record. This affected one (Resident #1) of five residents reviewed for advanced directives. Resident #1 executed a DNRO while in the facility, however, facility staff failed to file the order in the resident's clinical record. This resulted in staff initiating cardiopulmonary resuscitation (CPR) after he was found unresponsive in opposition to Resident #1's advanced directives. […]