Aviata at the Sea - Pasadena

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF623May 15, 2023

  Based on observations, record review, and interviews, the facility failed to ensure a 30-day discharge notice contained an explanation to support the action, and a physician signature for three (Resident #1, #3, and #5) of three residents reviewed for discharge process. In addition, the facility failed to ensure a copy of the 30-day discharge notice was placed in the clinical chart of the residents for three (Resident #1, #3, and #5) of three sampled residents reviewed for discharge process. Findings include: 1. On 05/15/2023 at 10:18 a.m., an interview was conducted with Resident #1. Resident #1 was observed independently ambulating in her room, dressed in seasonally appropriate clothing, and she agreed to be interviewed. She confirmed she had received a 30-day notice from the facility. […]

• No harm, potential for more than minimal, patternF943May 15, 2023

  Based on interview and employee file review, the facility failed to conduct abuse and neglect training for 5 out of 5 employee files reviewed. Findings included: On 5/15/23 at 3:00 p.m. a request was made to the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) for 5 employee files to include their abuse and neglect training. The NHA indicated she would obtain the employee files. On 5/15/23 at 5:00 p.m. the NHA provided 2 employee files and indicated the Human Resource Director was not at the facility and she was unable to obtain the other 3 employee files. All 5 of the employee files did not include abuse and neglect training and there was no evidence provided by the end of survey that the 5 employee's had received abuse and neglect training.

• No harm, potential for more than minimal, patternF689Feb 2, 2023

  Based on observations, staff and resident interviews, and medical record review, the facility failed to 1. ensure safety and supervision for smoking for five (Residents (#42, #98, #44, #99, and #38) of twenty-one sampled residents and 2. failed to ensure fifteen minute checks were performed and a toileting program was implemented to prevent falls for one (Resident #6) of one sampled resident. Findings included: 1. On 1/30/2023 at 8:55 a.m. prior to entering the building for first day of survey, Resident #99 was observed on the fence line of the side parking lot and seated in a chair, along with three other residents next to her. She was observed smoking and had her own cigarettes and lighter on her person. […]

• No harm, potential for more than minimal, patternF761Feb 2, 2023

  Based on observations, interviews, and policy reviews the facility failed to properly secure medication in one of two medication carts, in one of two treatment carts, in one of one medication refrigerator and for three (Residents #1, #10, and #21) of 31 sampled residents. Findings included: An observation was made upon entering the facility on [DATE] at 9:10 a.m. of a treatment cart in the south hallway. The cart was unlocked, and no nurses were in site of the cart. The cart contained prescription topical medications. (Photographic evidence obtained.) An observation was made in the room of Resident #1 on [DATE] at 10:34 a.m. of a bottle of Tums antacid sitting on the bedside table. The resident was out of the facility at the time and the door was open. […]

• No harm, potential for more than minimal, patternF761Feb 3, 2022

  Based on observations, interview, and facility policy review the facility failed to store medications and biologicals in a safe and secure manner for 4 out of 5 observations for 2 out of 2 treatment carts on 2 out of 2 shifts. Findings included: On 2/3/22 at 9:20 a.m., 2 out of 2 treatment carts were observed to be unlocked in the resident hallway with no staff member around. The Nursing Home Administrator (NHA) locked the nursing treatment carts. On 2/3/2022 at 2:20 p.m., 1 of 2 treatment carts were observed to be unlocked sitting in the resident hallway unattended by a staff member. […]