Avina on 32nd

In the surveyor’s words

From the most serious findings on record at Avina on 32nd, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 20, 2024

  Based on observations, interviews, and record review, the facility did not ensure that 13 of 13 residents reviewed for smoking and/or vaping (R2, R3, R299, R36, R299, R14, R37, R34, R31, R32, R22, R31, R150, R38, R149, R43, and R36) and one resident reviewed for transfers (R199) were provided with an environment that was free of accident hazards and/or provided with appropriate supervision. R2 was allowed to vape (use an electronic cigarette) while using oxygen in her room instead of being restricted to designated smoking areas away from oxygen. In addition, the facility allowed charging of the e-cigarette in the resident's room. R3 is severely cognitively impaired. R3 was allowed to smoke without supervision and was allowed to smoke outside of the designated area. […]

• Actual harm, isolatedF686Jun 28, 2023

  Based on interview, observation, and record review, the facility did not ensure 2 (R9 and R7) of 6 residents reviewed for pressure injuries received the necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. *R9 was identified to be at risk for pressure injuries. R9 developed a stage 2 pressure injury to the sacrum on 11/16/23. R9 was hospitalized on [DATE] returning to the facility on [DATE]. R9 was readmitted on [DATE] with a Stage 3 pressure injury to the sacrum on 11/23/23. […]

• No harm, potential for more than minimal, widespreadF801Jun 30, 2026

  Based on interview and record review, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services.Dietary Manager (DM)-G did not have a qualified certificate to manage the kitchen.This deficient practice had the ability to affect all 50 residents who receive meals from the kitchen.Findings include:On 6/23/26 at 11:04 AM, DM-G provided Surveyor a copy of their certificate of completion for Food Safety for Handlers. DM-G stated they are working on getting a manager certificate. Surveyor confirmed that DM-G's certificate is not a national certification for food service management and safety from a national certifying body. […]

• No harm, potential for more than minimal, widespreadF851Jun 30, 2026

  Based on interview and record review, the facility did not ensure accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers of Medicare and Medicaid Services (CMS).Staffing information for Fiscal Year Quarter 2 2026 (January 1, 2026 - March 31, 2026) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 51 residents residing in the facility.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, documents: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2024

  Based on observations, interviews, and facility policy review, the facility failed to ensure food was properly labeled and dated as to when they expired, and all expired foods were disposed of in accordance with professional standards for food service safety as required for 51 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: Review of a facility's policy titled, Food Storage, dated [DATE], revealed Food will be purchased in quantities that can be stored properly, and arranged in food groups for organized storage and inventory .Old stock is always used first .Food should be dated as it is placed on the shelves .Date marking will be visible on all high-risk food to… […]