Aviata at Green Cove Springs

Inspectors wroteBased on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to clean the juice dispenser hose attachment connected to the thickened water bag in box and the 100% apple blend juice (regular consistency) on the juice machine. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on facility record review, staff interview, and a review of facility policy and procedure, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are especially at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. [...]

Inspectors wroteBased on observations, interviews, record review, and a review of facility policies and procedures, the facility failed to ensure that one (Resident #84) of four residents reviewed for accident hazards, from a total survey sample of 36 residents, had an environment as free of accident hazards as possible. Hydrogen peroxide, isopropyl alcohol, and disinfectant spray were found on Resident #84's chest of drawers.

Inspectors wroteBased on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure titled G-Tube Care, the facility failed to 1) Follow treatment ordered by the physician for G-tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) dressing changes, 2) Arrange G-tube removal in a timely manner, and 3) Prevent complications of the G-tube, specifically, recurrent stoma infections for one (Resident #80) of three residents reviewed with G-Tubes, from a total of 36 residents in the sample.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours on February, 27, 2023. Nurse staffing in nursing homes has a substantial impact on the quality of care and outcomes that residents experience. Failure to staff a registered nurse for at least 8 hours a day could result in a negative impact on resident care.

Inspectors wroteBased on observations and interviews with staff, the facility failed to dispose of garbage and refuse properly and in a manner to prevent invitation, harboring and feeding of pests which can carry infectious diseases. This had the potential to affect all 103 residents residing in the facility at the time of the survey by risking exposure to vermin and disease.

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to provide sufficient storage to accommodate personal belongings for one (Resident #756) of two residents reviewed for accommodation of needs from a total of 36 residents in the sample.

Inspectors wroteBased on observations, resident and staff interviews, and a review of resident records, the facility failed to review and revise the plan of care to reflect the discontinuation of a gastrostomy tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and fluids) after the resident resumed food and medications by mouth for one (Resident #46) of three residents reviewed for g-tubes from a total of 36 residents in the sample.

Inspectors wroteBased on observations, resident and staff interviews, a review of resident records, and the facility's policy and procedure for Care of Nails, the facility failed to provide appropriate grooming, personal hygiene and oral care to three (Residents #88, #94 and #20) of six residents reviewed for activities of daily living (ADLs), from a total of 36 residents in the sample.

Inspectors wroteBased on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure behavior monitoring was conducted for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample.

Inspectors wroteBased on observation, record review, interviews with staff, and a review of the facility's policy and procedure for Medication Management for Psychotropic Medications, the facility failed to ensure psychotropic medications ordered as needed included a stop date for one (Resident #83) of five residents reviewed for unnecessary medication use, from a total of 36 residents in the sample. Resident #83 was receiving Lorazepam (benzodiazepine sometimes used for agitation) as needed for aggression with no stop date noted or rationale for continuing the medication beyond 14 days.

Inspectors wroteBased on observations, staff and resident interviews, a review of resident records and the resident handbook, the facility failed to ensure that food received and/or prepared by resident families, friends and/or other outside sources was handled safely once it was brought into the facility for two (Residents #18 and #88) of two residents observed storing and eating unrefrigerated perishable foods in their rooms, from a total of 36 residents in the sample.

Inspectors wroteBased on observation, a review of resident records, and interviews with staff, the facility failed to ensure resident clinical records were accurately documented and reflective of the care provided for one (Resident #46) of three residents reviewed with gastrostomy tubes (g-tube; a tube inserted through the wall of the abdomen directly into the stomach to provide liquid nutrition, medications and liquids), out of 25 residents whose clinical records were reviewed, from a total of 36 residents in the sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respond appropriately to a resident's change in condition for one (Resident #37) of one resident reviewed from a total of 34 residents in the sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide assistance with showers for one (Resident #16) of three residents reviewed for activities of daily living (ADLs), from a total of 34 residents in the sample.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #21 & #81) of three residents reviewed for pressure ulcers, from a total of 34 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide effective pain management by 1) Failing to administer pain medication prior to treatment of a stage four pressure injury, and 2) Failing to identify non-verbal indicators of pain (and failing to intervene appropriately) during treatment of a stage four pressure ulcer for one (Resident # 81) of two residents reviewed for pain management from a total of 34 residents in the sample.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's medical record included documentation that indicated, at a minimum, the following: That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal for two (Residents #94 and #12) of five residents reviewed from a total of 34 residents in the sample.