Aviata at Jacksonville

Inspectors wroteBased on food service observations, staff interviews, 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, by failing to clean one of two microwaves located in a unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on interviews and record reviews, the facility failed to document and respond appropriately to resident grievances regarding missing clothing items for 1 out of 5 residents reviewed. (Resident #46)

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately to the administrator and to other officials in one of one identified occurrence. (Resident #118)

Inspectors wroteBased on observations, interviews, and policy and procedure review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline.

Inspectors wroteBased on observations, interviews, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserve nutritive value and appearance by failing to provide appetizing and appealing food in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting on their ability to heal, and possibly resulting in an overall health status decline.

Inspectors wroteBased on record reviews and interviews, the facility failed to appropriately document side effects and behaviors for psychotropic medications, in accordance with the corresponding key on the Medication Administration Record for two of five residents reviewed for psychotropic medications. (Residents #15 & #72)

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and clean interior for two (Residents #208 and #3) of 30 residents in the sample.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide two (Resident #90 and Resident #84) residents who were unable to carry out activities of daily living, from a total sample of 30 residents, the necessary services to maintain personal hygiene (fingernail care).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement interventions, including monitoring placement and function of wander-alarm devices, consistent with a resident's needs, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident for one (Resident #93) of 30 residents sampled. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, received that care as ordered and consistent with professional standards of practice, for one (Resident #35) of a total sample of 30 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure medication error rates were not 5% or greater. Two errors were identified out of 32 opportunities for error, resulting in a medication error rate of 6.25% and affecting two (Residents #64 and #33) of five residents observed during medication administration, from a total of 30 residents in the sample.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections, by inappropriately storing and disposing of used sharps.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure it provided an effective discharge planning process that evaluated and identified changes requiring modifications and updates as needed for 1 (Resident #1) of 4 residents reviewed for discharge. Failure to effectively communicate discharge concerns and assess individual needs can potential put residents at risk for an unsafe discharge.

Inspectors wroteBased on observations, interviews, record review and facility policy and procedure review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary in five resident rooms (102, 500, 501, 512 and 511) affecting six (Residents #4, #59, #19, # 49, #151, and #92) out of a total of 41 residents in the sample. Specifically, there were concerns with sticky floors in bathrooms, dead roaches, debris on floors and under resident's beds, enteral feeding product splattered on feeding pumps, IV poles, walls, mattresses, bed frames and floors, and Air Conditioning (AC)/Heating units filters were not clean. A clean-living environment is necessary to reduce the spread of infection and promotes the highest well-being of residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure physician's orders for oxygen were in place prior to administering oxygen for two (Residents #301 and #453) of eight residents receiving treatment for respiratory care, out of a total of 41 residents sampled. This could result in the resident not receiving appropriate care and/or clinical complications.

Inspectors wroteBased on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure nutritional supplements kept in 2 of 2 nourishment refrigerators were stored in accordance with professional standards for food service saftey and failed to ensure equipment in the nourishment rooms were clean and free of debris.

Inspectors wroteBased on observations, clinical record review and interviews, the facility failed to provide reasonable accommodation of individual needs by ensuring one (Resident #92) of 41 residents in the sample, from a total of 102 residents had access to his call light at all times.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident's right to make choices about aspects of his or her life by failing to make appointments for health care services for one (Resident #51) of three residents reviewed for medical appointments, out of a total of 41 residents in the sample.

Inspectors wroteBased on interviews, record review and facility policy and procedure review, the facility failed to adequately investigate grievances to ensure satisfaction with the resolution for two (Residents #59 and #47) of two residents reviewed for grievances, related to staff behavior and missing items, out of a total of 41 residents in the sample.

Inspectors wroteBased on medical record reviews, interviews and facility policy and procedure for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that three (Residents #9, #59 and #73) out of a total of 41 residents in the sample, were screened for a Level II.

Inspectors wroteBased on observation, medical record review and interviews, the facility failed to provide appropriate services and communication devices for one (Resident #4) out of two residents sampled for communication, out of a total of 41 residents in the sample. The resident's communication board was stapled to the bulletin board in her room under an activities department calendar. Failure to provide a communication device for a resident whose ability to communicate is impaired could potentially affect the resident's ability to communicate in an emergency and negatively affect his/her health outcome.

Inspectors wroteBased on observation, record reviews, interviews, and facility policy and procedure review, the facility failed to ensure that two (Residents #300 and #452) of six residents receiving antibiotics, out of a total of 41 residents in the sample, remained free of significant medication errors by failing to administer antibiotic medication as ordered.