Aviata at Oldsmar

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were from significant medication errors for 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of 32 residents who evacuated from Facility A to Facility B, for four of four days reviewed (10/18/24, 10/19/24, 10/20/24 and 10/21/24).

Inspectors wroteBased on observations and interview, the facility failed to dispose of garbage appropriately for two of two (In front of kitchen door, to the right of kitchen door) outside dumpster areas.

Inspectors wroteBased on observations, interview, and policy review, the facility did not ensure proper infection control practices for two out of two units related to staff not using personal protective equipment (PPE), staff not knowing isolation precaution procedures, and uncovered oxygen equipment.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to ensure medications were stored as required for two (Residents #247 and #70) of two residents, two of two units, three of four medication carts, one of one treatment cart, and one of two medication storage rooms.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that staff appropriately utilized hair restraints when preparing, distributing resident food. for 2 of 4 (Staff K, Staff M) staff working on the food tray-line.

Inspectors wroteBased on interviews and record review, facility did not ensure there was a communication plan between hospice providers and the facility for two (Residents #50 and #247) of three reviewed for hospice services.

Inspectors wroteBased on record review and interview the facility failed to provide residents who had Medicare days remaining with appropriate notice for 2 of 3 (#15, #59) residents sampled for beneficiary notification.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for six of six months reviewed and one (Resident #65) of three residents sampled.

Inspectors wroteBased on interviews, records, and policy review, the facility failed to ensure the admission Procedure was implemented for five (Residents #247, #245, #343, #143, and #144) of five residents who were reviewed for admission paperwork.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) for 1 of 3 (#1) sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified.

Inspectors wroteBased on record review, interview, and review of the facility's policy, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Residents #41 and #50) of nineteen residents sampled for PASRR.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plans were developed to address identified needs for five (Residents #50, #67, #69, #71, #247) of 31 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were revised to reflect two (Residents #10 and #41) out of 19 sampled residents current needs, preferences and changing goals.

Inspectors wroteBased on observation, record review and interview the facility failed to provide the appropriate treatment and assistive device to maintain residents hearing abilities for 1 of 31 (#71) total sampled residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure appropriate services and equipment related to splint application for one (Resident #64) of two sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services for two (Residents #245 and #45) of five residents reviewed for timely medication administration. They also failed to ensure sufficient staffing to provide call light assistance for residents based on Resident Council Meeting Minutes for two of six months reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three (Residents #79, #48, #45) out of five sampled residents who were administered medications. This resulted in seven errors from 27 medication administration opportunities for a medication error rate of 25.93%. Findings Included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper diet, free of allergens, was served to one (Resident #42) of three reviewed for dietary restrictions.

Inspectors wroteBased on observations, interviews, record review, facility policy review, and plan of correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification and complaint survey conducted on 2/5/24 through 2/21/2024 and was cited F761. On 4/2/2024 the facility was recited F761. The facility had developed a Plan of Correction with a completion date 3/21/2024.

Inspectors wroteBased on observation, interview, and record review facility failed to ensure two residents (#79 and #65) out of three residents reviewed for blood pressure medication were free from significant medication errors related to blood pressure medication.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (Resident #5) out of three residents reviewed for reporting allegations of abuse, neglect, exploitation, or mistreatment, had an immediate report submitted no later than 2 hours after an allegation that resulted in serious bodily injury.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement provider orders for one diabetic ulcer and document the presence of a developed wound whose etiology was to be determined for one (#1) out of one resident sampled for diabetic foot ulcers resulting in a delay of treatment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-one medication administration opportunities were observed and seventeen (17) errors were identified for three (#6, #7, and #8) of three residents observed. These errors constituted a 77.27% medication error rate.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to treat four (Residents #30, #31, #37, and #57) of thirty sampled residents with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary catheter care and maintenance was conducted for one (Resident #46) of two sampled residents. Findings Included: An observation of Resident #46 on 10/26/21 at 9:53 a.m., revealed that the resident's catheter was draining dark amber urine with sediment. An observation of Resident #46's catheter on 10/27/21 at 12:10 p.m., revealed the urine that was draining was thick, cloudy, and pink in color. During an observation on 10/27/21 at 12:12 p.m., of the indwelling catheter with Staff G, RN, she said, He does not have an order to flush the catheter but I will check and left the room. Observation of Resident #46's catheter on 10/27/21 at 2:27 p.m., revealed cloudy, pink in color urine with thick white chunks in the catheter tubing. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure that treatment with a continuous positive airway pressure (CPAP) machine was delivered properly and hygienically for one (Resident #59) out of two residents in the facility receiving treatment from a CPAP machine.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed, and four errors were identified for one (Resident #1) of five residents observed. These errors constituted a 15.38% medication error rate.

Inspectors wroteBased on observation and interview, the facility failed to ensure four staff members knocked, announced themselves, and requested permission to enter resident occupied rooms during two of four days (02/09/20 and 2/11/20) of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an accurate assessment of the resident's capacity for one (#30) of 37 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure interventions were implemented for one (#38) out of 39 sampled residents after a fall with a major injury.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (#113) out of seven residents with a nothing by mouth diet did not receive oral intake.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure that psychoactive medications for four (#113,# 74, #80, and # 83) out of five residents were being monitored for target behaviors and side effects. Findings Included: 1. Resident #113 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified schizophrenia and other recurrent depressive disorders. The residents' physician orders included an order for Fluoxetine 20 milligram - give 2 capsules via Percutaneous endoscopic gastrostomy (PEG) tube at bedtime related to other recurrent depressive disorders, start date 10/29/19. The February 2010 Medication Administration Record (MAR) indicated the resident had received Fluoxetine daily at bedtime. [...]

Inspectors wroteBased on observations, interviews, policy and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two errors were identified for two (#94 and #58) of four residents observed. These errors constituted an 8.00% medication error rate.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to store medications safely, per manufacturer recommendations, and inaccessible to unauthorized persons in two (North 400 back & North 400 front) out of three observed medication carts and one out of one observed treatment carts (400 hall).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was served at an appetizing temperature and menu items were changed according to season. On 2/11/20 at 11:00 a.m., a Comprehensive Tour was done of the kitchen with Staff E, Dietary Manager. Six staff members were observed present and assisting with meal preparation. Staff E stated she would be checking the temperature of each food item, and that the temperature for the items had not been taken prior. Staff E stated, All of the puree food items were served hot because that's the way the residents like it. Staff E stated, It's been that way since I've been here.

Inspectors wroteBased on observation, interview and medical record & policy review, the facility failed to ensure that applied infection control practices for four (# 58, 94, 166, and 84) of thirty-nine sampled residents were consistent with facility policy and/or current standards of practice including: 1. An invasive device was cleaned and sanitized in between use for one (#58) resident; 2. That a non-invasive device was cleaned and sanitized after use for one (#94) resident; 3. That appropriate hand hygiene was utilized for one (#166) resident with Clostridioides Difficile; 4. And that personal care equipment was not removed from the room after being used for one (#84) resident with Methicillin-resistant Staphylococcus aureus to a wound. Findings Included: 1. During the observation of medication administration, which began at 10:08 a.m. [...]