Aviata at Palm Bay

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician's ordered discharge medications were timely provided for 1 of 3 residents reviewed for Admission, Transfer, and Discharge, of a total sample of 8 residents, (#7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a laboratory specimen was obtained and submitted per physician's orders for 1 of 4 residents reviewed for Quality of Care, of a total sample of 8 residents, (#7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 of 3 residents reviewed for elopement, of a total sample of 3 residents, (#1). Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included Traumatic Brain Injury (TBI), psychosis, persistent mood disorders, cognitive impairment, lack of coordination, and difficulty in walking. The most recent Quarterly Minimum Data Set Assessment with an Assessment Reference Date of 7/25/24 noted during the look back periods, resident #1 had impaired vision and he scored 8 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a resident later identified with a Mental Illness (MI), for one of six residents reviewed for PASRR, of a total sample of 40 residents, (#47).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed prior to accepting a new admission, (#92), failed to request Level I, (#21) and Level II evaluations, (#66), for 3 of 6 residents reviewed for PASARR, of a total sample of 40 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate the risk and prevent elopement for 1 of 3 residents reviewed for Elopement, of a total sample of 23 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury, impairment, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost or been hit by a vehicle. On 12/28/2023 at approximately 3:30 PM, resident #1, a vulnerable [AGE] year old female was admitted to the facility from the hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 3 sampled residents reviewed for elopement, of a total sample of 23 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for injury, impairment, or even death. While resident #1 was out of the facility unsupervised, there was high likelihood she could have fallen and sustained serious injury, become lost, been accosted by a stranger, or hit by a car and died. On [DATE] at approximately 3:30 PM, resident #1, a vulnerable [AGE] year-old female was admitted to the facility from the hospital. While at the hospital, she was determined to be at risk of wandering unsafely without 24-hour supervision and required care and services to monitor her to ensure her safety. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an appropriate discharge process to the community was followed for facility-initiated discharges for 2 of 3 residents reviewed for discharge status of a total sample of 23 residents, (#21 and #29). The facility's failure to safely discharge a resident to the community resulted in actual harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the residents or their representatives of a facility-initiated discharge in a timely manner and in writing and failed to submit a copy of the notice to the State Long-Term Care (LTC) Ombudsman for 3 of 3 residents reviewed for discharge status out of a total sample of 23 residents, (#21, #28 and #29).

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of policies to include thorough monitoring of previously identified areas of concern and adequately track performance to ensure prior improvement measures for discharge notifications were realized and sustained.

Inspectors wroteBased on interview, and record review, the facility failed to obtain written authorization to manage personal funds for 1 of 3 residents reviewed for personal funds, of a total sample of 23 residents, (#23).

Inspectors wrote14. Resident #59's medical record revealed the resident was admitted on [DATE]. Her diagnoses included encephalopathy, muscle weakness, other lack of coordination, unsteadiness on feet, difficulty in walking, psychosis, delusional disorders and unspecified mood disorder. Her admission MDS assessment dated [DATE] revealed she had severe cognitive impairment. She required limited assistance of one staff for bed mobility, dressing, eating and personal hygiene; she also required supervision for transfer. Resident #59 used a walker or wheelchair for mobility. Record review revealed that on 08/29/22, resident #59 had orders to discontinue PT services after 08/29/22 treatment. The Therapy Communication to Restorative Nursing Program form dated 08/29/22 indicated resident #59 had weakness on bilateral lower extremities and decrease in standing balance. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate nurse staffing to meet the needs of residents who required splinting and range of motion services through the Restorative Nursing Program (RNP) for 19 of 19 residents reviewed who were referred to the RNP of a total sample of 57 residents (#78, 97, 25, 62, 52, 69, 17, 83, 59, 21, 11, 18, 85, 23, 43, 19, 34, 93 & 7).

Inspectors wroteBased on interview and record review, the facility failed to utilize its resources effectively to adequately provide staff for the Restorative Nursing Program (RNP) to ensure residents received needed therapy services.

Inspectors wroteBased on interview and record review, the facility failed to obtain a written authorization for disbursements from the resident trust account for 1 of 1 resident reviewed for personal funds out of a total sample of 57 residents (#54).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) related to nail care for 1 of 2 dependent residents reviewed for ADLs out of a total sample of 57 residents (#43).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order for wound treatment for 1 of 2 sampled residents reviewed for skin condition out of a total sample of 57 residents (#50).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received supplemental oxygen as ordered for 1 of 1 resident reviewed for respiratory care out of 57 total sampled residents (#29).