Aviata at Palma Sola Bay

Inspectors wroteCross Reference F842 Based on observation, interview, and record review, the facility failed to ensure a newly admitted resident (#6) out of five newly admitted residents reviewed was free from significant medication errors as evidenced by not receiving physician ordered medications for a period of seven days resulting in a readmission to a local hospital due to a hematoma and exacerbation of her medical diagnoses to include a flare-up of Multiple Sclerosis (MS) symptoms to include paralysis in her hands, confusion, and a low hemoglobin requiring a transfusion of packed red blood cells (PRBCs) . On 8/9/24, Resident #6 was admitted to the facility with medication orders from the acute facility. Resident #6's ordered medications were not entered into the electronic medical record. [...]

Inspectors wroteCross Reference F760 Based on observation, review of medical records, policy and procedure review, interviews with residents, resident representative, nursing staff, key management staff, the residents' physician and pharmacist, it was determined the facility failed to ensure the medical records were complete and accurate in accordance to accepted professional standards and practices for two residents (#3, and #6) out of 9 residents reviewed. This failure contributed to the lack of communication amongst staff in delivering care and services for Resident #3 and Resident #6 resulting in the residents not receiving physician ordered medications. The facility staff did not ensure documentation was completed upon admission for Resident #6 related to medication reconciliation. [...]

Inspectors wroteCross Reference F600, F684, F726, and F880 Based on observation, interview, and record review the facility's Quality Assurance Performance Improvement Program (QAPI) failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 7/8/24 through 7/12/24 as evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure preferences were honored for one resident (#248) out of nine sampled residents. Findings Included: On 07/08/24 at 10:33 a.m. Resident #248 was observed lying in a geriatric chair by the entrance to the courtyard and facing the nurses' station. On 07/08/24 at 12:33 p.m. Resident #248 was observed upright in a geriatric chair with a family member assisting him with his meal. On 07/08/24 at 03:05 p.m. an interview was conducted with Resident #248's. The family member said Resident #248 likes to sleep in a quiet area and he is always placed by the nurses' station which is noisy. On 07/09/24 at 8:32 a.m. an interview and observation was conducted with Resident #248. Resident #248 was sitting in a geriatric chair facing the nurses' station. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a comprehensive care plan related to the use of a sling for one resident (#18) out of 26 residents sampled.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain and implement an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to prevent the development and transmission of communicable diseases and infections as evidenced by a lack of enhanced barrier precaution signage on doors of two residents (#81, #297) out of 20 residents on enhanced barrier precautions.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from abuse/neglect by 1) failing to respond to a serious change in condition in a timely manner for one resident (#404) out of seven residents sampled for abuse/neglect and, 2) use of a Geri-chair as a restraint to limit a residents movement for one resident (#248) out of seven sampled for abuse/neglect. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. The bleeding required four dressing changes to the upper extremities and two dressing changes to the lower extremities due to bleeding through the dressings over the course of 17 hours. On [DATE] at 7:25 a.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1) a failure to communicate a significant change of condition to other licensed nurses and the physician, resulting in a delay of treatment for one resident (#404) out of seven residents sampled; 2) a failure to implement physician orders related to vital signs monitoring for one resident (#94) out of seven residents sampled and, 3) a failure to recognize and respond to a change in condition related to hypotension for one resident (#401) out of seven residents sampled. Resident #404 experienced a change of condition secondary to bleeding from four skin wounds on his arms and legs, which began on [DATE] at 1:00 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there were competent staff to provide nursing services in order to assure resident safety and well-being for three residents (#404, #94, and #401) out of seven residents sampled.

Inspectors wroteBased on interviews and record review the facility failed to complete a thorough investigation of an allegation of neglect for one resident (#404) out of seven residents sampled for abuse/neglect.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed obtain physician's admission orders related to 1. continuous oxygen for two (Residents #198 and #76) of ten residents who wear oxygen, 2. failed to input physician orders related to wound care for one (Resident #346) of two residents, and 3. catheter care for two (Resident, #52, #197) of six residents with indwelling catheters.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure up to date resident assessments were completed related to 1) quarterly elopement assessments for three (Resident #58, #7, and #24) of three residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #250) of four resident's advanced directives were verified and accurate within a timely manner.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (Resident #7) of eighteen residents residing on the secured memory care unit received hair care as necessary to prevent matting.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a change in condition was documented and monitored for one (Resident #97) of one resident sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure one (Resident #34) of three residents sampled for nutrition was weighed at least monthly and documented in their health record.

Inspectors wroteBased on interview, resident record, and policy review, the facility failed to provide the least restrictive behavioral health services to one (Resident #251) of two residents to aid in behavioral de-escalation.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (Resident #7) of five residents sampled for the administration of unnecessary medications received adequate monitoring for abnormal movements related to the use of antipsychotic medications.

Inspectors wroteBased on observation, interview, and record review, the facility's quality assurance and assessment (QAA) committee failed to implement an effective plan of action related to infection control and prevention as evidenced by the potential for cross-contamination when gloves were not changed and hand hygiene was not performed during a wound care procedure.

Inspectors wroteBased on observations, interviews, policy review, and Centers for Disease Control and Prevention and Control (CDC) guidelines the facility did not ensure infection control and prevention practices were implemented to prevent the spread of COVID-19 on one nursing unit (new admission observation unit) of three nursing units as evidence by: 1. Two staff members (A, and B) failed to perform hand hygiene after removing gloves when exiting resident rooms, and failed to changed gloves and perform hand hygiene between providing care for two residents (#327 and #328) and failed to handle trash and soiled linens in a manner to prevent the spread of COVID-19, and 2. Failed to ensure two staff members (D and E) were wearing eye protection on the new admission observation unit, and 3. [...]