Aviata at Sand Key

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement effective pest control and prevention for three resident rooms (207, 407, and 415) located in two out of four nursing units in the facility.

Inspectors wroteBased on record review and interview, the facility failed to respond to un-timely call bell light grievances voiced by Resident Council for three of three sampled months, June, July and August of 2024.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by discoloration on ceiling tiles in one of two resident day rooms; discoloration on ceiling tile in room [ROOM NUMBER] with evidence of water by the air conditioning wall unit; ceiling damage from rain in room [ROOM NUMBER]; discoloration on ceiling air vents above one of two nursing stations; and a fallen tree limb in one of one resident courtyard.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services to residents on four (100, 200, 300 and 400) of four halls observed Findings Include: 1. On 1/29/2024 at 7:00 AM an observation occurred of Staff O, Registered Nurse (RN) stating to another employee, I refuse to take over two medications carts that are across the building, that is too much. On 1/29/2024 at 7:30 AM an observation of Staff O, RN was in the Nurse Manager office stating, only taking the cart accepted on the 300 hallway and to accept the cart for 100 hallway is too much for one nurse. On 1/29/2024 at 7:45 AM an observation of Staff O, RN speaking to Staff C, RN. Staff O, RN explained that Staff O, RN would not be taking over the care of the residents on the 100 cart. An interview was conducted with Staff C, RN on 1/29/2024 at 10:45 AM. [...]

Inspectors wroteBased on observations, policy review and interview, the facility failed to provide a clean, clutter free, comfortable, and homelike environment in three (100 Hall, 200 Hall, 400 Hall) of four halls, and in one (#47) of one resident rooms.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and ten errors were identified for three (#86, #29, and #63) of six residents observed. These errors constituted a 28.57% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to store medications appropriately and safely as evidenced by improper temperature in one (north) of two medication room refrigerators, failed to ensure medications were stored when administering medications on one (100) out of four hallways, and failed to ensure medications were not left at the resident's bedside unattended in five (104a, 302, 303b, 304b, and 308b) of five resident rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure one (north) of two nourishment refrigerator/freezer was maintained to prevent the potential for foodborne illness and to ensure that food items were dated and labeled. Findings Included: On 01/31/ 2024 at 9:00 AM an observation was made in North and South Nourishment Rooms with the dietary manager and Nursing Home Administrator. The North nourishment room was observed dirty with food items stored in the refrigerator and freezer not dated or labeled. On 01/31/2024 at 9: 20 AM an interview was conducted with the Certified Dietary Manager. He said the nourishment room refrigerator and freezer were maintained by the dietary staff daily. The refrigerators and freezers in the nourishment rooms should be kept clean. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreements presented to two residents of of three residents reviewed provided for the selection of a venue convenient to both parties and selection a neutral arbitrator agreed upon by both parties.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure infection control practices were followed related to 1.) cleanliness and prevention of biogrowth on two (north and south) ice machines; 2.) use of Personal Protective Equipment (PPE) as required by door signage for two (#342, #20) of two residents; 3.) hand hygiene on three of four halls (100, 200 and 400) halls; and 4.) cleanliness of resident equipment/supplies in resident rooms for residents #47 and #66

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident's medical record included documentation indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal for five (#12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not include influenza and pneumococcal immunization education and vaccine consents. A review of the immunization and miscellaneous sections of the resident's Electronic Health Record (EHR) where vaccine administration and related education are documented was conducted. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure screening and eligibility to offer the COVID -19 vaccine and vaccine education regarding the benefits and potential side effects was documented according with national recommendations for five (# 12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not reveal COVID-19 immunization education, refusal or consents related to vaccines. On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON), said vaccine administration is documented in the Medication Administration Record (MAR). When vaccine education is provided the Vaccine Information Sheet (VIS) is scanned to the resident's Electronic Health Record (EHR). Documentation can also be found in the immunization section of the EHR. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure two residents (#20 and #78) out of two residents the at will right to access persons and services outside the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (#81) out of four residents utilizing a Geri-chair was assessed for its use, a physician order had been obtained for its use, and it did not restrict the residents movement.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four (#74, #81, #14, and #45) of thirty-eight initially sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and/or later identified.

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a care plan related to a urinary catheter for one resident (# 62) out of three residents sampled.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure splints were applied and oxygen flow rate was accurate and completed per physicians' orders for one (Resident #47) of one sampled resident.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to document a fall, assess the resident, and notify the physician of an injury for one (#74) out of four residents sampled for accidents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to recognize, document, and educate staff regarding triggers for two (#74 and #14) out of two residents sampled for Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide and obtain medication per physician orders for one resident (Resident #35) of the sampled six residents.

Inspectors wroteBased on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to protect the resident's right to be free from neglect for one Resident (#1) of three residents reviewed for change in condition. On [DATE] during a 12 hour shift when Resident #1 exhibited shortness of breath and not feeling well, was unable to perform her normal daily activities, unusual behaviors and was begging to go to the hospital the nurses on duty neglected to respond with in a way that could have helped the resident. There were no PRN (as needed) medications provided to the resident except pain medication, no documented assessments or vital signs (VS), no call to the resident's provider, and no call to the resident's family. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) started. [...]

Inspectors wroteBased on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure nursing staff were competent to recognize and respond to a change in condition for one resident (#1) out of three residents reviewed for change in condition. On [DATE] Resident #1 complained of shortness of breath and not feeling well, was unable to perform her normal daily activities, exhibited unusual behaviors and was begging to go to the hospital. The aide assigned to the resident notified the nurses on duty of the resident's condition and complaints multiple times during a 12-hour shift. There were no documented assessments, vital signs (VS) or notifications to a physician or family member. There were no PRN (as needed) medications provided to the resident except pain medication. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure air conditioning (A/C) units were maintained in a sanitary manner on one (Hall 100) of four halls observed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure two (Resident #19 and #33) of two sampled residents were free from potential accident hazards related to unsafe smoking in undesignated smoking areas.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to ensure a care plan intervention was implemented for one (Resident #9) of thirty-four residents in the sample group. Findings Included: An initial observation was conducted on 12/07/2021 at 9:47 a.m. of Resident #9 lying in bed, not wearing the physician-ordered splint to her right hand. A later observation was made on 12/08/2021 at 12:47 p.m. During the observation, Resident #9's hand splint was not applied to her right hand for a contracture. An observation was made later in the day on 12/08/2021 at 3:35 p.m. During the observation, an interview was conducted with Resident #9's mother who was at bedside. Resident #9's mother revealed the resident wore a right-hand splint for her right-hand contracture. The resident's mother also confirmed that Resident #9 did not have the splint on at the time. [...]

Inspectors wroteBased on observation of the resident, interview with facility staff, and review of the medical record and facility policy the facility did not ensure that one resident (Resident #25) of 30 sampled residents, received a Level II PASRR evaluation prior to admission to the facility, as required since the resident had been identified on the Pre-admission Screening and Resident Review (PASRR) as not being eligible for admission to a nursing home because of serious mental illness.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement and develop a resident centered care plan for three (#20, #22, #80) of thirty sampled residents related to continuous oxygen use for Resident #20, activities of daily living (ADL) for Resident #22, and the use of Thrombo-Embolic Deterrent (TED) hoses for Resident #80.

Inspectors wroteBased on observation, clinical record review, and interview, the facility failed to ensure storage of respiratory equipment, of a facemask, in accordance with professional standards of practice for three residents (#4, #20 and #44) of 17 residents receiving respiratory treatments for four of four days observed.

Inspectors wroteBased on observation of the resident, review of the resident's medical record, and interview with facility staff, the facility did not ensure that one resident (#25) of 30 sampled residents, received mental health services appropriate for his assessed needs.

Inspectors wroteBased on record review and interview the facility failed to ensure a drug regimen review was conducted and communicated to report and correct irregularities for 3 out of 5 (Resident #30, Resident # 22, Resident # 17) residents sampled for unnecessary medications regarding lack of recommendations related to missing data on the Medication Administration Record (MAR), lack of monitoring of medications used to control resident behavior and failure to ensure that the consultant pharmacist recommendations were reviewed and acted on.

Inspectors wroteBased on record review and interview the facility failed to assure 2 out of 5 (#30, #44) sampled residents were free from unnecessary medications related to Gradual Dose Reductions (GDR), lack of monitoring medications used to control behavior.

Inspectors wroteBased on observation, interviews, and record review the facility failed to appropriately secure medications in three of four medication carts.

Inspectors wroteBased on observations, review of maintenance requests and proposals for work, an interview with the Director of Dietary, the Director of Maintenance and the Administrator, the facility failed to maintain equipment and the facility premises in safe operating condition as evidence by the facility: 1. failed to ensure that four ceiling tiles surrounding air vents in two of four resident halls were clean and free of dark stains and black spots; 2. failed to replace floor tiles and a loose wall board in the kitchen; and 3. failed to replace a freezer door that was identified as not fitting the door frame due to a build-up of ice.

Inspectors wroteBased on observation interview and record review the facility failed to ensure that the environment was maintained in a safe manner in three of eight resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) located on one of four resident halls (200 hall) related to a wrapped call light string and holes in the walls.