Aviata at Seminole

Inspectors wroteBased on interviews and record reviews, the facility did not ensure four residents (#1, #3, #6, #10) out of five residents reviewed were informed in advance of changes to their plan of care related to medication.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the recertification survey conducted on 12/15/2025-12/16/2025 regarding maintaining a clean, sanitary and safe physical environment.

Inspectors wroteBased on observations and interviews the facility did not ensure proper infection control practices on five halls (100, 200, 400, 500, 600) out of six halls in the facility related to contact precautions, personal protective equipment (PPE) use, clean linen storage, and improper storage of oxygen equipment.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain a blood pressure prior to the administration of an antihypertensive with physician ordered parameters for one resident (#16) of two residents sampled during medication administration.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to notify and consult with the resident's physician on their known use of illicit drugs, related to the potential for medication contraindication for one resident (#4) out of eight residents sampled. Findings Included: On 10/07/2025 at 10:58 A.M. Resident #4 was observed in his wheelchair in the parking lot smoking. He said he goes to the west side of the parking lot for more privacy. He had a bottle of cologne on his lap and started spraying it on his body. Resident #4 said he was smoking marijuana (a psychoactive drug derived from the dried leaves, flowers, and stems of the Cannabis sativa or Cannabis indica plants, with effects Relaxation, Euphoria, Increased appetite, Altered perception, Impaired coordination, and Anxiety (in some users). Source:https://en.wikipedia.org/wiki/Cannabis. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, and sanitary environment, in one common room and in two resident rooms (407 and 108) located in two halls (400 and 100) of six halls observed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to protect residents from neglect and verbal abuse by two staff members (A & B) for eight residents (#1, #2, #3, #4, #5, #6, #8, and #9) out of eight sampled for abuse and neglect.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a functioning grievance process for two residents (#1 and #9 ) of ten residents sampled.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure an allegation of neglect was reported to the appropriate Agencies for one (#9) of ten sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were assesed to need constatnt supervision during smoking received adequate supervision for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents.

Inspectors wroteBased on observations, interviews, and facility record review, the facility failed to ensure sufficient staffing met the needs of the residents as evidenced by: 1. Resident interviews on untimely call light response for five residents (#5, #23, #24, #25 and #26) of six residents sampled, 2. Unresolved grievances related to call light response times for one resident (#5) of two residents reviewed for grievances. Findings Included: An interview was conducted on 04/02/2025 at 9:45 a.m. with Resident #23 and #24. Resident #24 stated that the staffing was often a problem. She stated staff often said they were Short-handed and didn't have time to assist her or she had to wait longer for assistance. Resident #24 stated she was often provided with incontinence care only one time during the first shift of the day. Resident #23 confirmed that she had brought up her concerns. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have a system in place to enable accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and implement a Quality Assurance and Performance Improvement Program (QAPI) that enabled accurate reconciliation and accounting for all controlled medications for 4 out of 6 sampled medication carts.

Inspectors wroteBased on observation, interview and record review the facility failed to abide by their smoking policy of ensuring residents are provided a safe, designated smoking area for nine (#10, #13, #8, #12, #14, #9, #11, #15 and #26) of 27 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a transfer notice was provided to the resident and the resident representative for one (Resident #3) of three residents sampled for emergency transfers.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin that resulted in a transfer to a higher level of care for one (#1) of one resident out of ten residents reviewed. Findings Included: A review of Resident #1's admission Record showed an original admit date of [DATE] with a readmission date of [DATE] with the following diagnoses: Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side Other abnormal of gait and mobility Need for assistance with personal care Difficulty in walking, not elsewhere classified. Muscle weakness (generalized) Muscle wasting and atrophy, not elsewhere classified, unspecified site A review of Resident #1's care plan dated [DATE] showed a Focus area: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 1. provide treatment and services in accordance with physician orders for one (#9) out of three residents reviewed; and 2. failed to ensure call lights were answered within a timely manner for four (#5, #6, #7, and #8) of ten sampled residents. Findings Included: 1. Review of the admission Record showed Resident #9 was admitted to the facility on [DATE] with diagnoses to include acute osteomyelitis, chronic ulcer of the right heel and midfoot, peripheral vascular disease, and type 2 diabetes mellitus with foot ulcer. Review of Resident #9's Medication Administration Record for November 2024 showed the following: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure adequate nail care and consistent shower services for one (Resident #1) of three residents sampled for Activity of Daily Living services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a dignified existence was provided to one resident (#16) out of eight residents sampled.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a reasonable accommodation of resident needs for one resident (#44) out of eight sampled residents related to having an appropriate bed to sleep in.

Inspectors wroteBased on record review, interview, and review of the facility's policy Preadmission Screening and Resident Review (PASRR), the facility failed to ensure residents received an accurate Level I Preadmission Screening and Resident Review (PASRR) for four residents (#6, #68, #36 and #43) of twenty-three sampled residents who were reviewed for PASRR screens.

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a person-centered care plan to meet the resident's communication needs for one (Resident #491) of one sampled resident and for one (Resident #87) of one resident sampled for Cardiopulmonary Resuscitation (CPR) status.

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the care plan for one resident (#87) out of the sampled thirty-nine residents.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the proper and timely interventions to prevent pressure ulcers for one (Resident #290) out of three sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one (Resident #87) out of the sampled seven residents, who was fed by enteral means, received appropriate treatment and services per physician orders.

Inspectors wroteBased on record review, interview, and review of the facility's policy Medication Management-Psychotropic Medications, the facility failed to ensure side effects monitoring was in place for one (Resident #8) out of five residents reviewed for unnecessary and psychotropic medication regimen review.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and three errors were identified for three residents (Residents #79, #22 and #6) of six residents observed. These errors constituted a 11.54% medication error rate. Findings Include: On 5/22/24 at 9:29 a.m., an observation was conducted during medication administration with Staff C, Licensed Practical Nurse (LPN) for Resident #79. Staff C dispensed the following medication: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control practices for two (Residents #51 and #22) out of six residents observed during medication administration.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure the kitchen equipment and area were maintained in a sanitary manner, and food was prepared, distributed and served in accordance with professional standards for food service safety, to include not ensuring the milk cooler maintained appropriate temperatures as evidenced by a temperature of 49 degrees Fahrenheit, and the facility failed to ensure the two nourishment rooms located on the 200 and 500 hall for residents were maintained and clean as well as have foods that were labeled properly, and foods were disposed of properly for three days (01/11/22, 01/12/22 and 01/13/22) of four days of survey.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure dignity was maintained for four residents (#71, #23, #25 and #11) of four residents related to 1. three staff members (O, J, H) assisting two residents (#71, #23) with meals while standing, 2. not ensuring catheter bags for two residents (#71 and #11) were covered with privacy bags, and 3. not ensuring privacy during wound care for one resident (#25), for a total of three days (01/11/22, 01/12/22 and 01/13/22) of four days.

Inspectors wroteBased on observations, record review, interviews, and the plan of correction review, the facility failed to ensure it had a functioning Quality Assurance system. The facility was actively involved in the creation, implementation, and monitoring of an effective plan of correction for deficient practice identified during a recertification survey, conducted on 01/11/2022 to 01/14/2022, and cited at F812. The facility developed a plan of correction with a compliance date of 02/14/2022. During a revisit survey, conducted on 02/24/2022, deficient practice was again identified at F812 related to kitchen equipment and food storage.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide services with reasonable accommodation of a resident's need and preference related to smoking during the assigned smoking times for one resident (#59) of a total sample of 15 residents who smoked for four days (01/11/22, 01/12/22, 01/13/22 and 01/14/22) out of four days.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure appropriate treatment and services of an indwelling catheter for two residents (#11, and #71) of seven residents with indwelling catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered, and two errors were identified for two (Resident #21 and #49) of three residents observed. These errors constituted a medication error rate of 8.00 percent.

Inspectors wroteBased on record review and interviews, the facility failed to ensure ordered medication was available to dispense on an as needed (PRN) basis for one resident (#61) of four residents reviewed for the provision of ordered medications.

Inspectors wroteBased on observation, interview and record review the facility did not ensure nutritional parameters were addressed and maintained for one resident (#79), related to weight loss, for three residents reviewed for nutritional care.

Inspectors wroteBased on observations, interviews, record review, and policy review the facility did not practice infection control procedures to avoid potential infection as evidenced by 1) failure to practice hand hygiene during medication administration by one (Staff A) of four nurses observed, and 2) failure to disinfect a glucometer for one (#73) of three residents observed for blood glucose monitoring during the medication administration task by one (Staff A) of four nurses observed.