Aviata at South Daytona

Inspectors wroteBased on record review, interviews, and review of facility records, the facility failed to ensure the residents' right to be free from neglect by failing to implement sufficient safeguards and supervision to prevent one (Resident #1) of five residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with subsequent fractures of the lower right femur (thigh bone) and right patella (kneecap). The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance and the use of a mechanical lift during transfers for Resident #1. On April 22, 2026, one certified nursing assistant (CNA) attempted to transfer Resident #1 from her bed to her chair by using a stand-and pivot method rather than following the resident's care plan indicating the need for a mechanical lift and two staff members for transfers. [...]

Inspectors wroteBased on record review, interviews, and review of facility records, the facility failed to implement sufficient safeguards and supervision to prevent one (Resident #1) of five residents reviewed for Activities of Daily Living (ADL) care from an avoidable fall with subsequent fractures of the lower right femur (thigh bone) and right patella (kneecap). The facility failed to ensure that staff implemented care plan interventions specifying two-person assistance and the use of a mechanical lift during transfers for Resident #1. On April 22, 2026, one certified nursing assistant (CNA) attempted to transfer Resident #1 from her bed to her chair by using a stand-and pivot method rather than following the resident's care plan indicating the need for a mechanical lift and two staff members for transfers. The resident fell during the transfer and sustained right femur and patellar fractures. [...]

Inspectors wroteBased on observations, interviews, facility record review, and a review of facility policies and procedures, the facility failed to ensure it provided a clean, comfortable and homelike environment in four (Rooms #7, #8, #12 and #16) of 30 sampled rooms.

Inspectors wroteBased on a main nursing station refrigerator observation, facility documentation, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a limited number of residents who consumed foods from the facility, by failing to properly monitor and log temperatures of the main nursing station refrigerator. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on interviews, record review, facility document review, and the facility Policy and Procedure, the facility failed to ensure the Pharmacist Medication Regimen Reviews were maintained and carried out to minimize or prevent adverse consequences, to the extent possible for two (Residents #4 and #43) of five residents reviewed in a total survey sample of 30 residents.

Inspectors wroteBased on observations, interviews, and policy and procedure review, the facility failed to ensure staff followed the facility's infection prevention and control program (IPCP) and adhered to isolation precautions for one (Resident #8) of six residents who were positive for COVID-19, by entering the resident's room without donning the required personal protective equipment (PPE) and transporting the resident without a mask to a common area, exposing other residents to COVID-19.

Inspectors wroteBased on observations, record reviews, interviews, and a review of facility policies and procedures, the facility failed to ensure that the call system was accessible to residents while in their beds for three (Residents #10, #20, and # 31) of a facility census of 59 residents.

Inspectors wroteBased on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain a sanitary and comfortable environment for residents and staff by failing to ensure hot water was available in resident rooms, resident shower rooms and employee bathrooms. This deficient practice had the potential to impact all 51 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%. There were five errors with 38 opportunities for error, resulting in an error rate of 13.15789% and involving four (Residents #24, #29, #44, and #9) of six residents observed during medication administration, from a total of 22 residents in the sample.

Inspectors wroteBased on observations throughout the facility and interviews with staff, the facility failed to provide a sanitary, homelike environment for residents, staff and visitors by neglecting to maintain walls that housed resident personal air conditioner units in five of five rooms observed on the east wing (rooms 2, 3, 4, 6 and 12) out of 10 rooms on the unit and a total of 22 resident rooms in the facility. The facility also failed to provide needed maintenance and cleaning to the baseboards and the carpeted walls under the handrails on both the east and west wings.

Inspectors wroteBased on a review of resident records, facility policies and procedures, and interviews with staff, the facility failed to provide written notification of emergency transfer and failed to send that notification to the Office of the State Long-Term Care Ombudsman for one (Resident #47) of one resident reviewed for [NAME] Acts (voluntary or involuntary hospital admission for psychiatric care and stabilization), from a total of 22 residents in the sample.

Inspectors wroteBased on a review of resident records, facility policies and procedures, and interviews with staff, the facility failed to provide written information prior to hospital transfer that notified the resident/representative of the facility's bed hold policy for one (Resident #47) of one resident (Resident 47) reviewed for a hospital transfer/Baker Act, from a total of 22 residents in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #1) of two residents who were unable to carry out activities of daily living (ADL) independently, from a sample of 22 residents, received the care and services necessary to maintain good grooming and personal hygiene. Resident #1 was not provided adequate nail care.

Inspectors wroteBased on observations and staff interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. This failure affected all 54 residents who received meals from the kitchen, as well as any residents who received food from the nourishment room, from a total of 55 residents in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to ensure dining throughout the facility was provided in a way to maximize independence, personalization, and a comfortable, homelike environment at mealtimes. This had the potential to affect all 54 residents in the facility. The facility also failed to ensure resident bed linens were clean and in good condition for one (Resident #2) of eight sampled residents reviewed for environmental concerns, from a total of 30 residents in the sample.

Inspectors wroteBased on observations, a review of resident records, and staff interviews, the facility failed to ensure each resident's right to a dignified existence by failing to 1) Ensure privacy during enteral feeding for one (Resident #12) of three residents reviewed for dignity, 2) Refrain from using labels to identify residents by their dining needs in the presence of the resident for one (Resident #38) of three residents reviewed for dignity, and 3) Respectfully escort one (Resident #44) of one resistive resident to her room for incontinence care, from a total of three residents reviewed for dignity and a total of 30 residents in the sample.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one (Resident #23) of four residents reviewed for nutritional risk, out of 30 sampled residents, was properly monitored for acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #23 was properly monitored for potential weight loss.

Inspectors wroteBased on observation, review of facility records and interviews with staff, the facility failed to post daily staffing information that included the name of the facility and the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) on one of four days during the survey, and on an indeterminate number of days between 10/27/21 and 11/7/21.

Inspectors wroteBased on a review of resident records, interviews with staff, and a review of facility policies and procedures, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days, and were not renewed unless the prescribing practitioner evaluated the resident for one (Resident #5) of one residents with an open-ended PRN order, out of six residents reviewed for unnecessary medications, from a total of 30 residents in the sample.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who required restorative services to assist with carrying out activities of daily living, received those services. Specifically, the facility failed to ensure one (Resident #50) of three residents reviewed for activities of daily living (ADLs), from a total of 30 sampled residents, received appropriate restorative assistance with dining.

Inspectors wroteBased on a review of resident records and interviews with staff, the facility failed to ensure accurate documentation of psychotropic medication administration for one (Resident #5) of six residents reviewed for unnecessary and psychotropic medications, from a total of 30 residents in the sample.

Inspectors wroteBased on staff interviews, a review of resident records, and a review of facility policies and procedures, the facility failed to maintain a current hospice plan of care in the resident records for one (Resident #5) of two residents reviewed for hospice services, out of four residents receiving hospice, from a total of 30 residents in the sample.