Aviata at Tallahassee

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to submit an incident report within the required 2 hour timeframe for 2 of 2 reports reviewed for abuse and neglect.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, safe and home-like environment for 3 of 58 occupied rooms and 2 of 111 residents screened during the initial tour. (Rooms #126, #216, #200, and Residents #63 and #100)Room observations (Photographic evidence obtained of all issues) On 9/15/2025 at 11:53 AM, Room # 216 (which was occupied) bathroom's toilet lid had a crack. The room's entry area ceiling had a brown-colored rust-like metal between the tiles. On 9/16/2025 at 9:21 AM, room [ROOM NUMBER]'s wall had brown-colored stains and paint had scratches. The room was being occupied. 09/15/2025 at 12:00 PM, a small refrigerator in room [ROOM NUMBER] was observed and a foul odor was detected. Inside a spilled brown liquid was present along with two unfinished bottles of soda. The freezer compartment had ice cream spilled throughout. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents by not screening 1 of 1 resident sampled for smoking. (Resident #164)On 9/18/25, a chart review was conducted of the electronic medical record (EMR) for Resident #164. No safe smoker screening was documented in the record. On 9/18/25 at approximately 3:25 pm, an interview was conducted with the Director of Nursing (DON). She was asked about the facility process for screening residents for smoking safety. She stated a smoking screen is done on every resident on admission. If the resident smokes, teaching is provided to the resident. The resident is added to the smoking list kept by activities staff. Activities staff are responsible for providing supervision and assistance to residents who smoke. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer prescribe pain medication and failed to refill pain medications for 1 of 1 residents sampled for pain medication. (Resident #52) On 9/16/25, a phone interview was performed with the daughter of Resident # 52. She stated that Resident #52 had not been receiving her nightly dose of MS Contin 75 ER for several days. A phone call was performed with the facility's pharmacy on 09/16/2025 at 1:36 PM. They stated that the facility requested a refill of MS Contin 75 mg ER for Resident # 52 on 7/2/2025 (25-day supply, ended 8/6/2025) and 8/4/2025 (25-day supply, ended 8/31/2025). No further refill requests had been received since then. On 09/16/2025 at 2:30 PM, the Director and Assistant Director of Nursing were interviewed. They demonstrated the procedure for refilling medications to prevent missing any days. [...]

Inspectors wroteBased on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to provide safe and secure storage of medications for 2 of5 residents observed for medication. (Residents # 24 and 42)

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to maintain medical records that were accurate and complete for 1 of 1 resident sampled. (Resident #63)

Inspectors wroteBased on observations, record and policy review, and interviews, the facility failed to follow infection control practices for 1 of 1 resident sampled for wound care treatment (Resident #159), 1 of 2 residents sampled for droplet isolation precautions (Resident #34), and 1 of 1 resident sampled for contact isolation precautions. (Resident #107)Resident #107 A chart review conducted on Resident #107 revealed a physician order which stated, Isolation Type - CONTACT-methicillin resistant staphylococcus aureus (MRSA) every shift for monitoring. Observations of the resident’s room door revealed a sign for Enhanced Barrier Precautions (EBP) [a different category of contact precautions] hung on an over-the-door caddy containing Personal Protective Equipment (PPE) supplies such as gown, gloves, and masks. [...]

Inspectors wroteBased on record review, policy review and staff interviews, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 of 3 residents (Resident #1). The facility neglected the resident's needs for emergency care allowing the resident to expire despite a full code status.

Inspectors wroteBased on review of resident records, interview, and review of facility policy, the facility failed to obtain consent for 1 of 2 psychotropic medications ordered for 1 of 3 residents reviewed for psychotropic medication usage. (Resident #3)

Inspectors wroteBased on observation and interview, the facility failed to maintain an adequately equipped call light system for the 100 hall of the building.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate and updated medical records for 1 out of 8 residents sampled. (Resident #2)

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. There were issues found with the dish cleaning process, cold food storage, non-food items and personal drinks stored on food preparation stations and a lack of hair containment during food preparation.

Inspectors wroteBased on observations, review of the electronic medical record (EMR), interviews with staff and residents, and review of the facility policies and procedures, the facility failed to provide a dignified existence for 5 of 6 residents sampled for dignity. (Residents 104, 65, 116, 41, and 120)

Inspectors wroteBased on observations and staff interviews the facility failed to provide a safe, clean, and homelike environment in the laundry room, main hallway, and the 100 and 200 residential areas.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to properly store medications maintain medication carts, including disposal of expired medications and properly labeling medications in 3 of 3 medication carts reviewed.

Inspectors wroteBased on observations, resident intervew, staff interview, review of meal tray tickets and electronic medical record (EMR) review, the facility failed to serve each resident a palatable diet and failed to address special dietary needs and physician orders for 3 of 7 residents sampled for food related concerns, Resident #22, #248 and #135).

Inspectors wroteBased on observations, staff interviews, and policy reviews the facility failed to maintain all garbage areas in a safe and sanitary manner.

Inspectors wroteBased on observations, interviews, and policy reviews the facility failed to maintain food service related equipment in safe operating condition in the kitchen and food pantries.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure accuracy of Preadmission Screening and Resident Review (PASARR) for 3 of 3 residents sampled (Residents #18, #62, and #126).

Inspectors wroteBased on observations, staff interviews, and review of the electronic medical record (EMR), the facility failed to develop a comprehensive care plan for anxiety for 1 of 2 residents sampled. (Resident #123)

Inspectors wroteBased upon record review and staff interview, the facility failed to ensure the accuracy of narcotic counts and that the stored narcotics were consistent with physician orders for 1 of 37 residents reviewed, Resident #143.

Inspectors wroteBased on observation and interview, the facility failed to consistently post nurse staffing information.

Inspectors wroteBased on interviews and record review, the facility failed to communicate with resident's representative concerning a resident's changes of antipsychotic medication for 1 of 1 resident sampled. (Resident #4)

Inspectors wroteBased on observations, interviews, review of facility grievance logs and policy review the facility failed to ensure that all grievances had a prompt resolution for 1 of 2 residents (resident # 23) sampled for personal property.

Inspectors wroteBased on observations, record reviews, staff interviews, and policy review, the facility failed to implement the care plans for 1 of 3 residents reviewed nutrition (Resident #68), 2 of 3 residents reviewed for pain management (Resident #518 and #77) and for 1 of 1 resident sampled for bowel and bladder (Resident #28).

Inspectors wroteBased on observations, record review, staff interview, and policy review the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 1 residents reviewed for limited range of motion. (Resident #1)

Inspectors wroteBased on observation, resident and staff interview, record review and review of facility policy, the facility failed to ensure implement interventions to prevent accidents following a resident fall for 1 of 1 resident sampled #565).

Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to provide care and services in accordance with the physician orders for 1 of 1 sampled residents with a urinary catheter (Resident #108) and failed to provide timely incontinent care for 1 of 1 residents sampled for bowel and bladder (Resident #28).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to appropriately administer enteral feedings to prevent possible complications for 1 of 1 resident sampled for enteral feeding (Resident #123).

Inspectors wroteBased on observations, interview, and review of facility policies, the facility failed to provide appropriate infection control measures during wound care for 1 of 3 residents (resident #77) sampled for pressure ulcers.