Aviata at Kissimmee Gardens

In the surveyor’s words

From the most serious findings on record at Aviata at Kissimmee Gardens, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 8, 2023

  Based on interview, and record review, the facility's nursing staff neglected to address escalating exit seeking behaviors for a cognitively impaired resident, failed to provide adequate supervision, and failed to secure an exit door to prevent a vulnerable, cognitively impaired resident from exiting the facility for 1 of 3 residents reviewed for neglect, out of a total sample of 7 residents, (#2). These failures contributed to the elopement of resident #2 and placed him at risk for serious injury/harm/death. […]

• Immediate jeopardy, isolatedF689Feb 8, 2023

  Based on observation, interview, and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility unsupervised, failed to conduct assessments to identify risk for elopement and implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision and secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 7 residents, (#2). On 1/14/23 at approximately 5:40 PM, resident #2, a physically and cognitively impaired resident, walked away from the nurses' station on the Pebble Stone Unit, through an occupied unit and exited through a fire egress door that was deactivated and unlocked near the therapy gym. […]

• Immediate jeopardy, isolatedF578Nov 10, 2021

  Based on interview and record review, the facility failed to honor advanced directives for a Do Not Resuscitate Order (DNRO) for 1 of 5 residents sampled for DNROs of a total of 17 residents residing in the facility with DNROs, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) despite her explicit wish for a natural, dignified death and placed her at risk for serious injury / impairment / prolonged death. While resident #1 suffered resuscitation attempts including chest compressions, there was likelihood she experienced pain, broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 6:00 AM, resident #1 suddenly became unresponsive at the Pebblestone unit nurses' station. […]

• Immediate jeopardy, isolatedF600Aug 15, 2021

  Based on interview and record review, the facility neglected to perform neurological assessments after falls to monitor for and identify signs and symptoms of serious injury for 1 of 5 residents reviewed for falls, (#3). On 08/10/21 at 8:00 PM, resident #3 fell and was found sitting in his bathtub incontinent of urine. Facility staff returned the resident to his wheelchair but did not initiate neurological assessments to assess for any head injury the resident may have sustained after he fell in the bathtub. Three hours later, at 11:00 PM, resident #3 fell a second time in his room. […]

• Immediate jeopardy, isolatedF689Aug 15, 2021

  Based on interview and record review, the facility failed to provide appropriate supervision for a cognitively impaired resident identified at high risk for falls, to prevent a fall with head injury and transfer to a higher level of care for 1 of 5 residents reviewed for falls, (#3). On 8/10/21 at 8:00 PM, resident #3 fell and was found sitting in his bathtub, incontinent of urine. Facility staff returned the resident to his wheelchair but did not implement increased supervision or additional fall prevention interventions. Subsequently, 3 hours later at 11:00 PM, the resident suffered a second fall in his room. He was found on the floor with his head on the metal base of the over bed table, bleeding from a laceration to the back of his head. […]