Aviata at Oldsmar

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Nov 4, 2022

  Based on observation, review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to protect the resident's right to be free from abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, a Certified Nursing Assistant (CNA) reported to a Licensed Nurse Supervisor that Resident #7 was found in bed with a sheet tied across her midsection and fastened to the bedframe. […]

• Immediate jeopardy, isolatedF609Nov 4, 2022

  Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to [MEDICATION(S)] to promptly report abuse of one (Resident #7) of three residents reviewed for abuse. On 10/25/2022 a nursing staff member reported to their superior that they found Resident #7 in her bed with a sheet tied across her midsection and fastened to the bedframe during performance of morning care tasks. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA). […]

• Immediate jeopardy, isolatedF610Nov 4, 2022

  Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's medical director, it was determined the facility failed to conduct a thorough investigation in response to allegations of witnessed abuse and mistreatment for one (Resident #7) of three residents reviewed for abuse, failed to protect one (Resident #7) of three residents reviewed for abuse from further abuse and mistreatment, and failed to implement corrective action in a timely manner to protect all facility residents from a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, serious… […]

• Immediate jeopardy, isolatedF835Nov 4, 2022

  Based on record review, interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's Medical Director, the facility Administration failed to use its resouces effectively to lead and direct the overall operations of the facility in accordance with resident needs, regulations, and company policies related to abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, Resident #7, a cognitively and physically impaired resident who had a communication deficit and was dependent on staff for all care and services, was found by a Certified Nursing Assistant (CNA) restrained to her bed by a sheet placed across her midsection and tied to the bedframe. […]

• Actual harm, isolatedF760Oct 21, 2024

  Based on observations, interviews, and record review, the facility failed to ensure residents were from significant medication errors for 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of 32 residents who evacuated from Facility A to Facility B, for four of four days reviewed (10/18/24, 10/19/24, 10/20/24 and 10/21/24). Findings included: 1. During a post storm assessment tour conducted on 10/21/24 at 3:10 p.m., Resident #1 was heard from the hallway screaming and yelling. An observation revealed the resident lying on her bed making twisting and turning movements on the bed. The resident did not respond to the interview. An immediate interview was conducted with Staff A, Registered Nurse (RN) assigned to Resident #1 on 10/21/24 at 3:10 p.m. […]