Aviata at Orange Park

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Feb 10, 2021

  Based on record reviews and staff interviews, the facility failed to: 1) Honor a resident's Do Not Resuscitate Order (DNRO) when he was discovered to be unresponsive and without vital signs, and 2) Ensure that a resident's Do Not Resuscitate preference was reflected in the resident's electronic medical record. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 had a DNRO and staff initiated cardiopulmonary resuscitation (CPR) with chest compressions and artificial respirations in opposition to Resident #1's Advanced Directives. […]

• Immediate jeopardy, isolatedF678Feb 10, 2021

  Based on record reviews and staff interviews, the facility failed to follow the facility's Cardiopulmonary Resuscitation (CPR) policy and ensure staff were familiar with facility policies. The facility policies related to CPR required two nurses to verify resident information and Do Not Resuscitate Orders (DNROs) before CPR was initiated. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 was discovered unresponsive and without respirations by a certified nursing assistant (CNA). The resident's assigned nurse was immediately notified and went to the resident's bedside. She found him without a pulse or respirations and provided CPR. Facility policy required two nurses to verify a resident's code status prior to the provision of CPR. […]

• No harm, potential for more than minimal, widespreadF812Nov 9, 2023

  Based on kitchen food service observations, staff interviews, facility document review, 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 all residents who consumed foods from the facility. The facility failed to maintain cleanliness and good repair of the walls in the chemical storage closet, kitchen floors, and baseboards. Live roaches were observed crawling on plastic drink lids and packages of bread. The facility failed to seal and date mark two open bundles of bread on the bread rack and failed to clean one of two microwaves located in the north unit nourishment room. […]

• No harm, potential for more than minimal, patternF812Nov 20, 2025

  Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety sanitation standards and food handling practices to prevent injury to residents and the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to serve dinnerware and trays in clean and good condition, clean food debris stuck on and around the meat slicer blade, and clean one of two microwaves located in the 300-600 unit nourishment room. Food handling and sanitation are important in health care settings serving nursing home residents. […]

• No harm, potential for more than minimal, patternF565Jan 21, 2022

  Based on resident interviews, staff interviews, and record review, the facility failed to consider resident group views, and act promptly upon the grievances and recommendations of the group's concerns regarding resident care and life in the facility. Specifically, the facility failed to act promptly to concerns regarding food preferences, timeliness of food service, and palatability of food. The facility failed to demonstrate its response and rationale for such response. The findings include: A review of the Food Committee minutes for 10/2021, revealed that residents had voiced concerns regarding not getting food that they like, Residents want more meat for breakfast., and Residents want more food, larger portions. […]