Aviata at Rosewood

In the surveyor’s words

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

• Immediate jeopardy, patternF600Oct 21, 2022

  Based on observation, interview, and record review, the facility neglected to provide adequate oversight of staff, effectively utilize interdisciplinary team (IDT) communication, and implement processes to ensure the plan of care reflected care needs; and failed to provide necessary care and services to prevent the development of a traumatic wound for 1 of 6 residents reviewed for splints of a total sample of 8 residents, (#3). Resident #3 suffered significant pain and discomfort as a splint remained on her left leg and foot continuously for six months. She was placed at risk for skin breakdown and infection, and subsequently sustained a traumatic injury to her left heel during removal of the splint, which required ongoing daily wound care. […]

• Immediate jeopardy, patternF684Oct 21, 2022

  Based on observation, interview and record review, the facility failed to obtain and implement orders in a timely manner after orthopedic consults to ensure appropriate care for 2 of 3 residents reviewed for consults, (#2 & #3); and failed to provide care and services in accordance with facility policies and procedures and professional standards of practice to prevent the development of a traumatic wound and promote wound healing for 1 of 6 residents reviewed for splints, (#3) of a total sample of 8 residents. Resident #3 suffered significant pain and discomfort as the splint remained on her left leg and foot continuously for six months. […]

• Immediate jeopardy, patternF726Oct 21, 2022

  Based on observation, interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to recognize and address the absence of physician and consultant orders for care, perform thorough and accurate skin evaluations, identify potential concerns related to a splint, follow wound treatment orders, and report significant findings to nursing management and the physician for 1 of 6 residents reviewed for splints of a total sample of 8 residents, (#3). Resident #3 suffered significant pain and discomfort as nursing staff left a removable splint on her left leg and foot continuously for six months. […]

• No harm, potential for more than minimal, widespreadF812Apr 26, 2024

  Based on observation and interview, the facility failed to ensure dishware were rinsed with the proper level of sanitizer in regard to the manufacturer's instructions. Finding: On 4/22/24 at 10:15 AM, during kitchen observation, staff were observed running dishware through the dish machine. Dietary Aide G was observed removing items from the machine and placing them on racks and shelves in the kitchen. The Dietary Manager stated the dish machine was a low temperature machine which used a chemical to sanitize the dishes. He stated the chemical should be at 100 parts per million (ppm) and attempted to test the ppm level twice. The test strips did not activate. […]

• No harm, potential for more than minimal, patternF609Jul 9, 2026

  Based on interview, and record review, the facility failed to report allegations of abuse to the state Agency for Health Care Administration (AHCA) within the required timeframes for 2 of 5 residents reviewed for abuse, in a total sample of 15 residents, (#4 and #9).Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including gastritis, anxiety disorder, major depression disorder, and osteoarthritis. Review of the admission Minimum Data Set assessment with an Assessment Reference Date of 6/16/26 revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. […]