Aviata at the Gardens - Tallahassee

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Aug 4, 2022

  Based on staff and family interviews, medical record reviews, policy reviews, and police report review, the facility failed to establish and follow an effective resident identification process for 1 of 3 residents sampled for admission/discharge (Resident #1). The failure to ensure that residents admitted to the facility were correctly entered into the electronic medical record system resulted in Resident #1 being admitted under the name of a resident (Resident #3) who had been discharged from the facility over 5 years ago. Interviews with the resident's spouse revealed the resident was transferred within 24 hours of admission. Resident #1 was admitted under the wrong name and with an incorrect medication list and demographic sheet (containing emergency contact information). […]

• Immediate jeopardy, isolatedF867Aug 4, 2022

  Based on medical record review, police report review, and staff and family interviews, the facility's Quality Assurance Performance Improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to admitting and transferring a resident using the wrong resident name. This resulted in law enforcement investigating a missing person, the resident receiving the wrong medications, and being transferred to another facility with the wrong history and physical, incorrect medication list, and an incorrect marital status for 1 of 3 residents reviewed for admission/transfer (Resident #1). The situation resulted in a finding of Immediate Jeopardy at a scope and severity of J, isolated. […]

• Actual harm, isolatedF656Feb 19, 2021

  Based on observation, staff interview and resident record review, the facility failed to implement a comprehensive care plan to meet the needs of a resident for 1 of 4 residents sampled for pressure ulcers and failed to develop a comprehensive care plan for 1 of 5 residents requiring assistance with Activities of Daily Living (ADL) oral care. (Resident #4) The findings include: Pressure Ulcer On 02/12/2021 an electronic medical record review was conducted for Resident #4, a [AGE] year-old admitted into the facility on [DATE] of post-surgical rehabilitation. […]

• Actual harm, isolatedF686Feb 19, 2021

  Based on observation, staff interview and resident record review, the facility failed to prevent the development and worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident #4). The findings include: On 02/12/2021 an electronic medical record review was conducted for Resident #4, a [AGE] year-old admitted into the facility on [DATE] for post-surgery rehabilitation. The nursing assessment completed on admission included a skin assessment which identified scabbing and flaking skin on her lower extremities, no other skin concerns were identified. A review of the Weekly Skin Integrity Review reports failed to reveal skin assessments for the week of 01/10/2021 to 01/17/21. […]

• Actual harm, isolatedF692Feb 19, 2021

  Based on staff interview, observation and resident record review, the facility failed to implement dietary recommendations to ensure that residents received sufficient fluid and nutritional intake to prevent weight loss for residents identified at risk of malnutrition for 1 of 4 residents reviewed for hydration/nutrition (Resident #3) The findings include: Review of the record was conducted for Resident #3 which revealed that the Registered Dietitian (RD) had completed a Nutritional Evaluation on 01/19/2021. […]