Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Tallahassee during CMS and state inspections, most recent first.
Delayed Reporting of Abuse and Neglect Allegations: The facility failed to report two allegations within the required timeframe. One involved an allegation of physical abuse that was not reported to the state agency until hours after staff became aware of it, and the other involved neglect affecting 17 residents who missed morning medications, with the report not created or submitted until well after the incident was known to the LPN, Unit Manager, DON, and Administrator. The Administrator stated the delay was due to waiting for facts and staff statements, and the Regional Nurse Consultant said the ADON failed to act and did not notify the Administrator timely.
Surveyors found that the facility did not maintain a clean and safe environment for several residents, including cracked bathroom fixtures, stained walls, a persistently dirty refrigerator that a resident could not clean due to physical limitations, unclean personal items for a bedbound resident, and a wheelchair with exposed foam. Staff interviews confirmed that CNAs were responsible for daily cleaning, and facility leadership acknowledged the issues.
A resident was not screened for safe smoking despite being observed smoking and having access to cigarettes, contrary to facility policy requiring a safe smoking assessment for all smokers. The resident's name was only informally added to the smoking list, and no documentation of a smoking screen was found in the medical record.
Two residents were found with various medications, including topical creams and nasal sprays, stored at their bedside over several days without physician orders for self-administration. These medications were not kept in locked compartments as required, and no documentation supported resident self-administration.
A resident's medical records were found to be incomplete and inaccurate, with missing documentation of wound care on multiple days and an incorrect diagnosis of morbid obesity included in the record, as confirmed by the RD.
The facility did not follow infection control protocols in multiple cases, including not posting required contact isolation signage for a resident with MRSA, placing another resident on droplet isolation without a physician order, and improper wound care technique by a CNA who reused a soiled rag during a dressing change until corrected by an RN.
A resident did not receive prescribed MS Contin 75 mg ER for several days due to the facility's failure to timely reorder and administer the medication. Pharmacy records showed no refill requests after the previous supply ended, and the MAR documented missed doses with the medication marked as unavailable. Staff acknowledged the lapse in timely reordering.
A facility failed to obtain consent for a psychotropic medication prescribed to a resident. The resident was taking Mirtazapine and Trazodone for depression, but only Mirtazapine had a signed consent. The facility's policy required consent for psychotropic medications, but the DON incorrectly stated that consent was not needed for antidepressants. The psychiatric nurse practitioner claimed to have discussed the medication's risks and benefits with the resident's representative, but no documentation was found. Additionally, PRN orders for Trazodone lacked proper justification, leading to the deficiency.
The facility's 100 hall lacked a functioning call light system, with residents using handheld bells instead. The Administrator acknowledged the system had been broken for a long time, and there was no call system in the private bathrooms. Parts for repairs had recently arrived.
A resident's DNR status was not updated in the electronic medical record due to miscommunication and procedural lapses. The SSA placed the DNR form in the advance directives book without ensuring a nurse updated the record, leading to CPR being performed when the resident was found unresponsive.
The facility was found deficient in food safety and staff hygiene standards. Observations revealed unsanitary conditions in the kitchen, including improper dish cleaning, inadequate cold storage, and personal items on food prep stations. Staff failed to document food temperatures and did not adhere to hair containment policies. The cook did not wash hands before taking food temperatures and used improper cleaning techniques for the thermometer.
Several residents experienced dignity issues due to laundry service failures and privacy breaches. A resident wore a hospital gown due to unwashed clothes, while two others faced similar clothing issues, with one arriving without personal clothing. Observations revealed unsorted laundry and staffing shortages. Another resident's privacy was compromised during toileting care, and a resident's access to personal belongings was restricted, contradicting her care plan.
The facility was found to have multiple environmental deficiencies, including cluttered and unsanitary conditions in the laundry room, hazardous spills in the main hallway, and maintenance issues in residential areas. These deficiencies were observed during a survey, highlighting the facility's failure to maintain a safe and clean environment for residents.
The facility failed to properly store and label medications across three medication carts. Unidentified tablets, unlabeled medications, and expired items were found, with improper disposal methods used by LPNs. Insulin pens and inhalers lacked necessary labeling and dates, raising concerns about their storage conditions. The DON acknowledged these issues despite previous audits.
The facility failed to provide a palatable and appropriate diet to residents, as evidenced by multiple observations and interviews. A resident with end-stage renal disease did not receive a bagged lunch on dialysis days, contrary to physician orders. Another resident reported the food as cold and unpalatable, leading to stomach upset and diarrhea. A third resident noted meals were often cold and undercooked, with missing condiments. Staff interviews revealed that residents must request condiments, which are not automatically provided.
The facility failed to maintain a sanitary dumpster area, with garbage and medical waste observed on the ground. Broken items and debris were found around the dumpsters, and garbage cans containing linens were improperly stored. The Plant Operations Manager was aware of the issues but did not take corrective actions. Facility policies on garbage disposal were not followed, resulting in the deficiency.
The facility failed to maintain kitchen and pantry equipment in safe operating condition. Issues included leaking pipes, improper dish cleaning, and malfunctioning refrigerators and freezers. The kitchen's dishwasher and refrigerator had significant maintenance problems, and pantry ice machines and refrigerators were not properly maintained. The facility's policies on equipment maintenance were not followed, leading to these deficiencies.
The facility failed to ensure accurate PASARR documentation for three residents. One resident's Level II evaluation was missing despite a diagnosis of dementia and suspected mental illness. Another resident's PASARR did not reflect multiple mental health diagnoses present in the medical record. A third resident's PASARR failed to indicate existing diagnoses of bipolar disorder and schizoaffective disorder. The facility's policy requires accurate PASARR screenings prior to admission.
A facility failed to create a comprehensive care plan for a resident with an anxiety disorder. The resident was observed calling for help and appeared anxious, but only had scheduled Trazodone without PRN medications for anxiety. The care plan lacked interventions for monitoring mood or behavior, despite a psychiatric history of depression and anxiety. A psych consult was ordered for medication management, and a psychiatric note indicated agitation related to wound care.
A facility failed to ensure accurate narcotic counts and consistency with physician orders for a resident. A discrepancy was found between the narcotic count sheet and the actual tablets present. A staff member administered medication without updating the narcotic book, leading to a resident receiving the wrong dosage due to an unawareness of a change in the physician's order.
The facility failed to consistently post nurse staffing information on the 100 and 200 halls. On two consecutive days, the required information was missing. Interviews with the responsible LPNs revealed that one assumed the task was being done by others, while the other cited time constraints, indicating that updates do not always occur at the beginning of shifts.
Delayed Reporting of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to submit incident reports within the required timeframe for two allegations of abuse and neglect. In one case, staff were aware of an allegation of physical abuse on 4/23/26 at 2:00 PM, but the Administrator was not notified until 6:30 PM that same day, and the report was not filed with the state agency until 9:05 PM. During interview, the Administrator acknowledged the report was submitted later than the required 2-hour timeframe and stated he did not recall why the reporting was delayed, noting he may have been collecting data for the report. In a second case, an allegation of neglect involved 17 residents who did not receive morning medications on 4/18/26. The investigation showed the LPN and Unit Manager were aware of the incident at 6:40 AM on 4/18/26, but the Administrator was not notified until 7:30 PM on 4/19/26. A preliminary incident report was not created until 4/20/26 at 4:11 PM, and the incident was reported to the Abuse Registry at 6:21 PM that day. The Administrator stated the facility had been working with the corporate team and waited to gather facts and staff statements, and the Regional Nurse Consultant stated the report was very late because the ADON did absolutely nothing to act on the information and failed to notify the Administrator timely.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and homelike environment in several resident rooms. In one occupied room, the bathroom toilet lid was cracked and the ceiling near the entryway had a brown, rust-like substance between the tiles. Another occupied room had brown stains and scratched paint on the wall. A small refrigerator in a resident's room contained a foul odor, spilled brown liquid, unfinished bottles of soda, and ice cream spilled throughout the freezer compartment; the resident confirmed the refrigerator had not been cleaned for a long time and was unable to clean it herself due to physical limitations. Multiple follow-up observations confirmed the refrigerator remained dirty over several days. A bedbound resident was observed with a pillow and board used to hold a cell phone, both of which had stains and organic particles that remained uncleaned over several days. Another resident's wheelchair had an armrest with exposed foam. During an interview, an LPN stated that CNAs were responsible for wiping surfaces daily and as needed. The facility's Administrator, Maintenance Director, and Housekeeping Account Manager acknowledged these issues during a tour.
Failure to Screen Resident for Safe Smoking Practices
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents by not conducting a safe smoking assessment as required by facility policy. A review of the electronic medical record for the resident revealed no documentation of a safe smoker screening. The DON stated that a smoking screen is performed on every resident upon admission and that residents who smoke are provided with education and added to a smoking list managed by activities staff. However, the DON indicated that the resident in question did not smoke and would only be screened if she chose to start smoking. Contrary to the DON's statement, an activities assistant reported observing the resident smoking and confirmed that the resident had cigarettes stored in a lockbox designated for residents' smoking supplies. Upon review, the resident's name was found handwritten at the bottom of the smoking list, suggesting a lack of formal inclusion and oversight. The facility's policy requires a safe smoking assessment for all patients electing to smoke, but this was not completed or documented for the resident involved.
Failure to Securely Store Medications at Bedside
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications for two residents, as required by professional standards. For one resident, multiple medications including medicated body powder, isopropyl alcohol, ointments, creams, and an ophthalmic solution were observed stored at the bedside table over several days, with no physician order for self-administration documented in the medical record. Similarly, another resident was found with allergy relief nasal sprays at their bedside on multiple occasions, also without any orders for self-administration or physician authorization for these medications. These observations were confirmed through direct inspection, review of the electronic medical record, and photographic evidence, indicating that medications were not stored in locked compartments as required.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was admitted with multiple diagnoses, including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and a documented diagnosis of morbid obesity. During interviews and record reviews, it was found that the resident had a wound on the left forearm requiring daily dressing changes per physician's orders. However, the Treatment Administration Record (TAR) for this wound care was left blank on several dates, indicating a lack of documentation for the required treatment. Additionally, a review of the resident's medical record with the Registered Dietitian revealed an inaccurate diagnosis of morbid obesity, as the resident had never been obese according to the RD, despite the diagnosis being present in the record.
Failure to Follow Infection Control Practices and Physician Orders
Penalty
Summary
The facility failed to follow infection prevention and control practices in several instances. For one resident with a physician order for contact isolation due to MRSA, the required contact isolation signage was not posted on the resident’s door. Instead, signage for Enhanced Barrier Precautions (EBP) was displayed, and staff did not update the signage even after reviewing the physician’s order. The Assistant Director of Nursing decided to maintain EBP signage, citing a perceived low risk of transmission due to antibiotic treatment, without consulting the physician for clarification. Facility policy required that appropriate transmission-based precaution signage be posted when such precautions are ordered. Another resident was placed on droplet isolation for COVID-19, as indicated by signage on the room door, but there was no corresponding physician order for droplet isolation in the medical record. Additionally, during wound care for a third resident, a CNA was observed reusing a soiled rag to clean the skin around a wound, contaminating the soapy water and the wound area, until corrected by an RN. These actions demonstrate lapses in following established infection control protocols and physician orders.
Failure to Timely Refill and Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer prescribed pain medication and did not timely refill pain medication for a resident requiring such services. Record review and interviews revealed that the resident did not receive her nightly dose of MS Contin 75 mg ER for several days, as confirmed by her daughter. Pharmacy records indicated that the last refill requests were made on 7/2 and 8/4, with no further requests submitted after the supply ended on 8/31. Despite documentation on the Medication Administration Record indicating the medication was given, staff acknowledged that the medication was not available and was not administered from 9/10 to 9/13. The staff also confirmed that the medication should have been reordered in a more timely manner.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for one of the psychotropic medications prescribed to a resident. The resident was taking Mirtazapine and Trazodone for depression and mood disorder. While there was a signed consent for Mirtazapine, no consent was found for Trazodone. The psychiatric notes indicated that the medication was started due to an exacerbation of depression, and the provider claimed to have discussed the risks, benefits, and alternatives, but it was unclear with whom these were discussed. The facility's policy required that consent be obtained for psychotropic medications, but the Director of Nursing incorrectly stated that consent was not needed for antidepressants. The psychiatric nurse practitioner recalled explaining the risks and benefits to the resident's representative before initiating Trazodone, but no documentation of consent was found in the resident's record. The facility's policy also required that PRN orders for psychotropic medications be limited to 14 days unless otherwise justified by the prescribing practitioner. However, there was no documentation of such justification for the PRN order of Trazodone. This lack of documentation and adherence to policy led to the deficiency identified during the review.
Inadequate Call Light System in 100 Hall
Penalty
Summary
The facility failed to maintain an adequately equipped call light system for the 100 hall of the building. During an initial tour, it was observed that all residents in the 100 hall were using handheld bells at their bedsides instead of a functioning call light system. The Administrator confirmed that the call light system had been broken for a very long time and that the bells were a temporary measure. Additionally, it was noted that there was no system for calling staff located in the private bathrooms of the residents' rooms. The Administrator mentioned that parts for the call light system had recently arrived, and repairs were expected to occur soon.
Failure to Update DNR Status in Medical Records
Penalty
Summary
The facility failed to maintain accurate and updated medical records for a resident whose code status was changed to Do Not Resuscitate (DNR) by the family. The process was initiated, and the facility assisted in obtaining the necessary doctor's signature on the same day. However, the Social Service Assistant (SSA) placed the completed DNR form in the advance directives book without ensuring that a nurse updated the electronic medical record. Consequently, when the resident was found without respirations, the electronic record still indicated a Full Code status, leading staff to initiate CPR until paramedics pronounced the resident expired. Interviews revealed a breakdown in communication and procedure adherence. The Regional Director of Clinical Services stated that the advance directives book should remain at the nurse's station and that only nurses are authorized to update orders. The LPN on duty when the DNR was received did not update the electronic record, as she had not been requested to do so and had not verified the form. The SSA assumed the nurse would update the record but did not confirm this action. This miscommunication and failure to follow protocol resulted in the resident's DNR status not being reflected in the electronic medical record at the time of the incident.
Deficiencies in Food Safety and Staff Hygiene
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a kitchen tour. The dish cleaning process was inadequate, with food particles found on supposedly clean dishes and a significant buildup of rust and limescale on the dishwasher. The kitchen environment was unsanitary, with water and food debris on the floor, rust on the garbage disposal, and personal items improperly stored on food preparation stations. Additionally, the cold food storage was compromised, with a broken thermometer in the refrigerator and a temperature reading of 60 degrees F, indicating improper cooling. Further observations revealed that staff did not follow proper food handling procedures. Personal drinks and electronic devices were found on food preparation tables, and staff failed to document food temperatures before service. The cook, Staff I, did not wash her hands before donning gloves to take food temperatures and used improper techniques to clean the thermometer between uses. The kitchen manager acknowledged these issues but stated that the staff were nervous due to the surveyor's presence. The facility also failed to enforce proper hair containment and attire policies. Staff members, including the cook and dietary aides, were observed without appropriate hair or beard nets, and the cook had long acrylic nails, which are against facility policy. The facility administrator was also seen in the kitchen without a hair net. These observations indicate a lack of adherence to the facility's policies on staff attire and hygiene, contributing to the overall deficiency in maintaining a sanitary food preparation environment.
Deficiencies in Laundry Services and Resident Privacy
Penalty
Summary
The facility failed to provide a dignified existence for several residents due to issues with laundry services and privacy. Resident #104 was observed wearing a hospital gown because she had no clean clothes, despite having a closet full of dirty laundry. The confusion between housekeeping and nursing staff regarding the responsibility for transporting and laundering personal clothing contributed to this issue. Interviews with staff revealed a lack of clarity on the process, leading to Resident #104's prolonged use of a hospital gown. Residents #65 and #116 also experienced issues with clothing. Resident #65 arrived at the facility without personal clothing and was observed wearing a patient gown throughout the survey period. Despite expressing a desire for clothes, he had not received any. Resident #116 reported having to re-wear pants due to delays in laundry processing, despite filing a grievance about missing clothes. Observations in the laundry room revealed unsorted and improperly stored clothing, with the Laundry Services Supervisor acknowledging staffing shortages and delays in processing resident clothing. Resident #41's dignity was compromised when a CNA left the bathroom door open while providing toileting care, exposing the resident to the hallway. The CNA cited space constraints and the resident's urgency as reasons for not closing the door. Additionally, Resident #120's access to personal belongings was restricted by turning her dresser and armoire to face the wall, limiting her ability to change clothes. This was done to prevent frequent clothing changes, but it contradicted the resident's care plan, which emphasized self-care and dressing independence.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in several areas, including the laundry room, main hallway, and residential areas. During a tour of the laundry services area, it was observed that the soiled laundry processing area was cluttered with linens and pillows stacked to the ceiling, some of which were on the floor. There were also large garbage disposal bins without lids between the washing machines. The Laundry Services Supervisor explained that the items on the shelves were waiting to be discarded and that the facility had been short-staffed, which contributed to the backlog of unsorted and unfolded laundry. In the main hallway, six unidentified large brown/green semi-liquid piles were observed, posing a slipping hazard. Several facility employees and a resident with a cane walked past the piles without alerting staff. The Director of Nursing was informed of the issue and stated that housekeeping would be called to clean up the piles. This incident highlights the facility's failure to promptly address environmental hazards that could endanger residents and staff. Further environmental concerns were noted during a tour, including a fallen windowsill, stained ceiling tiles, dark brown stains on privacy curtains and floors, a heavily soiled armchair, and exposed metal due to heavy wear on walls. Additionally, the shower rooms on the 100 and 200 hallways had issues such as unidentified brown matter under a shower chair and chipping/peeling paint. These observations indicate a lack of maintenance and cleanliness in the facility, compromising the safety and comfort of the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications across three medication carts, as observed during a survey. In the Split Haven medication cart, unidentified tablets were found in the drawers, and a Levemir insulin pen lacked an open date, raising concerns about its storage conditions. Additionally, Dorzolamide eye drops were found without a pharmacy label or received date. The LPN responsible for this cart disposed of the loose tablets into a sharp's container instead of using the facility's pill buster solution, which was available in the medication storage room. In the 100-hall medication cart, several unidentified tablets and a multi-dose vial of Lidocaine were found without proper labeling or dates. Symbicort inhalers and a ProAir RespiClick inhaler also lacked pharmacy labels and received dates. Insulin pens and vials were found without open dates, which is crucial for determining their storage requirements. The LPN for this cart used the pill buster for disposal when the issues were pointed out. In the 300-hall medication cart, an unidentified tablet was found, and the LPN initially planned to flush it down the toilet, contrary to the facility's policy of using the pill buster solution. Additionally, a Glucose Gel with an expired date was found. The Director of Nursing acknowledged these issues, despite previous audits by the pharmacist.
Deficiencies in Meal Service and Dietary Compliance
Penalty
Summary
The facility failed to provide a palatable and appropriate diet to residents, as evidenced by multiple observations and interviews. Resident #22, who has end-stage renal disease and is dependent on dialysis, reported not receiving a bagged lunch on dialysis days despite physician orders. Observations showed discrepancies between meal tickets and actual food served, such as receiving milk despite a 'no dairy' diet order. The kitchen manager acknowledged the issue, attributing it to staff not reading meal tickets properly and stated that condiments are provided in bulk, leaving it to nursing staff to distribute them. Resident #248 expressed dissatisfaction with the food quality, describing it as often cold and unpalatable, leading her to avoid eating facility meals. She reported experiencing stomach upset and diarrhea after consuming the food. Observations confirmed missing items on her meal tray, such as syrup and margarine, and noted that the milk was warm. Despite her complaints to staff, the issues persisted, and she opted to bring her own food. Resident #135 also reported issues with food quality, noting that meals were frequently cold and sometimes appeared undercooked. She expressed concern for other residents who might not notice these issues. Her meal tray was missing condiments, and the milk was warm, similar to Resident #248's experience. The resident also mentioned experiencing diarrhea, suspecting it might be related to the food. Interviews with staff revealed that residents must request condiments, which are not automatically provided with meals.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a safe and sanitary manner, as observed during a survey. Upon initial entrance, a moderate amount of garbage and medical waste was found on the ground surrounding two dumpsters. The first dumpster was clean, but the second had an open side access door and was surrounded by broken items, including a plastic cart, a metal cart, and a wooden table. Further observations revealed that the situation remained unchanged, with the top cover of the second dumpster left open. Additional inspections found five garbage cans alongside the building, three of which contained bags of linens from inside the facility, along with more broken items and debris. The Plant Operations Manager was interviewed and admitted awareness of the pallets and broken items behind the dumpsters. He stated that pallets were picked up weekly but could not confirm when they were last collected or if the accumulation was typical for a weekend. He also acknowledged seeing the garbage cans with linens but did not specify where they should be moved or inspect their contents. The facility's policies on garbage disposal and environmental maintenance, dated 2017, were reviewed and indicated that all garbage should be collected and disposed of safely, with the surrounding area kept free of debris. However, these policies were not adhered to, leading to the observed deficiencies.
Deficiencies in Kitchen and Pantry Equipment Maintenance
Penalty
Summary
The facility failed to maintain food service-related equipment in safe operating condition, as observed during a survey. In the kitchen, a significant amount of water was found on the floor due to a leaking sprayer nozzle and a pipe under the sink. Additionally, there was a buildup of food particles on the clean side of the dishwasher, and dishes were not properly cleaned, as they contained water, soap bubbles, and food particles. The Kitchen Manager acknowledged these issues but did not provide a satisfactory explanation for the improper cleaning process. The facility's Administrator was aware of the dishwasher concern but failed to address the leaking pipe under the sink. The walk-in refrigerator and freezer also presented issues, with water on the floor, condensation on containers, a broken inner door handle, and a broken thermometer. The temperature in the refrigerator was found to be 60 degrees F, which is above the required 41 degrees F for perishable foods. The freezer had a significant buildup of ice, and the temperature was 10 degrees F. The Kitchen Manager admitted that the refrigerator had trouble maintaining temperature during warm weather and that these issues had persisted for over a year without resolution from the administration. In the pantry rooms, one ice machine was unplugged, and another was leaking water, causing a wet floor. The refrigerators in these pantries had a large buildup of ice, indicating a lack of maintenance. The interim Plant Operations Manager was unaware of these issues, and no work orders or maintenance logs were provided to address these concerns. The facility's policies on warewashing, food storage, equipment maintenance, and ice machine sanitation were not followed, leading to these deficiencies.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Preadmission Screening and Resident Review (PASARR) for three residents. For Resident #18, a review of the PASARR dated 3/3/17 showed no evidence of a Level II evaluation, despite the resident having a primary diagnosis of dementia and suspected mental illness. The Regional Social Services Director acknowledged the absence of the Level II review, attributing it to a possible oversight during the transition to electronic records. Similarly, the Regional Clinical Director confirmed the inability to locate the Level II PASARR for this resident. Resident #62's PASARR, dated 1/18/23, did not reflect several mental health diagnoses documented in the medical record, including recurrent depressive disorders and schizophreniform disorder. The Regional Director of Social Services agreed that the PASARR was inaccurate and should have been updated. For Resident #126, the PASARR form dated 3/14/24 failed to indicate the resident's diagnoses of bipolar disorder and schizoaffective disorder, despite these being present upon admission and documented in the care plan. The Regional Social Services Director acknowledged the need for correction. The facility's policy requires PASARR screenings to be conducted and results obtained prior to admission, with updates coordinated by Social Services if necessary.
Failure to Develop Comprehensive Care Plan for Anxiety
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with an anxiety disorder. On June 17, 2024, the resident was observed calling out for help and expressing difficulty breathing, appearing anxious. Nursing staff responded by administering oxygen, but the resident continued to exhibit signs of anxiety. Interviews with staff revealed that the resident, who can become agitated, does not have any PRN medications for anxiety, only scheduled Trazodone. The resident's care plan, initiated on May 17, 2024, lacked interventions for monitoring mood, behavior, or anxiety, despite a psychiatric history of depression and anxiety. A psych consult was ordered on May 30, 2024, for medication management, and a psychiatric note from June 6, 2024, indicated the resident's mood was agitated related to wound care, although her appearance was calm.
Inaccurate Narcotic Count and Medication Error
Penalty
Summary
The facility failed to ensure the accuracy of narcotic counts and the consistency of stored narcotics with physician orders for a resident. During a review, it was found that the narcotic count sheet for a resident's Hydrocodone/APAP medication indicated 66 tablets, while only 65 tablets were present in the medication cart. Staff P admitted to administering the medication at noon but did not sign it out in the narcotic book, although it was recorded in the computerized Medication Administration Record (MAR). Further investigation revealed a discrepancy between the physician's order and the medication administered, as the order was for a different dosage of Hydrocodone/APAP. Staff P was unaware of the change in the order, resulting in the resident receiving the incorrect medication dosage.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post nurse staffing information as required. On two consecutive days, staffing information was not posted on the 100 and 200 halls. On the first day, at approximately 9:11 AM, and on the second day, at approximately 10:09 AM, the required staffing information was missing. Interviews with the staff responsible for updating the boards revealed a lack of consistent practice. Staff O, an LPN for the 100 hall, acknowledged her responsibility for updating the board but assumed it was being done by someone else. Staff N, the LPN for the 200 hall, admitted she had not updated the board that day, citing time constraints and indicating that while it is the nurse's responsibility to update the board every shift, it does not always happen at the beginning of the shift.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tallahassee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seven Hills Health & Rehabilitation Center | 0.3 mi | ★★★★★ | 7 | 0 |
| Centre Pointe Health And Rehab Center | 0.8 mi | ★★★★★ | 10 | 0 |
| Aviata At The Gardens - Tallahassee | 1.3 mi | ★★★★★ | 10 | 0 |
| Westminster Oaks | 1.4 mi | ★★★★★ | 14 | 0 |
| Tallahassee Memorial Hospital Extended Care | 2.1 mi | ★★★★★ | 0 | 0 |
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