Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff/resident interviews and medical record review, the facility failed to ensure one (#182) of
twenty-five sampled residents was free from hot liquid accident/injury hazard during one (3/10/2020) of four
days observed.
Findings included:
On 3/11/2020, during medical record review for resident #182, a nurse progress note dated 3/10/2020 8:30
p.m. revealed that while a CNA (Certified Nursing Assistant) was helping the resident back into bed and
providing peri care to him, she noticed that he had a blister on his left inner thigh. When asked what
happened, he told the CNA and nurse that he spilled hot coffee on himself, and didn't think he needed to
report it to staff. The physician was notified. This note was documented by Nurse Employee A.
On 3/11/2020 at 9:00 a.m. the Dietary Manager, was asked how he and his staff maintain coffee
temperatures coming from the kitchen. He indicated that their coffee station/machine in the kitchen made
the coffee and heated water. He indicated that coffee and hot water go out on three carts to the west unit,
east unit, and dining room. He expressed that the coffee was about 160 degrees Fahrenheit when it came
out of the coffee and hot water machine. He further stated that he did not believe there was a log for the
temperatures of the coffee and water coming from the machine or when it left the kitchen. He was asked if
the coffee machine temperature could be adjusted. He said he did not believe it could. He indicated that
water came from the boiler and that maintenance adjusted the temperature from there. Further interview
with the Dietary Manager revealed he was unaware of any resident getting burned from coffee in the past
and certainly not from last night (3/10/2020). He was told that resident #182 goes out on leave of absences
and had been observed with coffee cups from various places in the community. The Dietary Manager
further confirmed that he had not been made aware of any residents getting burned with coffee.
On 3/11/2020 at 10:00 a.m., the kitchen was toured to conduct coffee and hot water temperatures. The
Dietary Manager indicated that coffee went out of the kitchen around 10:00 a.m., daily to both units and the
dining room. The Dietary Manager utilized a non-digital stick thermometer and indicated he had calibrated it
in water and ice earlier in the morning. He walked over to the coffee service machine and poured a cup of
coffee from the spigot. He tested the temperature with the thermometer. The final reading was 142 degrees
Fahrenheit. He then got a cup of hot water from the same service station machine and tested it. The final
reading was 171 degrees Fahrenheit. The Dietary Manager did not know if the temperatures were too hot
for residents and indicated that he could not adjust the temperature on the machine. He said, he believed
the water came from the facility boiler, which was
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
105132
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105132
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
adjusted by the Maintenance Director. At this time, the Dietary Manger escorted this surveyor to the
Maintenance Office where the boiler was located. The temperature gauge read at 145 - 150 degrees
Fahrenheit. An interview with a maintenance employee, Employee C., revealed the boiler that provided hot
water to the kitchen was in the laundry room. Employee C. escorted this surveyor to the laundry room
where the large boiler was located. He provided visual demonstration of where the temperature gauge was
set and read very close to 160 degrees Fahrenheit.
Employee C., the Dietary Manager and the Maintenance Director were unaware if the coffee service
machine in the kitchen had its own independent heating booster. However, in an interview with the
Maintenance Director and the Regional Dietary Manager both indicated that the water came from the boiler
in the laundry room to the coffee machine in the kitchen. The coffee machine had a setting and the ability to
boost the temperature. They further revealed that the setting on the coffee service machine could not be
adjusted by facility staff and that they would have to call the manufacturer to see if there were alternate
ways to decrease the temperature.
On 3/11/2020 at 10:45 a.m. observation of the the Regional Dietary Manager revealed that he tested coffee
temperatures for the coffee that was brought out to the main dining room. The Regional Dietary Manager
utilized a digital stick thermometer, which was calibrated earlier in the morning. He poured a cup of hot
water from the thermos station. The temperature had a final reading of 158 degrees Fahrenheit. The coffee
temperature was at a final temperature of 145 degrees Fahrenheit.
The Regional Dietary Manager indicated that the coffee service station manufacturer specified that in order
for the coffee to get a good brew, it must get to at least over 180 degrees Fahrenheit. and or higher. He
indicated he would speak with the coffee service station company and have them come out to adjust the
temperatures as it may be too hot still. But in doing so, the coffee may not brew correctly.
On 3/11/2020 at 11:20 a.m. an interview with the Nursing Home Administrator, who was also the Risk
Manager, revealed that she was just made aware of the incident that occurred last night and she was in the
process of doing an investigation. She indicated she was not communicated with verbally by the nurse,
Employee A. who documented the note of resident #182 having a blister on his leg. The Administrator
indicated that she received information about it through the kitchen staff just moments ago. This incident
was only brought to her attention as a result of this surveyor speaking to kitchen staff about resident #182
and the alleged burn.
Review of the medical record revealed resident #182 was admitted to the facility for long term care on
5/7/2012 and readmitted recently from the hospital on 3/3/2020. Review of the advance directives revealed
resident #182 was his own decision maker and had multiple family members listed as contacts.
Review of the MDS (Minimum Data Set) assessments revealed:
- 2/19/2020 (Quarterly) - Cognition/Brief Interview Mental Summary score 15 of 15, which meant the
resident was cognitively intact. Activities of Daily Living with Eating - Independent, no set up.
- 2/26/202 (Discharge) - Cognitive/Brief Interview Mental Summary score - no score but indicated memory
ok and independent with decision making skills. Activities of Daily Living with Eating - Independent.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105132
If continuation sheet
Page 2 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105132
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Other assessments included and revealed:
Level of Harm - Minimal harm
or potential for actual harm
- Functional status evaluation admission assessment dated [DATE] revealed: resident requires no
assistance with eating and drinking; no sensory impairment; no safety risks documented.
Residents Affected - Few
- Interdisciplinary Therapy Screen dated 3/12/2020 revealed:
Review of the nurse progress notes dated from 12/2/2019 through to 3/12/2020 revealed: Patient stated his
cup of hot liquids spilled due to a broken lid. Occupational Therapy observed him drinking out of cup with
lid. No spills or upper extremity tremors noted which would increase risk of spills. He is safe with hot liquids
with lid. He does not want an Occupational Therapy official evaluation at this time.
12/4/2019 8:51a.m. (Activity note) Loves gardening, loves to take care of the patio. Participates in coffee
social and some of the parties.
12/13/2020 9:52 p.m. (Activity note) Likes to drink coffee
3/11/2020 11:35 a.m. (Nurse Progress Note) Resident continues to refuse treatment much of time. Has
recently thrown staff out from room. Refuses to let this nurse assess his burn but later accepted. There are
blisters on inner thigh and intact. See non pressure wound assessment
The Change of Condition, Situation, Background, Assessment, and Recommendation, (SBAR) incident
note dated 3/10/2020, revealed: Resident spilled hot coffee on self, it wasn't reported to staff. CNA found
blister inner left thigh and reported it to nurse. Treatment: Wound care consult, Anacept gel topically daily,
until healed; Skin evaluation: Blister and Burn; No pain; Appearance: Resident spilled hot coffee on self, a
blister came afterward. Physician notified and treatment in place.
Review of the current care plans with next review date 6/8/2020 revealed the following areas, but not limited
to:
1. Requires assist with Activities of Daily Living related to a spinal injury, impaired, non ambulatory related
to paraplegia. He is able to propel himself, able to feed self, with interventions in place to include, but not
limited to: EATING: able to feed self and set up as needed.
2. Resistive to care, non compliant with care and treatment. Does not like to shower, will not off load and go
back to bed, feels he knows what is best. Often refuses wound treatments, removes dressings, will not keep
lid on coffee cup (as of 1/14/2019).
3. New care plans as of evening of 3/11/2020: Resident has impairment to skin integrity of the related burn
with interventions to include: Observe/document location, size and treatment of skin injury. Report
abnormalities, failure to heal , signs and symptoms of infection, maceration etc. to Physician, and Therapy
screen for motor function.
On 3/12/2020 at 9:32 a.m. in an interview with the DON (Director of Nursing) and the NHA (Nursing Home
Administrator) both revealed that they were now aware that resident #182 spilled coffee on his left leg and
received a burn. The DON revealed that on 3/10/2020, an aide reported to the nurse, Employee A. that a
blister was observed on resident #182's left thigh. She indicated that the resident never reported it to staff
and it was only found when the aide was assisting with the resident during
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105132
If continuation sheet
Page 3 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105132
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
care and services. The DON revealed that resident #182 was his own decision maker and was independent
with most to all Activities of Daily Living to include eating and drinking. The DON indicated that resident
#182 had never spilled hot liquids on himself before and was not assessed as unsafe with hot liquids. She
indicated that the nurse, Employee A. identified and assessed resident #182 and found a blister/burn,
reported it to the doctor, and received orders for treatment. The Administrator, who was also the Risk
Manager, revealed that it had not been brought to her attention yet, but it was less than 24 hours ago. She
confirmed that staff were still within the timeframe to report the incident to the Risk Manager. She also
confirmed that Resident #182 was not in need of a transfer to a higher level of care to include the
Emergency Room/Hospital.
The DON and Administrator revealed that they had started an immediate investigation and interviewed and
re-reassessed Resident #182. The DON and Administrator said that upon interview with resident #182, he
indicated that he had spilled some coffee from out of the cup and felt that the lid or cup was cracked. The
DON and Administrator had the cup with the plastic lid that was used by the resident. Observations
revealed the cup did not have any cracks or chips. The lid was secured tightly, also with no cracks or chips.
The only place liquid could come out was through the small sip hole. Note, Photographic evidence was
taken of the actual coffee cup used by resident #182.
The DON and Administrator both confirmed that the kitchen staff and or nursing had not logged hot liquid
temperatures prior to 3/10/2020. They indicated that there had not been a need or concern in the past and
basically were unaware that the coffee machine produced high liquid temperatures. The NHA and DON
both revealed that there had not been any other resident with skin burn injuries, related to hot liquids.
On 3/13/2020 at 9:00 a.m. and during the afternoon at 12:04 p.m. attempts were made to interview
Resident #182. He did not want to discuss his coffee burn and indicated there was Too much of a big deal
Resident #182 was pleasant with surveyor but kept changing the subject and indicated that he had been
talking with so many people about it and he was done. He started to talk about his paintings/pictures on the
wall. He was asked more than three times about the coffee spill and he indicated he did not want to talk
about it again.
On 3/10/20120 during lunch meal observations in the dining room, there were over four residents seated at
one table who directed an aide, Employee B., to reheat their coffee as it was very cold. Steam had been
observed coming off the tops of the coffee cups.
On 3/11/2020 during both the breakfast and lunch meal observations in the main dining room with six
random and interviewable residents, all indicated that the coffee temperatures were fine and that they have
never burned themselves with hot liquids.
On 3/12/2020 at 10:30 a.m. interviews with ten random residents, who were all in their rooms on the
[NAME] and East units, all indicated that they have never been burned by the coffee or water, and feel that
coffee temperatures were satisfactory. They also confirmed that they have never heard of any residents
being burned by hot liquids.
Review of the Coffee Service Station manufacturer specification manual, titled Curtis [NAME] Curtis
Company, Inc. Service Manual - ThermoPro Twin Brewer, dated with print date 9/2006, revealed the
following information:
a.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105132
If continuation sheet
Page 4 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105132
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St
Dunedin, FL 34698
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Following are Factory Settings for your G3 Coffee Brewing Systems: Brew Temperature = 200 degrees
Fahrenheit.
b.
Set up Steps to include: #5; The heating tank will require 20 to 30 minutes to reach operating temperature
(200 degree Fahrenheit.) as indicated by the READ-TO-BREW indicator. The specifications sheet continued
to indicate: Water will fill the tank approximately 2-3 minutes depending on water flow rate. When the proper
level is reached, [NAME] Curtis Heating will appear on the screen. It takes approximately 20 minutes to
reach set point temperature of 200 degrees Fahrenheit. Further, control will display, [NAME] Curtis Ready
to Brew when temperature reaches the set point 200 degrees F. Unit is now ready to brew.
The diagram grid of the specifications sheet revealed the brew temperature setting is within a range of 174
to 204 degrees F.
Review of the facility's policy and procedure titled, Re-Heating Resident Food and Beverages, with effective
date 11/30/2014 revealed:
Policy: To reduce the risk of Resident burns to hot beverages, liquids and food, and to provide guidance on
re-heating resident food and/or liquids. Staff members only are to re-heat resident food and or liquids in the
microwave to temperatures that are safe and palatable for residents.
The procedure section of this policy revealed, The staff member is to use the dial thermometer to ensure
the item or liquid reaches 165 degrees F. to prevent foodborne illness. The staff member is to use the dial
thermometer provided to ensure a maximum temperature of the item is not greater than 140 degrees F. at
the time of service.
Interview with the Dietary Manager and the Nursing Home Administrator both confirmed that hot liquids
should not go out to residents over 165 degrees Fahrenheit and that coffee should be cooled if reaches that
degree of heat or higher.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105132
If continuation sheet
Page 5 of 5
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the March 13, 2020 survey of AVIATA AT LAKESIDE OAKS?
This was a inspection survey of AVIATA AT LAKESIDE OAKS on March 13, 2020. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIATA AT LAKESIDE OAKS on March 13, 2020?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.