F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, staff interview, and policy review, the facility failed to maintain restroom faucets and over bed
tables in good condition in 5 of 16 sampled rooms. (Rooms 200, 203, 211, 403, and 405)
The findings include:
A tour of the 200 and 400 halls was conducted in the presence of the Administrator on 12/20/23 at 3:35
PM.
On 12/20/23 at 3:35 PM, it was observed that the sink faucets in rooms 200, 203, 211, 403, and 405 were
heavily tarnished. At this time, the Administrator acknowledged that the faucets were tarnished and
housekeeping had attempted to clean them, but admitted it may have made the tarnish worse. The
Administrator also observed the over bed table in room [ROOM NUMBER] B and confirmed the frame was
rusted. (Photographic evidence obtained.)
A review of the facility policy Maintenance Plan (effective 11/30/2014) revealed the following: The Company
will hire staff or contract for services to ensure the continued maintenance of the Residence. The building
and grounds will be maintained in a clean, orderly condition and in good repair either by staff or a
contracted landscaper. All equipment and furnishings will be maintained in good condition.
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 2
Event ID:
105148
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
105148
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Emerald Shores
626 N Tyndall Pkwy
Callaway, FL 32404
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 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and facility policy review, the facility failed to ensure staff do not administer expired
intravenous antibiotics to 1 of 2 sampled residents reviewed for IV antibiotics. (Resident #19)
Residents Affected - Few
The findings include:
On [DATE] at approximately 1:09 PM, an observation was made of Resident #19. During the observation,
an intravenous antibiotic bag was observed to be hanging on the intravenous pole. The antibiotic bag
displayed three stickers indicating the resident's name, the name of the antibiotic (Ertapenem), and the
prescribed dosage (1 gm/100 ml). There was a small, orange square shaped sticker located in the right top
corner of the bag indicating an expiration date of [DATE].
On [DATE], a review of Resident #19's Medication Administration Record indicated the intravenous
antibiotic was administered on [DATE] at 9:00 AM and signed off as administered by the Infection
Preventionist (IP).
On [DATE] at approximately 4:01 PM, a phone interview was conducted with the facility's Pharmacist. The
Pharmacist was given the prescription number of the expired intravenous antibiotic for validation. The
pharmacist indicated the antibiotic was delivered to the facility on [DATE] from the pharmacy. The
pharmacist confirmed that the orange sticker indicates the expiration date for the antibiotic and the
intravenous fluid the antibiotic was mixed within.
On [DATE] at approximately 10:35 AM, an interview was conducted with the Infection Preventionist (IP). The
IP confirmed she administered the expired dose of antibiotic. The IP indicated she recalled administering
the antibiotic as she was working the floor the morning of [DATE]. The IP indicated she did not notice the
expiration date on the intravenous antibiotic bag.
On [DATE], a review of the facility's policy entitled Administering Medications (revised [DATE]) indicated,
.the expiration/beyond use date on the medication label must be checked prior to administering the
medication.
On [DATE] at approximately 10:20 AM, an interview was conducted with the Director of Nursing (DON)
regarding the expired intravenous antibiotic. The DON indicated the IP should have noticed the expiration
sticker located on the intravenous antibiotic bag.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105148
If continuation sheet
Page 2 of 2
