Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
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.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #70
Residents Affected - Some
On 11/13/23 at 2:51 PM, an interview was conducted with the family of Resident #70, who stated that the
family has purchased numerous clothing items for Resident #70 and yet he continues to not have any
clothes to wear. She stated the facility is losing his clothes and, when they purchase more, the facility will
lose them as well.
On 11/14/23 at 4:11 PM, an observation of Resident #70 revealed he was in his bed wearing a hospital
gown. At this time, the Director of Nursing (DON) was present while this surveyor conducted an observation
of the closet for Resident #70. The closet only had one suit/jacket and pants and one pair of jeans and one
pair of green khaki pants. No shirts, shoes, socks or other clothing items were observed. The DON
confirmed the resident has no clothes to wear other than what was in the closet. She also confirmed that
the resident wears the hospital gown daily.
On 11/15/23 at 09:54 AM, 12:43 PM, and 2:53 PM, Resident #70 was in his room in bed, still wearing only
a hospital gown.
On 11/15/23 at 12:20 PM an interview with Staff B, Registered Nurse (RN), revealed that there has been a
chronic issue with missing clothing so the Social Services Director (SSD) had a call and invited all the
resident's family members to participate and discuss a new laundry process for a net bag and new
processes for ensuring the residents clothing stays together during the laundry process. She stated they
also reeducated the aides to watch for families bringing in new items to ensure they get them labeled
appropriately.
Review of the resident's medical record revealed there was no resident inventory sheet.
Review of the facility policy for Personal Items Inventory, dated 10/24/22, revealed, Residents have the right
to retain and use personal belongings including but not limited to furnishing, clothing and other personal
items, as long as space permits, and it does not interfere with the rights or health and safety of other
residents. The Procedure for this policy includes entering the resident name, room number and medical
record number and the date of the inventory on the Inventory of Personal Effects Identify articles as listed,
indicating the quantity and presence with check.
Based on observations, interviews, record review and facility policy review, the facility failed to provide a
safe, clean, comfortable, and homelike environment for 4 of 26 residents sampled. (Residents #1, #46, #70
and #242)
(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 9
Event ID:
105764
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0584
The findings include:
Level of Harm - Minimal harm
or potential for actual harm
Resident #46:
Residents Affected - Some
On 11/13/23 at 12:12 PM, an interview was conducted with Resident #46. She stated the facility did not
have enough supplies to provide incontinence care and did not have enough linens. She further stated she
had personal clothing missing for months, including last week when laundry took some new clothes that
she bought and they have not been returned yet.
On 11/13/23 at 12:21 PM, an interview was conducted with Staff G, a Certified Nurse Assistant (CNA). She
stated she was aware Resident #46 had been missing clothing for 30 days. She stated laundry kept telling
her that they would find her clothes and they did not. She further stated the facility was always short on had
washcloths, towels, and linens.
A review of the facility's grievances was conducted. Resident #46's grievance stated she sent 2 church
outfits to laundry and they had not been returned. The facility's findings of the investigation stated inventory
sheets did not reflect any of the missing items and items could not be found. The Social Services Director
(SSD) and the care team will continue to work on insuring people's belongings are accounted for on the
Performance Improvement Plan (PIP).
Resident #242:
On 11/13/23 at 12:41 PM, an interview was conducted with Resident #242. She stated she was recently
hospitalized and, when she returned, her clothes were missing.
On 11/15/23 at 01:08 PM, an interview was conducted with Resident #242's mother. She stated they did
not provide an inventory sheet for her daughter on her most recent admission. She further stated she had
labeled the clothes but her clothes still ended up missing.
On 11/15/23 at 01:22 PM, an interview was conducted with Resident #242's pastor. He stated he brought in
4 pairs of pajama pants and 5 long sleeve shirts to the resident 2 weeks ago which were labeled with a
permanent marker. He confirmed those items were missing from her room. He stated Resident #242 was
not provided with an inventory sheet.
On 11/15/23 at 12:13 PM, an interview was conducted with the facility's Director of Nursing (DON). She
explained the facility's process to ensure the resident's clothes were covered. She stated the family
members or the CNA's would label the clothes, then the CNAs would ensure the inventory sheet is filled
upon admission and signed by the resident. She further stated extra clothing is added to the inventory
sheet. The DON stated the inventory sheet is uploaded to the electronic medical record (EMR). A review of
Resident #242's EMR was conducted with the DON. Resident #242 was admitted on [DATE]. The DON
confirmed there was no inventory sheet uploaded into the EMR. The DON also confirmed Resident #242
did not have a paper inventory sheet on file.
On 11/15/23 at 12:25 PM, an interview was conducted with Staff B, a Registered Nurse (RN) and unit
manager. She stated the facility was trying to remediate the issue with the inventory sheets of not being
filled and uploaded and the facility was aware there were multiple issues of clothing missing. Staff B stated
it was an ongoing issue at the facility and the facility had been working on it for months.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 2 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 11/15/23 at 12:34 PM, an interview was conducted with the Social Services Director (SSD). The SSD
reviewed Resident #46's grievance dated 10/17/23 and stated there have been issues with the facility's
clothing not being returned back to residents. The SSD further stated the facility had a recent in-service on
how to fill up the inventory sheet. The SSD stated the facility did not currently have an efficient system in
place and was aware labeling with markers was not working. The SSD stated the facility had started a
Performance Improvement Plan (PIP). Upon review of Resident #242's missing inventory sheet, she stated
the staff education had not been effective.
On 11/16/23 at 11:50 AM a review of Resident # 242's EMR and paper medical records was conducted
with Staff B, RN, unit manager. Upon reviewing, Staff B confirmed there was no inventory sheet.
On 11/16/23 at 12:28 PM, an interview was conducted with Staff F, Medical Records. She stated the
inventory sheet was part of the forms to be completed upon admission. Staff F verified Resident # 242 had
no inventory sheet uploaded into the EMR.
On 11/15/23, a review of the facility's education in-service dated 10/26/23, Labeling personal items and
completing the inventory sheet was conducted. A review was conducted with Social Services Director. SSD
reviewed resident # 242 medical record and confirmed there was no inventory sheet for resident 242. SSD
stated Medical Records was responsible of uploading the inventory forms into the Electronic Medical
Records (EMR).
A review of facility policy Personal Property-loss or theft revised 7/24/2017 was conducted. Policy stated at
admission resident's belongings will be identified and recorded.
Laundry
On 11/14/23 at 1:24 AM a tour of the laundry room was conducted with Staff C, laundry personnel. During
the tour, 1 of 2 washer machines and 1 of 2 dryers were observed to be non-operational.
On 11/14/23 at 1:30 PM, an interview was conducted with Staff C, who stated the washing machine had not
been functioning for about a year and the dryer had not been working for about 6 months.
On 11/16/23 at 10:31 AM, an interview was conducted with Staff H, a Personal Care Assistant (PCA). Staff
H stated the facility still did not have enough clean clothes to assist residents that are incontinent as of
today.
On 11/16/23 at 12:56 PM, an interview conducted with the Corporate District Manager who managed
Housekeeping and Laundry services at the facility. The Administrator was also present. The Manager stated
she had brought some towels and linens in this week. She also stated there was an issue with keeping up
with the laundry because there was only one washing machine and one dryer. The Administrator added he
had recently purchased more towels, washcloths, gowns and under pads. An invoice was reviewed and
revealed order was placed on 11/15/23 at 1:21 PM.
Resident #1
On 11/13/23 at approximately 12:40 PM, Resident #1's room was observed to have dark stains on the floor,
piles of trash bags full of trash, water damage on the walls, a broken towel rack in the bathroom and
warped floorboards. The peeling floorboards were between the bed and the window. Opened bags of briefs
were observed leaning against the wall with the water damage. During the observation, the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 3 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0584
resident stated she did not like living in such a dirty place.
Level of Harm - Minimal harm
or potential for actual harm
On 11/14/23 at approximately 3:56 PM, the residents room still had the dark stains. In addition, there was a
large spill of a red liquid on the floor and her opened bags of briefs were still leaning against the wall with
the water damage. After moving the briefs, the wall paint was observed chipping off. A pile of dirty bedding
was also observed on the floor by the foot of the bed.
Residents Affected - Some
On 11/16/23 at approximately 1:46 PM, an interview with Staff A, Licensed Practical Nurse (LPN), was
performed. When Staff A was asked about the environmental concerns of the room, she stated she was
very concerned about the briefs leaning against the wall. She stated, I do not think it is acceptable that
someone lives with her briefs touching humidity or with such a dirty floor. Staff A also stated the dark
substance on the floor could be blood, because Resident #1 pulls her scabs often and her arms bleed. Staff
A also stated that it was hard to clean in the room because Resident #1 does not like staff touching her
stuff. Staff A was asked what the process was to report items that needed to be fixed. She explained staff
need to add the issue to the maintenance log book, located at the nurses station. Immediately following the
interview, the log was reviewed. Nothing regarding Resident #1's room was noted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 4 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on record review and interview, the facility failed to provide transfer or discharge notices to 2 out of 2
resident sampled for discharge notices. (Residents#30 and #1)
Residents Affected - Few
The findings include:
A record review revealed that the facility did not provide transfer or discharge notices at the time Residents
#30 and #1 were discharged to the hospital.
An interview was conducted on 11/15/23 at approximately 2:58 PM with the business office manager. She
was asked where the transfer or discharge notices could be found, as they were not part of the record. She
stated that medical records could provide a copy.
An interview was conducted on 11/15/23 at approximately 3:08 PM with medical records. The medical
records staff stated they did not have a copy of any transfer or discharge notices for Residents #30 and #1.
An interview was conducted on 11/15/23 at approximately 4:19 PM with the Social Services Director. She
stated she is the one that sends the discharge notices to the Ombudsman. When asked for a copy of the
discharge notices for Resident #30 and Resident #1 that were sent to the ombudsman, she stated she did
not have it and has no idea where to get it. She stated she has not done those particular discharges
because she has not been in her current position for very long.
A follow up interview was conducted on 11/28/2023 at approximately 9:48 AM with the local Ombudsman
office. She verified that the facility has not been sending discharge notices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 5 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based on record review and interview the facility failed to provide bed-hold notices to 2 out of 2 resident
sampled for hospital discharge. (Residents #30 and #1)
Residents Affected - Few
The findings include:
A record review revealed no evidence that the facility provided a bed-hold notice at the time Residents #30
and #1 were discharged to the hospital.
On 11/15/23 at approximately 2:58 PM, an interview conducted with the Business Office Manager, who
stated that the facility does not do bed-hold notices. She stated, We do not do bed-hold notices for anyone,
we do not need to do that.
On 11/15/23 at approximately 3:20 PM, the Facility Administrator provided a copy of the facilities bed-hold
policy, which states, At the time of transfer to the hospital or therapeutic leave, the center will provide a copy
of notification of bed-hold.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 6 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on record reviews and interviews, the facility failed to develop a comprehensive care plans for
antibiotic use for 1 of 1 residents sampled. (Resident #34)
Residents Affected - Few
The findings include:
On 11/13/2023, a record review was conducted for Resident #34. The resident's care plan only included a
nutrition care plan. There was a baseline care plan document scanned into Point Click Care under the
Miscellaneous tab that was not legible. No evidence of a care plan related to her antibiotic use could be
located.
(photographic evidence obtained)
On 11/15/2023 at approximately 9:12 AM, an interview was conducted with the Minimum Data Set (MDS)
Coordinator. When asked about the comprehensive care plans for antibiotic use not being completed for
Resident #34, the MDS Coordinator stated she has another MDS Coordinator who comes in and helps her
and she would have been the one who did the assessment for Resident #34. The MDS Coordinator stated
she is not sure why she didn't complete the care plans and stated, Honestly, she just failed to do it. When
asked where the paper copy for the baseline care plans that was scanned could be found, she stated that
copy was probably thrown away. When asked if she could look at the care plan document scanned in, she
verbalized that the baseline care plan is not legible to her. She reached out to medical records and reported
that documents, once they're scanned into the system, are then shredded, and no copy is left in the chart.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 7 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on interviews and records review, the facility failed to develop and implement written standards,
policies, and procedures for the Infection Prevention and Control Program (IPCP) and failed to conduct an
annual review of its IPCP.
Residents Affected - Few
The findings include:
On 11/15/23 at approximately 10:50 AM, in an interview with the Director of Nursing and Unit Manager,
they disclosed that they are both recently trained in Infection Control. They stated that the facility does not
have a formal training program on Transmission Based Precautions (TBP), education is provided on a case
by case basis. Surveillance of compliance is conducted intermittently and as needed. Any cluster of 2 or
more infections are tracked and recorded. Department of Health (DOH) contact is used as a resource and
reporting is done according to their DOH guidelines.
On 11/15/23 at 12:10 PM, a review of Infection Prevention and Control Program (Revised date: October
2018) in the Quality Assurance and Performance Improvement manual with the Administrator revealed no
review of the IPCP in the past 12 months of records.
The documents provided as the facility IPCP was lacking specific Policies and Procedures for Standard and
TBP/Isolation Procedures. A monthly report of Infection control surveillance was verified in monthly QAPI
meeting.
Education In-service records were reviewed and found to include Enhanced Barrier Precautions on
7/8/2023, Isolation Covid Precautions/Donn/Doff Personal Protective Equipment (PPE) education
6/28/2023 & 6/29/2023 and Hand Hygiene In-Service on 6/28/23-6/29/2023 and 9/2/2023.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 8 of 9
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
105764
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at the Gardens - Tallahassee
1650 Phillips Rd
Tallahassee, FL 32308
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interviews and record review, the facility failed to develop, maintain, or follow policies and
procedures for immunization of residents against influenza and pneumococcal disease in accordance with
national standards of practice for 2 of 5 clinical records reviewed. (Residents #36 and #46)
Residents Affected - Few
The findings include:
On 11/15/23 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON)
and the RN Unit Manager (UM). Patient records for five sampled patients were reviewed. Of the five
residents sampled, 2 were lacking documentation of Route of Administration, amount administered,
Location given, Manufacturer's Name, expiration date or Lot number for the Influenza vaccine as required
by Facility policy. (photographic evidence obtained) The remaining 3 residents had signed refusals on file.
The DON and UM confirmed that required documentation was not in the records provided. Per the UM, a
possible secondary source of documentation could be in the pharmacy records but the missing documents
cannot be retrieved because it would be kept by the previous Contracted Pharmacy service who can no
longer provide information due to a contract change as of 11/02/2023. Only one of 5 resident charts
contained documentation of dates of vaccination for Pneumococcal and Covid Vaccines. Both the DON and
UM confirmed there was no scanned documentation in medical records of education that was provided to
the residents or health care surrogates regarding Risks/Benefits of the vaccines.
On 11/15/2023, a review of facility policy and procedure for Influenza and Pneumococcal Vaccines
indicates that For those who receive the vaccine, the date of vaccination, lot number, expiration date,
person administering, and the site of vaccination will be documented in the resident's/employee's medical
record.
The Centers for Disease Control states documentation of vaccine administration must include, at a
minimum, the date of administration, the name of the manufacturer of the vaccine, the Lot number, and the
name of person administering vaccine.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 9 of 9
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Back to topCitations
8 citations 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.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
F584 - Safe Environment
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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the November 16, 2023 survey of AVIATA AT THE GARDENS - TALLAHASSEE?
This was a inspection survey of AVIATA AT THE GARDENS - TALLAHASSEE on November 16, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVIATA AT THE GARDENS - TALLAHASSEE on November 16, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly select, install, inspect, or maintain portable fire extinguishes."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.