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 and interviews, the facility failed to provide a clean, safe and home-like environment for 11 of
94 occupied areas.
The findings include:
On 2/28/24 at 10:34, during the initial tour of the facility, the following environmental concerns were
observed:
Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains.
Occupied room [ROOM NUMBER]-B had an overhead table with exposed edges.
Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains.
Occupied room [ROOM NUMBER]-A had a fall mat with sticky tape covered with a dark brown substance.
Occupied room [ROOM NUMBER]-B had a fall mat with sticky tape covered with a dark brown substance.
Occupied room [ROOM NUMBER]-A had wall paper peeling off the wall and a patched up white substance
on the wall.
Occupied room [ROOM NUMBER] had overhead tables with the plastic rim detached, exposing particle
wood.
Occupied room [ROOM NUMBER]-A had an overhead table with edges that are chipped. Additionally, the
bed's frame is rusted.
Occupied room [ROOM NUMBER]-A had an overhead table with the plastic rim detached, exposing particle
wood.
Occupied room [ROOM NUMBER]-B had an overhead table with the plastic rim detached exposing particle
wood, and dresser also had particle wood exposed on the edges.
In the public 200 Hallway, there was an approximately 6 foot long baseboard that was detached from the
wall.
(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 3
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
02/29/2024
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
(Photographic evidence was obtained)
Level of Harm - Minimal harm
or potential for actual harm
On 2/29/24 at 12:50, a follow-up tour was conducted with the Administrator, DON and Regional Consultant.
The Administrator stated all the overhead tables and the fall mat would be replaced for new ones. The DON
stated the wall paper in room [ROOM NUMBER] would be replaced immediately. The Administrator further
stated the bed in room [ROOM NUMBER]-A would be fixed by a new one once the impending shipment
arrived. Invoices showing this bed was ordered was requested but were not provided.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 2 of 3
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
02/29/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on record review and staff interview, the facility failed to administer a medication as ordered by a
physician for 1 of 3 resident sampled for medication administration. (Resident #2)
Residents Affected - Few
The findings include:
On 2/29/24, a review of Resident #2's medical record was conducted. A physician order stated to inject
dexamethasone sodium phosphate (a medication used to treat many inflammatory and autoimmune
disorders) 8 mg intramuscularly one time only for pain related to gout. This order was dated 12/29/24 with
an end date of 12/30/24. The physician order summary was reviewed and stated it was completed. The
Resident's Medication Administration Record (MAR) revealed medication was not documented as given on
12/29/23 and on 12/30/23 documentation was signed with nurse initials BT31 with a code number 9 that
indicated see progress notes. A review of progress notes dated 12/30/23 at 00:40 AM and signed by Staff
A, a Licensed Practical Nurse (LPN) stated dexamethasone sodium phosphate injection solution
medication unavailable to administer.
On 2/29/24 at 11:22 AM, an interview was conducted with Director of Nursing (DON). She reviewed
Resident #2's medical record and stated the facility kept the medication onsite. She further stated Staff A,
LPN, should have notified and follow up with the doctor. The DON added that this omission should not have
happened.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105764
If continuation sheet
Page 3 of 3
