Aviata At Lakeside Oaks
AVIATA AT LAKESIDE OAKS in DUNEDIN, FL — inspection on August 28, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/28/25 at approximately 1:30 PM with the SSD and the Regional SSD (RSSD), the RSSD said it is the company's policy to call the resident within three days of facility discharge to confirm HHS providers showed up and DME was delivered. He confirmed the three-day post discharge phone calls were not completed for Resident #1 or Resident #10.Review of facility's policy and procedure, titled Discharge of Resident to Home or Other Center, revised 8/3/2018 showed Procedure: 1.
Upon determination by the Interdisciplinary team that resident is appropriate for discharge, the Nurse will obtain a physician's order for discharge to include:-Place of discharge-Community resources or referrals required-Status of medications on discharge (i.e.
May discharge home with med)2.
Complete the Discharge Plan.3.
The list of medications may be printed from pharmacy for resident or legal representative review and signature.
Signed copy of the pharmacy discharged Resident Medication Transfer Record is to be faxed to the number indicated on the discharge resident medication transfer record printed from the pharmacy and filed in the clinical record.5.Provide resident a copy of the Discharge Plan, and the pharmacy Medication list.6.
Document final disposition in the resident's clinical record.-Resident's goals for admission and desired outcomes, as well as preferences and potential for future discharge- Individualized interventions that honor the resident's preferences and promote achievement of the resident's goal-Interdisciplinary approaches that maintain and/or build upon resident abilities, strengths and desired outcomes.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St Dunedin, FL 34698
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 8/28/25 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that post injury, Resident # 2, was placed in a sling and with instructions to follow up with orthopedics.
The resident has not seen orthopedics yet. I will have to check with the MRC about an appointment.
The resident refuses the sling often and will not wear it. At this point, there is no follow up about his refusal.
The normal process on post-acute care orders is that the primary nurse admitting the patient back from the hospital would put the orders in or the DON or Assistant Director of Nursing could place the orders.
The facility staff would verify the orders with our physician as well.
Review of a Facility Policy titled 'Admissions Procedure' revised 8/19/18 revealed: Any new information or changes noted during the collection of data from resident and/or Responsible Party will be communicated as necessary.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Lakeside Oaks
1061 Virginia St Dunedin, FL 34698
SUMMARY STATEMENT OF DEFICIENCIES
the locked medication cart and counted every shift.
Narcotics are reviewed at the management level at least every week. An audit is performed 10 times a month. If a discrepancy is reported, then he will try to figure out how it happened. If there was a diversion found, then one of the regional supervisors would be involved in the investigation.
The DON revealed that there have not been any investigations into narcotic discrepancies in the last six months. He also has never reported narcotic discrepancies to the state board, Drug Enforcement Administration (DEA), or law enforcement. He related that training is completed during the narcotic auditing and during employee onboarding training.
Discontinued medications are placed in a two-drawer locked file cabinet until destruction.
Destruction of narcotics is completed with the Pharmacy Consultant during the monthly review. On 8/28/2025 at 10:35 a.m., an interview was conducted with the Pharmacy Consultant. He stated that he monitors the controlled substances in this facility. He tracks what is coming into the facility, checks the logs, and ensures there are two nurses' signatures. He disposes of the pulled narcotics with the DON every month.
The audit review and disposals usually occur on the first Thursday of the month. He provides a monthly report for the facility that includes any discrepancies. He notes discrepancies such as scratch marks, missing numbers, and missing signatures.
When discrepancies are identified, he also talks to the DON. He is not aware of any diversion during narcotic handling.
His last audit and report was on August 1, 2025.On 8/28/2025 at 10:50 a.m., a follow up interview was conducted with Resident #3.
The resident confirmed that she only had an issue with not receiving pain medication on that one day. Resident #3 takes pain medication every eight hours.
The resident stressed that the medication is never refused because it is needed.
The night nurses may run late with medications, but the resident usually gets it sooner or later.On 8/28/2025 at 11:43 a.m. an interview with the DON was conducted.
The discrepancies found in the sampled residents records were discussed.
The DON stated that the staff should be signing the medication narcotics sheet and the MAR.
The staff did not sign them out as given, and that is an error. He provided a copy of the monthly report. He stated actions would be planned in reference to the monthly report and education would be provided for the staff.A review of the Monthly Medication Unit Review completed on 8/1/2025 by the Consultant Pharmacist revealed a no under sections titled: Controlled substance documentation is accurate and complete, and Controlled substance inventory is reconciled according to facility procedures.A review of the facility policy and procedure titled Medication-Oral Administration of with a revision date of 08/15/2019, revealed: on page 2, when documenting in the EMAR, the nurse will document immediately prior to administration and immediately post administration based on individual professional practice of the nurse.A review of the facility pharmacy policy and procedure titled 4.0 Schedule II Controlled Substance Medication with no listed effective date, revealed: on page 4-8, Section H (5), When a controlled dangerous substance medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials.
Facility ID: