Aviata At Harts Harbor
AVIATA AT HARTS HARBOR in JACKSONVILLE, FL — inspection on October 22, 2025.
Found 2 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
interventions based on Patient/Residents' risk.
Document individualized interventions in the patient/resident Care Plan and Kardex. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day.Maintain the Elopement Risk Alerts in an easily accessible location.
Complete routine elopement drills monthly and review in QAPI meeting. QAPI: Review trends of elopement drills by the QAPI team.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Harts Harbor
11565 Harts Rd Jacksonville, FL 32218
SUMMARY STATEMENT OF DEFICIENCIES
wandering behaviors noted.Care plan revised on 1/19/22 indicated that Resident #3 is an elopement risk/wanderer- wander guard in place to right ankle. exp Feb. 2026.Quarterly MDS ARD 7/26/25 - BIMS 15 No wandering (Care plan was not updated).
During an interview with Employe C Certified Nurse Assistant (CNA) on 10/22/25 at 4:35 pm, she stated that she had worked in the facility for almost 20 years and was familiar with Resident #3.
She stated that Resident #3 was independent with her care alert and oriented and able to make needs know.
She stated that resident had no exit seeking behaviors.During interview with the Administrator on 10/22/25 at 5:29 pm, he stated that he coordinated QAPI.
When asked how he ensured that the plan identified in the PIP was followed. He stated that PIP is discussed during clinical meeting conducted daily. He stated that the Elopement PIP was still ongoing and the facility was still conducing audits and training.
When asked for the weekly audits of residents at risk for elopement & elopement books, he stated that the DON was responsible to conduct the audit he confirmed that there were only three audits (Copies obtained). He stated that he did not review the audits during the September QAPI.Reviewed facility policy and procedure titled Quality Assurance Performance Improvement Program (QAPI) Document Name: PI-215 revised 10/24/25, revealed the following:Page 6: Performance Improvement Projects: The center utilizes performance improvement projects to improve a systemic problem or improve quality in absence of a problem.
Performance Improvement Projects (PIPs) are based on the centers services and resources identified in the Facility Assessment. At a minimum, the center must conduct one performance improvement project annually. a.
The PIP should focus on high-risk or problem prone areas, identified by the center.b.
The team may consist of one or more team membersc.
The team will complete the following functions: i.
Collect and analyze data. ii.
Determine Root Cause. iii.
Determine steps for resolution.iv.
Implement corrective action.v.
Evaluate effectiveness of the actions.vi.
Report progress to QAPI committee.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.