Aviata At St Cloud
Inspection Findings
F-Tag F609
F-F609 was again identified for concerns of investigating and reporting allegations of abuse and/or neglect. As a result of the repeat citation, it was identified there was insufficient auditing and oversight of the previous mentioned citation.
On 2/18/25 at 3:55 PM, the Administrator explained she did not look at the actual grievance forms, just the grievance log brought in monthly to the Quality Assurance and Performance Improvement (QAPI) meeting.
She stated the facility's last QAPI meeting was held on 2/13/25 and the focus was the facility's new QAPI plan. The Administrator stated she was not the Administrator during the survey in December 2024 when the facility was previously cited for failure to report allegations of abuse and neglect, and could not say what was done after those concerns were found to prevent repeat deficiencies from occurring.
Review of the facility's Complaint/Grievance policy revised on 10/24/22 revealed grievances would be review by the Quality Assurance Performance Improvement Program Committee.
Review of the facility's Abuse, Neglect, Exploitation & Misappropriation policy revised on 11/16/22 read, The center will review allegations of Abuse, Neglect, misappropriation of resident property and exploitation during QAPI meetings. QAPI committee will review info including but not limited to: The thoroughness of the investigation, Protection of the resident(s), Risk factors identified, Root-cause analysis of the investigation, Systemic changes that may be required.
Review of the facility's Quality Assurance Performance Improvement Program policy revised on 10/24/22 revealed the objective was to focus on indicators of the outcomes of care and quality of life. The document mentioned the review of activities such as resident/family complaints/satisfaction. The policy read, The center will collect and monitor data from different departments reflecting its performance. The center will identify data sources and timeframes for collection. Data sources may include but are not limited to . Grievance logs . Medical record reviews .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 105888
AVIATA AT ST CLOUD in SAINT CLOUD, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.