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Complaint Investigation

Aviata At Colonial Lakes

January 16, 2025 · Winter Garden, FL · 15204 W Colonial Dr
Citations 5
CMS Rating 2/5
Beds 180
Provider ID 105440
Healthcare Facility
Aviata At Colonial Lakes
Winter Garden, FL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

AVIATA AT COLONIAL LAKES in WINTER GARDEN, FL — inspection on January 16, 2025.

Found 5 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

FF0656
Develop and implement a complete care plan that meets all the resident's needs, with timetables and

Review of the facility's Policies and Procedures revised 9/25/17 revealed an individualized person-centered plan of care would be established by the interdisciplinary team (IDT) with the resident and/or representative and updated in accordance with state and federal regulatory requirements.

The policy detailed that the care plan must be reviewed, updated and/or revised based on changing goals, preferences, and needs of the resident and in response to current interventions as needed.

The document indicated that the IDT should ensure the plan of care addressed any resident needs and that the plan was oriented towards attaining or maintaining the highest practicable physical, mental, and psychosocial wellbeing.

105440 01/16/2025

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

jeopardy to resident health or puree.

Orders and care plans were updated accordingly to reflect the texture change.

The RD followed safety up with resident #1 on 12/26/24 with no new recommendations.

meeting and to review the progress made.

They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker.

There were no issues noted.

Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks.

Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

105440 01/16/2025

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

jeopardy to resident health or residents with dysphagia diagnosis were on the correct texture diets.

The audit was completed on safety 1/14/25 with no discrepancies noted.

puree.

Orders and care plan were updated accordingly to reflect the texture change.

Registered Diet (RD) followed up with resident on 12/26/24 with no new recommendations. * On 12/24/24 the Administrator and Interdisciplinary Team (IDT), including Medical Director, met for monthly QAPI meeting and to review the progress made.

They determined that all plans that had been put in place were effective. *On 12/30/24 the RD completed the second quality review to ensure diet orders in the electronic medical record matched the meal tracker.

There were no issues noted.

Interviews conducted from 01/15/25 through 01/16/25 with 21 total facility staff who represented the dietary and nursing departments revealed they were knowledgeable of the facility's policy and procedure for dysphagia diet orders, and appropriate snacks.

Interviews conducted with nursing staff, including 9 CNAs, 2 Registered Nurses, and 3 Licensed Practical Nurses, revealed they received education between 12/20/24 and 12/25/24.

Review of resident #1's physician orders for December 2024 revealed orders for a dysphagia mechanical soft texture diet since 8/29/23.

The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10 out of 15, which indicated moderate cognitive impairment.

She had no upper or lower extremity limitations, was independent for eating, and required set up or clean-up assistance for other Activities of Daily Living (ADLs).

She was not identified as having any symptoms of a swallowing disorder but was on a mechanically altered diet which required a change in food texture or liquids.

105440

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105440 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

Review of a nursing progress note revealed a change in condition note entered on 12/20/24 at 1:30 PM, that indicated resident #1 had respiratory arrest.

The note revealed resident #1's vital signs at that time were, blood pressure 85/56, pulse 44, no respirations, oxygen saturation 71% on room air, and mental status was unresponsive.

The LPN documented that she responded immediately and noticed the resident had something in her mouth and her face was discolored.

She started the Heimlich maneuver and soggy bread material was expelled from her mouth, so they lowered her to the floor on her side and suctioned. EMS was called, oxygen was applied on the resident, and the APRN gave the order to transfer the resident to the hospital. At 2:34 PM, the LPN documented she spoke with the resident's son who said he was at the hospital with the resident.

105440

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105440 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINTER GARDEN, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVIATA AT COLONIAL LAKES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

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.