Inspection Report Summary
The most recent inspection on August 12, 2025, identified deficiencies related to the grievance process, timely incontinence care, and repair of a call bell light. Earlier inspections also noted issues with grievance investigations, care plan implementation for residents at risk of elopement, and medication and wound care documentation. Prior reports cited concerns with resident dignity during dining, transfer notifications, and proper catheter care, including one instance that led to hospitalization. Complaint investigations were mostly substantiated regarding grievance handling, while enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring themes around grievance processes and resident care coordination, with no clear pattern of overall improvement or decline.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding grievances and care concerns at Aviata at Bradenton nursing home.
Complaint Details
The complaint involved Resident #2's grievance about a malfunctioning call bell light that was not repaired timely, causing delays in staff response. Family members reported ongoing issues with call bell responsiveness and incontinence care delays. The grievance was documented as resolved but the issue persisted. Maintenance delays and lack of formal work orders were noted.
Findings
The facility failed to ensure a functioning grievance process for one resident, timely and consistent incontinence care for three residents, and timely repair of a call bell light for one resident. Documentation issues and delays in addressing maintenance concerns were noted.
Deficiencies (3)
Failed to ensure a functioning grievance process for one resident (#2) related to a malfunctioning call bell light.
Failed to provide timely and consistent incontinence care for three residents (#2, #3, #4).
Failed to ensure timely repair of a call bell light for one resident (#2).
Report Facts
Residents reviewed for grievances: 4
Residents sampled for incontinence care: 4
Residents affected by grievance deficiency: 1
Residents affected by incontinence deficiency: 3
Residents affected by call bell light deficiency: 1
Grievance follow-up timeframe: 14
Dates of toileting hygiene documentation reviewed: 10
Dates of toileting hygiene documentation reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Interviewed regarding Resident #2's grievance and call bell light issue |
| Maintenance Director | Maintenance Director | Interviewed regarding repair efforts for Resident #2's call bell light |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding Resident #3's ADL documentation for toileting hygiene |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding ADL documentation and maintenance issues |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding Resident #3's ADL documentation and incontinence episodes |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator (MDS), RN | Interviewed regarding ADL documentation issues |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 19, 2023
Visit Reason
The inspection was conducted to investigate complaints and grievances related to resident care and services, specifically focusing on grievances voiced by Resident #1's family member and the implementation of care plans for residents at risk for elopement.
Complaint Details
The complaint investigation focused on grievances voiced by Resident #1's family member regarding care concerns including lack of assistance with checking and changing, insufficient hydration, and inadequate response to grievances. The facility's grievance log showed some complaints were investigated and resolved promptly, but a concern documented in a nurse's progress note was not forwarded for investigation. The Social Service Director and facility management were unaware of this concern. The facility's grievance policy was reviewed and found to outline procedures for timely investigation and resolution, but implementation was inconsistent.
Findings
The facility failed to ensure grievances were properly investigated and tracked to conclusion for Resident #1, with some concerns not forwarded for investigation. Additionally, the facility failed to implement care plan interventions related to elopement risk for Residents #3 and #4, including failure to maintain wandering devices as ordered.
Deficiencies (3)
Failed to ensure a grievance was investigated and tracked through to a conclusion for one resident (#1) out of five sampled residents.
Failed to ensure care plan interventions were implemented according to orders for two residents at risk for elopement (#3 and #4) related to use of Roam Alert bracelets.
Failed to ensure a wandering device was placed on one resident (#3) out of five residents reviewed to be at risk for elopement.
Report Facts
Months of grievance log reviewed: 9
BIMS score: 5
BIMS score: 8
BIMS score: 14
Date of Roam Alert order: 2023
Date of Roam Alert order: 2023
Date of wheelchair change: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Confirmed Resident #4 was an elopement risk and should wear a Roam Alert bracelet. |
| Staff F | Occupational Therapy Assistant (OTA) | Observed Resident #3 without wandering device on wheelchair. |
| Staff D | Licensed Practical Nurse (LPN) | Resident #3's nurse who confirmed wandering device order but had not checked for it. |
| Staff G | Occupational Therapist (OT) | Confirmed no documentation of wheelchair change and no wandering device on old wheelchair. |
| Staff H | Physical Therapist Assistant (PTA) | Changed Resident #3's wheelchair on 9/13/23 and confirmed no wandering device on old wheelchair. |
| Director of Nursing | Director of Nursing (DON) | Confirmed wandering device location in elopement books and observed Resident #3 without wandering device. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided grievance policy and comprehensive care plans for review. |
| Social Service Director | Social Service Director (SSD) | Responsible for grievance investigations and confirmed some complaints were not forwarded for investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to follow its grievance policy related to a resident's missing hygiene products.
Complaint Details
The complaint involved Resident #2 reporting missing hygiene products which were not documented in the grievance log. The Director of Nursing acknowledged the issue but did not file a formal grievance. The Social Services Director, as Grievance Coordinator, was unaware of the grievance and confirmed the grievance process was not followed.
Findings
The facility failed to follow its grievance policy for one resident out of thirty by not ensuring a prompt resolution of missing hygiene products. The grievance was not documented in the facility's grievance log, and staff interviews confirmed the grievance process was not properly followed.
Deficiencies (1)
Facility failed to follow grievance policy for one resident related to prompt resolution of missing hygiene products.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to the missing hygiene products grievance and failure to file a formal grievance. | |
| Social Services Director (Grievance Coordinator) | Interviewed regarding grievance process and lack of knowledge of the resident's missing hygiene products grievance. |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening, IV fluid administration, dialysis care, medication administration, wound care documentation, and overall facility compliance with professional standards.
Findings
The facility failed to complete PASARR Level II assessments for residents with new qualifying mental health diagnoses, did not provide safe administration of IV fluids and midline catheter care, failed to communicate adequately with the dialysis center for a resident, had a medication error rate exceeding 5%, and failed to maintain accurate wound care documentation for a resident.
Deficiencies (5)
Failed to complete PASARR Level II upon new qualifying mental health diagnosis for four residents.
Failed to provide safe, appropriate administration of IV fluids and care for midline and PICC catheters for two residents.
Failed to communicate with dialysis center for one resident receiving dialysis.
Medication error rate was 7.14%, exceeding the 5% threshold, due to failure to prime insulin pens before administration.
Failed to maintain complete and accurate wound care documentation for one resident, including inappropriate sign-off on wound vac orders when device was not in place.
Report Facts
Medication administration opportunities observed: 28
Medication errors identified: 2
Medication error rate: 7.14
Midline dressing change dates: 2
Wound vac change frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Lead MDS Coordinator | Reported on PASARR completion process and lack of referrals for Level II PASARR |
| Staff C | RN, Minimum Data Set Coordinator | Observed IV catheter dressing on Resident #45 |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations and deficiencies related to IV dressing labeling, dialysis communication, insulin pen preparation, and wound care documentation |
| Staff B | Licensed Practical Nurse | Observed Resident #31's catheter and nebulizer use, and described dialysis communication process |
| Staff F | Licensed Practical Nurse, Unit Coordinator | Observed medication administration error with insulin pen for Resident #136 |
| Staff H | Licensed Practical Nurse, Unit Coordinator | Observed medication administration error with insulin pen for Resident #45 |
| Staff E | Licensed Practical Nurse | Described dialysis vital sign documentation process |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 15, 2021
Visit Reason
The inspection was conducted based on complaints and observations regarding resident care, including medication self-administration, resident dignity during dining, transfer and discharge notifications, and assistance with activities of daily living.
Complaint Details
The complaint investigation included observations, interviews, and record reviews related to medication self-administration, resident dignity, transfer notifications, and assistance with activities of daily living.
Findings
The facility failed to properly assess and monitor a resident for self-administration of nebulizer treatment, maintain resident dignity during dining, provide timely and written transfer and bed hold notifications to residents or their representatives, and ensure adequate supervision and assistance with eating for a resident with declining abilities.
Deficiencies (4)
Failed to ensure one resident was properly assessed and monitored for self-administration of nebulizer treatment.
Failed to maintain resident dignity during dining, including staff not knocking before entering rooms and standing while assisting residents with eating.
Failed to provide timely written notification of transfer and bed hold policies to residents or their representatives.
Failed to provide adequate supervision and assistance with eating for one resident during multiple observations.
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Left resident #60 unattended during nebulizer treatment and unaware of self-administration assessment. |
| Staff A | Certified Nursing Assistant (CNA) | Observed entering rooms without knocking and standing while assisting residents with eating. |
| Staff M | Licensed Practical Nurse (LPN) | Observed standing while assisting residents with eating. |
| Staff G | South Unit Manager | Confirmed staff should be seated at resident level during eating assistance and knock before entering rooms. |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed training on dignified dining and provided recent training record. |
| Staff K | Social Services | Sends notification to State Long-Term Care Ombudsman on resident transfers; unaware of other notifications. |
| Staff J | Licensed Practical Nurse (LPN) | Described process for bed hold policy notification at admission. |
| Staff Q | Certified Nursing Assistant (CNA) | Described training on dignified dining including sitting at eye level with resident. |
| Staff C | Registered Nurse (RN) | Confirmed expectations for supervision and assistance with eating. |
| Staff P | Occupational Therapist | Referred resident #45 for occupational therapy to assist with eating utensils. |
| Director of Nursing | Provided policies, confirmed lapses in notification processes, and confirmed expectations for staff supervision. | |
| Nursing Home Administrator | Confirmed lapses in providing written transfer and bed hold notifications. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 17, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards including care planning, treatment and care according to physician orders, catheter care, and prevention of infections.
Findings
The facility failed to ensure interdisciplinary team participation in care planning for multiple residents, failed to provide physician-ordered antibiotics resulting in hospitalization for one resident, and failed to ensure proper catheter insertion technique to prevent urinary tract infection for another resident.
Deficiencies (3)
Failed to ensure required Interdisciplinary Team participation in resident care planning for 13 of 28 sampled residents.
Failed to provide one resident receiving outside wound care with physician ordered antibiotics for seven days after wound debridement and bone biopsy, resulting in hospitalization for cellulitis.
Failed to ensure urinary catheter was inserted according to professional standards to prevent urinary tract infection for one observed catheter insertion.
Report Facts
Residents affected: 13
Residents affected: 1
Residents affected: 1
Days antibiotic not administered: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member J | LPN | Involved in catheter insertion with improper technique |
| Staff member G | LPN Unit Manager | Interviewed regarding wound care and catheter insertion deficiencies |
| Staff member C | RN | Worked with Resident #54 on wound care day |
| Director of Nursing | DON | Interviewed regarding wound care and medication error |
| Assistant Director of Nursing | ADON | Confirmed competency training for catheter insertion was verbal only |
| Advanced Registered Nurse Practitioner | ARNP | Interviewed regarding wound care and medication orders |
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