Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Beneva during CMS and state inspections, most recent first.
Unsafe Storage of Smoking Materials: Staff failed to ensure ignition devices were stored appropriately for multiple residents who smoked and/or used oxygen. A resident with CVA, DM, seizure disorder, and anxiety kept cigarettes and a lighter in her purse, while another resident with moderate cognitive impairment and oxygen orders was observed using a lighter near staff with an oxygen concentrator at bedside. Other residents with current tobacco use also kept smoking materials in their possession, and staff reported the issue was ongoing despite repeated discussions about the smoking policy.
The facility failed to enforce its smoking policy and maintain oversight of residents’ ignition devices. Multiple residents were observed smoking while keeping cigarettes and lighters in their possession, including residents with oxygen orders and oxygen equipment at bedside. Records showed incomplete or absent smoking evaluations and missing smoking agreement documentation for some smokers. The DON stated there had been no monitoring or auditing for compliance, and the Administrator acknowledged residents were still keeping smoking supplies despite repeated discussions and resident council meetings.
A facility failed to use its QAPI program to address ongoing unsafe smoking practices involving multiple residents who smoked. Residents were observed keeping lighters and cigarettes in their possession, one resident reported missing smoking items after turning them in, and staff said the behavior continued despite repeated discussions. Two residents who smoked also had oxygen concentrators at bedside, and the DON said there was no monitoring or auditing to ensure compliance with the smoking policy. The Administrator said the issue had been discussed in QAPI, but no PI plan was put in place.
A facility failed to enforce its smoking policy for multiple residents who smoked and failed to prevent ignition devices from being kept in rooms where oxygen was used. One resident with CVA, DM, seizure disorder, and anxiety/depression was supposed to have constant smoking supervision but kept cigarettes and a lighter in her purse and room, while another resident with moderate cognitive impairment and oxygen orders was observed lighting a cigarette with a lighter and had an oxygen concentrator at bedside. Other smokers had incomplete smoking evaluations, and staff reported that residents commonly kept their own cigarettes and lighters despite the policy requiring staff storage.
A resident with a PEG tube, dysphagia, and cancer was ordered NPO with scheduled enteral feedings and flushes, but staff repeatedly observed feeding tube supplies and food items in the room. The resident was seen putting liquids into the tube himself, and an RN, LPN, unit manager, and DON confirmed he was not ordered to self-administer tube feedings and should not have a syringe in his room. The record also showed orders to remove PEG equipment and opened foods, yet these items remained present.
Unclean floor mats and room surfaces were observed in the rooms of three residents, along with a soiled water pitcher in one room. Facility policy required daily floor sanitizing and dust mopping, but staff interviews showed uncertainty about when mats were cleaned or replaced, and housekeeping leadership stated the mats should be cleaned every day and that one resident's mats appeared not to have been cleaned all week.
A resident with a stage 4 pressure ulcer, diabetes, ASHD, dysphagia, and dependence for bed mobility was not consistently turned/repositioned as ordered. Staff observations and resident/spouse interviews showed he remained on his back for long periods, the wedge was sometimes placed incorrectly, and staff did not respond appropriately to requests for turning, incontinence care, or repositioning. The DON/rehab staff noted the wedge should be placed at the lower back/hip area, but the Administrator reported no education on wedge use was available.
A resident with recurrent UTI, urinary incontinence, incomplete bladder emptying, chronic renal impairment, and CKD had an order for IV Daptomycin for 15 days, but one scheduled dose was not given because the medication was not available at the facility. The resident reported the missed dose to staff and became upset, and the record showed no documentation that the physician was notified of the missed antibiotic dose.
Failure to administer a consented pneumococcal vaccine was identified for a resident whose chart showed signed consent but no documentation that the vaccine was ever given. The DON and ICP reviewed both the electronic and paper records and could not find evidence of administration, and the DON stated the vaccine had been missed and that the facility had no policy for administering the pneumococcal vaccine.
Two dependent residents were not treated with dignity when staff repeatedly failed to answer call lights in a timely manner and did not consistently provide incontinent care. One resident with hemiparesis and hemiplegia reported being left in a soiled brief for 1 to 2 hours and said staff became upset when he kept pressing the call light; another resident reported waiting more than 45 minutes for help and feeling irritation when wet. CNA documentation showed multiple missed entries for incontinent care, and audits found call lights not answered within the expected time.
Two residents who were dependent for bathing did not receive showers as scheduled or according to their preferences. One resident with weakness and right-sided paralysis reported going days or weeks without a shower, and the CNA record showed inconsistent documentation, including bed baths, no care entries, and N/A on scheduled shower days. Another resident with intact cognition and ADL deficits related to decreased mobility, chronic pain, lymphedema, and leg weakness said she had not had a shower in several weeks, while CNA documentation also showed bed baths and N/A entries instead of showers. The Administrator said there was no policy on ADL care or bathing and staff were expected to follow the shower schedule.
A facility failed to maintain compliance with resident dignity and dependent care needs when call lights were not answered timely and incontinent care and scheduled showers were missed or inconsistently documented. One resident reported waiting 15 minutes to an hour for help when wet, while another was observed with overgrown fingernails, facial hair growth, and no clear staff awareness of shaving, nail care, or turning needs.
Failure to Timely Report Allegation of Physical Abuse: A resident with Parkinson's disease, dyskinesia, and anxiety alleged that a CNA hurt her arm while assisting her with toileting. Staff interviews showed the allegation was reported to the ADON, DON, and Administrator the next morning, but the report was not submitted to AHCA within the required 2-hour timeframe and was filed the following day.
An LPN left the 300-hall medication cart unlocked, unattended, and unsecured for several minutes while going to gather supplies for a resident. The cart was observed unlocked as residents and staff passed by, despite facility policy stating medication carts must be locked when out of sight or unattended.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not adequately implemented to stop new ulcers from developing.
Unsafe Storage of Smoking Materials
Penalty
Summary
The facility failed to implement processes to prevent avoidable accidents by not ensuring the appropriate storage of ignition devices for 6 of 23 residents who smoked tobacco products and/or used oxygen. Surveyors identified that residents were keeping lighters and cigarettes in their rooms or personal belongings, despite the facility policy stating that matches, lighters, and similar items were to be retained and stored by the center for all residents. The unsafe practice was cited as an Immediate Jeopardy and was linked to the presence of oxygen in resident rooms. Resident #9, who had a history of CVA, diabetes mellitus, seizure disorder, and depression with anxiety, was cognitively intact and used tobacco. She reported keeping cigarettes and a lighter in her purse and storing them in her room, despite knowing they were supposed to be turned in to the nurses' station. She was later observed leaving her room with her purse and handing a pack of cigarettes and a lighter to the Director of Patient Experience. Her record showed a smoking care plan requiring supervision and a smoking apron, but the last smoking evaluation was dated 11/23/23 and contained conflicting information, including that she was a safe smoker requiring constant supervision. Resident #71, who had moderate cognitive impairment and an order for oxygen at 2 liters as needed, was observed using a red lighter to light a cigarette in the presence of staff, and an oxygen concentrator was observed at the bedside later that day. His care plan identified him as a smoker requiring supervision, but it did not address his known violation of the smoking policy regarding storage of ignition devices. Resident #106, who had oxygen orders at 2 liters as needed and continuously, was observed entering the smoking area with cigarettes in her purse; the record lacked documentation of a smoking evaluation to identify unsafe smoking practices or determine supervision needs. Resident #26, Resident #43, and Resident #67 also had records showing current tobacco use and signed smoking agreements or smoking evaluations, but their evaluations did not address safe storage of ignition devices, and staff interviews confirmed that several residents routinely kept cigarettes and lighters in their possession despite repeated discussions about the smoking rules.
Unsafe Smoking Oversight and Ignition Device Control
Penalty
Summary
The facility administration failed to provide effective oversight and enforcement of safe smoking practices. The Administrator and DON both stated that concerns about residents keeping smoking supplies in their possession had been brought to their attention after they began working at the facility, and the report states this failure resulted in Immediate Jeopardy for all 101 residents in the single-story building. The Administrator’s job description required her to direct day-to-day operations, ensure a safe environment, and develop and implement policies and procedures necessary for quality care. The DON’s job description required her to plan, organize, develop, and direct nursing services and maintain and guide implementation of current policies and procedures. The facility policy titled Smoking-Supervised required residents who smoke to be evaluated on admission, re-admission, quarterly, and with a change in condition to determine whether assistance or supervision was needed. The policy also stated the center would retain and store matches, lighters, and similar items for all residents, and that residents would sign an agreement to follow smoking rules. The facility’s current smoker list identified six residents as smokers. Review of records showed one resident had a smoking evaluation last completed in November 2023 and was determined to be a safe smoker requiring constant supervision, while another resident had no smoking evaluation documented since admission in March 2024. Survey observations showed multiple residents smoking while keeping or accessing lighters and cigarettes themselves. One resident said her cigarettes and lighter had gone missing when turned into the nurses’ station and later was observed retrieving a pack of cigarettes and a lighter from her room. Another resident was observed in the smoking area with a lighter he would not give to staff and then used a red lighter to light a cigarette; that resident also had an oxygen order and an oxygen concentrator was observed at bedside. A third resident was observed smoking after staff lit a cigarette taken from her purse; that resident also had oxygen orders and an oxygen concentrator at bedside. Staff reported that several residents kept cigarettes and lighters in their possession, that residents refused to give them up, and that there had been times when as many as 17 residents were smoking at once, making close supervision difficult. The DON stated there had been no monitoring or auditing to ensure compliance with the smoking policy, and the Administrator acknowledged residents were keeping smoking supplies despite repeated discussions and resident council meetings about the rules.
QAPI Failure to Address Unsafe Smoking Practices
Penalty
Summary
The facility failed to have an effective QAPI program to address known unsafe smoking practices involving six residents who smoked tobacco products. The deficiency was tied to the facility’s failure to develop corrective actions for the safe storage of ignition devices and to its continued allowance of residents who used oxygen to keep lighters in their rooms. The report states this created a significant, avoidable fire safety risk affecting all 101 residents in the single-story facility and resulted in an immediate jeopardy determination. The facility’s QAPI policy stated that the program should be comprehensive, data-driven, and used to identify underlying causes of problems, develop corrective actions, and review effectiveness. The smoking policy stated that residents who wished to smoke would be evaluated on admission, readmission, quarterly, and with a change in condition, and that the center would retain and store matches, lighters, and similar items for all residents. The facility’s list of current smokers included six residents, and interviews and observations showed ongoing unsafe smoking practices among them. Resident interviews and observations showed that one resident reported missing cigarettes and a lighter after turning them in to the nursing station and said the concern had not been addressed, while another resident was observed with a red lighter in the designated smoking area. A staff member stated that several residents were known to keep lighters and cigarettes in their possession and that administration had discussed the smoking rules many times, but residents continued the behavior unless something was enforced. Observations also showed oxygen concentrators at the bedside of two residents who smoked. The DON stated the smoking concerns had been ongoing since she began employment and that there had been no monitoring or auditing to ensure compliance with the smoking policy. The Administrator said the unsafe smoking practices were discussed in a QAPI meeting, but no performance improvement plan was put in place, and she had not revoked smoking privileges for anyone.
Smoking policy not enforced; ignition devices kept by residents using oxygen
Penalty
Summary
The facility failed to implement and enforce its supervised smoking policy for six sampled smokers and failed to prohibit the storage of ignition devices around oxygen use for two sampled residents. The smoking policy stated that residents who smoke would be evaluated on admission, re-admission, quarterly, and with a change in condition to determine whether assistance or supervision was required, and that the center would retain and store matches, lighters, and similar items for all residents. The smoking agreement also stated that violations of the smoking policy could result in remedial action, and each smoker signed the agreement acknowledging the safety rules. Resident #9 had diagnoses including CVA, diabetes mellitus, seizure disorder, and depression with anxiety, and was documented as requiring constant supervision while smoking. During interview, the resident stated she kept cigarettes and a lighter in her purse and stored them in her room because the items had gone missing when she turned them in. She was later observed leaving her room with her purse, entering the smoking area, and handing cigarettes and a lighter to the Director of Patient Experience. Resident #71 had moderate cognitive impairment, used oxygen as needed, and was also documented as requiring constant supervision while smoking. The resident was observed lighting a cigarette with a red lighter he had with him, and an oxygen concentrator was observed at his bedside. Resident #106 had orders for oxygen at 2 liters as needed and continuously, but the clinical record lacked documentation of a smoking evaluation to identify unsafe smoking practices or determine whether assistance or supervision was required. Resident #26, Resident #43, and Resident #67 were all current tobacco users with smoking agreements on file, but their smoking evaluations did not include safe storage of ignition material. Interviews with staff showed that residents were known to keep cigarettes and lighters in their possession, that staff could ask for them but could not take them away, and that several residents would come to the smoking area with their own supplies. The Administrator, DON, and Unit Manager acknowledged issues with residents keeping smoking supplies and stated that smoking assessments were not consistently completed or tracked. The report also noted that management had no documentation that rounds identified unsafe storage of ignition devices in residents' rooms where oxygen was stored and used.
Failure to Follow PEG Tube Feeding Orders and Remove Feeding Supplies
Penalty
Summary
The facility failed to follow physician orders for enteral feeding supplies and tube-feeding care for one resident with a PEG tube. The resident was admitted with malignant neoplasm of the tongue, dysphagia, severe protein-calorie malnutrition, COPD, and later had a BIMS score of 12. Physician orders dated 10/5/25 directed the resident to be NPO and to receive Nutren 2.0 via PEG tube six times daily with ordered water flushes. The care plan documented that the resident required tube feeding related to dysphagia and cancer, and later notes documented that the resident did not cooperate with care and had a history of self-feeding. During multiple observations, the resident’s overbed table and bedside area contained a PEG tube syringe, water pitchers with dark liquid, cartons of Nutren, milk, and other cups with light brown liquid. The bedside table also contained a basin with pudding, sardines, chicken broth, and canned sausages. Similar items were observed again on later dates, including a feeding tube syringe on the bed and dark liquid in water pitchers. The clinical record also included orders to remove PEG equipment from the bedside every shift and to remove opened foods from the room when out of date, but the observations showed feeding tube supplies and food items remained in the resident’s room. Staff interviews confirmed the resident was putting liquids into his feeding tube himself and that he was not supposed to have a syringe in his room. An RN stated the resident said he was using a mixture of feeding formula and coffee and that she signed for a feeding she did not administer. An LPN said the resident was NPO, should not have a syringe in his room, and was giving himself formula. The DON and unit manager stated staff had been removing food and feeding supplies but that something was missed, and the DON confirmed there was no documentation of a self-administration assessment for tube feedings and no physician order allowing the resident to administer his own feedings.
Unclean floor mats and room surfaces
Penalty
Summary
The facility failed to provide a clean and sanitary environment for three sampled residents: Resident #82, Resident #41, and Resident #59. Facility policy titled "5-Step Room Cleaning" stated that the entire floor must be dust mopped, especially behind dressers and beds, and that the floor is the most important area of a patient's room to disinfect and must be sanitized daily. During a tour of the facility, two floor mats in Resident #82's room were observed covered with an unclean black substance. During the same tour, two floor mats in Resident #41's room were observed covered with an unclean black substance, and a soiled water pitcher was observed on the overbed table. In Resident #59's room, one floor mat and the floor were observed covered with a brown, sticky substance. In interviews, an LPN unit manager said housekeeping was responsible for cleaning and that nursing staff would stand soiled mats up and use sanitizer wipes if they saw them dirty. The floor technician said housekeeping was supposed to move the floor mats and clean the mats and floor every day, and the housekeeping manager said the mats should be cleaned every day and that Resident #82's mats should have been cleaned all week but appeared not to have been.
Failure to Reposition and Use Wedge Correctly for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a pressure ulcer. The resident had diagnoses including type 2 diabetes mellitus, atherosclerotic heart disease, dysphagia, need for assistance with ADLs, and a cardiac pacemaker. The clinical record showed a stage 4 pressure ulcer of the left ischium/buttocks, and the care plan and CNA Kardex directed staff to reposition/off load the torso as ordered/tolerated, use a foam wedge, turn every 2 hours, and avoid lying on the left side. During observations, the resident repeatedly stated that staff were not coming to turn him every 2 hours as required. He was observed lying on his back with a wedge positioning device placed under the left upper back on one occasion, and later with the wedge on the right side of the upper back. The resident’s spouse, who was also his roommate, confirmed staff had not been turning him every 2 hours. The Director of Rehabilitation stated the wedge should not be under the wound and should be placed at the lower back/hip area, with the ideal position being on the side. The resident and spouse continued to report that he was spending the night on his back and that no one was coming in to turn him. On another observation, the resident was scooted down in bed on his back, his head was resting on the side rail, and the call bell was activated while several staff walked past the room without answering it. The spouse reported repeated requests for help with turning, changing due to incontinence, and pulling the resident up in bed, but said the CNA did not understand her requests. When another CNA assisted, she had to show the assigned CNA how to turn and reposition the resident using the wedge. The Administrator stated there was no education available on the use of the position wedge.
Missed IV Antibiotic Dose for Resident with UTI
Penalty
Summary
The facility failed to administer an ordered IV antibiotic for Resident #90, who had diagnoses including recurrent UTI, urinary incontinence, incomplete bladder emptying, chronic renal impairment, and chronic kidney disease. The clinical record showed an order for Daptomycin IV solution, 300 milliliters daily for 15 days, to treat a UTI. A physician progress note documented that the resident had been started on IV Daptomycin and had a PICC line placed in the left arm, with complaints of pain and bleeding at the IV insertion site and follow-up planned with Infectious Disease. During observation, the resident stated she was receiving IV antibiotics for a kidney infection and later became upset when she reported she did not receive her 2:00 p.m. dose. The LPN told her the medication could not be given because only one of the medications was available and the other was not present. The resident’s progress note documented that the medication was not at the facility and was ordered by the writer. The record did not show documentation that the physician was notified of the missed antibiotic dose, and the DON confirmed there was no such documentation.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident who had consented to receive the pneumococcal vaccine actually received it unless medically contraindicated. Record review for Resident #5 showed an informed consent for the pneumococcal vaccine dated 11/30/25, with the resident indicating consent to receive the vaccine, but the chart did not contain documentation that the vaccine had been administered. During an interview on 1/8/26, the DON reviewed the electronic record and could not find documentation that the vaccine had been given, and the ICP also checked the hard paper chart without finding any record of administration. Neither the DON nor the ICP could explain why the consented vaccine had not been given, and the DON stated that it had been missed. The DON also stated that the facility did not have a policy for administering the pneumococcal vaccine.
Delayed Call Light Response and Missed Incontinent Care
Penalty
Summary
The facility failed to ensure that two dependent residents were treated with dignity by not responding timely to call lights and by not providing incontinent care to meet their needs. One resident, admitted with weakness, right-sided hemiparesis, and hemiplegia, was dependent for toileting, dressing, and bathing and was always incontinent of bowel and bladder. The resident stated staff often did not answer the call light after 5:30 p.m. to 6:00 p.m., sometimes turned it off and said they would return but did not, and that he had to sit in a soiled incontinent brief for 1 to 2 hours. He also reported staff became upset when he kept pressing the call light and that he had fallen trying to take himself to the bathroom. A second resident, who was dependent on staff for incontinent care, personal hygiene, and bathing, stated staff sometimes took more than 45 minutes to answer the call light and that when she was wet she felt irritation because staff did not come to change her. Review of CNA documentation showed multiple dates with no documented incontinent care for both residents, including several day, evening, and night shifts. The Administrator stated the facility had no policy on call light response time or incontinent care and said the expectation was to answer call lights within 5 minutes. The grievance log and complaint documentation also reflected repeated concerns about delayed call light response, and call light audits showed instances where lights were not answered within 10 minutes.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide assistance with showers as outlined in the residents’ care plans and according to their preferences for 2 dependent residents. Resident #900 was admitted with weakness, right-sided hemiparesis, and hemiplegia, and the admission MDS showed the resident was dependent for toileting, dressing, and bathing, with intact cognitive skills for daily decision-making. The resident stated he did not receive his scheduled showers and reported going days, even weeks, without a shower. The resident pointed to a posted shower schedule showing showers were to occur on Wednesday and Sunday during the 7:00 a.m. to 3:00 p.m. shift, but the CNA documentation for September and October 2025 showed shower days listed as Thursday and Sunday, with bed baths documented on some scheduled shower days, no documentation of care on other scheduled days, and N/A entered for shower on two dates. Resident #800 had an annual MDS showing intact cognition and dependence on staff for incontinent care, personal hygiene, and bathing. The care plan identified an ADL self-care performance deficit related to decreased mobility, chronic pain, lymphedema, and lower extremity weakness, with a goal that the resident would receive appropriate staff support with ADLs. The resident stated she liked to shower and have her hair washed but had not received a shower in several weeks. CNA documentation showed shower days were Monday and Thursday on the 7:00 a.m. to 3:00 p.m. shift, but the record reflected bed baths on multiple scheduled shower days and N/A documented on another date. The Administrator stated the facility had no policy on ADL care or bathing and that staff were expected to follow the shower schedule, and a CNA stated there was a shower list at the desk and residents would let staff know if they wanted a shower.
Failure to Provide Timely Call Light Response and Basic Dependent Care
Penalty
Summary
The facility failed to maintain ongoing compliance after previously cited deficiencies related to resident dignity and care needs. During the recertification and follow-up survey, surveyors found that dependent residents were not consistently answered timely when using call lights and were not consistently provided incontinent care or scheduled showers. One resident stated that call lights were often left unanswered for 15 to 30 minutes and sometimes up to an hour, and that when she was wet she did not like having to wait. Review of CNA documentation showed missed scheduled showers and instances where bed baths were provided instead of the scheduled showers. A second resident was observed with long fingernails extending about 1/2 inch past the fingertips, brown substance under the nail beds, and facial hair growth of about 3 days. The resident said the fingernails were painful because they cut into his left hand due to a contracture, that he did not have a splint, and that nothing was placed in his hand to prevent pressure. He also reported a wound on his left buttocks acquired at the facility that required two surgeries after an infection to the bone. A CNA assigned to the resident said he did not know about shaving, nail care, or repositioning/turning needs, and a unit manager stated he did not know when CNAs were supposed to shave or cut fingernails.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the Agency for Health Care Administration within the required 2-hour timeframe for one resident. The resident had an admission date of 7/9/25, diagnoses including Parkinson's Disease with dyskinesia and anxiety, and a Quarterly MDS assessment dated 9/30/25 showing a BIMS score of 15, indicating intact cognition. The care plan initiated on 10/1/25 documented that the resident required supervision or touching assist with one staff member for bed-to-chair and toilet transfers. The resident stated that during the night of 10/5/25, a CNA hurt her arm while assisting her to the bathroom, and she reported the incident to CNA Staff H on 10/6/25. Staff interviews showed the allegation was reported up the chain that morning, with the ADON stating she informed the Administrator on 10/6/25 at about 9:00 a.m., and LPN Staff I stating she reported it to the DON at about 8:30 a.m. The facility investigation documented that staff became aware of the incident on 10/6/25 at 12:00 p.m. and that the Administrator was notified at 2:07 p.m. The incident was not reported to AHCA within 2 hours after the allegation was made; the report was submitted on 10/7/25 at 1:07 p.m. The Administrator acknowledged that the allegation of physical abuse should have been reported within 2 hours and was not.
Unlocked Medication Cart Observed Unattended
Penalty
Summary
The facility failed to ensure medications were kept locked in 1 of 4 medication carts observed when not in use and under direct supervision. Review of the facility policy, Medication Dispensing System, stated that medication carts are always to be locked when out of sight or unattended. During a tour of the facility, the 300-hall medication cart was observed unlocked, unattended, and unsecured for approximately 4 minutes while residents and staff passed by. When the Licensed Practical Nurse returned, she stated she had gone to gather supplies for a resident and verified that she had left the medication cart unlocked and unattended for several minutes.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Harborview Sarasota | 1.6 mi | ★★★★★ | 15 | 0 |
| Sarasota Point Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Aviata At Sarasota | 1.9 mi | ★★★★★ | 4 | 0 |
| Vivo Healthcare Meadows | 2.1 mi | ★★★★★ | 2 | 0 |
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