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 Bradenton during CMS and state inspections, most recent first.
A resident with a neurogenic bladder and indwelling Foley catheter had physician orders for monthly and PRN catheter changes, behavior monitoring, and recording urine output each shift. The MAR showed a missed catheter change on the ordered monthly date with no documentation, a catheter change performed later in the month without rationale, and in a subsequent month, two catheter changes within days of each other without documented reasons. Behavior monitoring entries were largely marked as negative for behaviors without corresponding progress notes describing any behaviors. Orders to record Foley bag output were documented with non-numeric entries such as "y" and "NA" or left blank, and no alternative documentation of urine output was found in progress notes. The DON and involved LPNs confirmed these documentation gaps and inconsistencies during interviews.
Kitchen sanitation requirements were not met when surveyors observed corrosion, debris, buildup, holes in walls, a leaking faucet, and live flying insects in the chemical room. Surveyors also found undated food items in the freezer and pantry, and a nourishment pantry refrigerator with temperatures over 50 degrees containing resident food items labeled without names or room numbers.
Kitchen Pest Control Lapses: Live insects were observed in the dishwasher room and kitchen pantry, including a swarm that flew up when an equipment cart was moved and insects flying and resting on pantry shelves. A caddy in the pantry had sticky yellow residue and debris, and the DMD stated flies should not be present. The DMD and NHA were unaware of ongoing pest control and monitoring, no pest policy was provided, and vendor logs showed no fly treatment for two months.
Soiled PTAC Air Filters Not Maintained: Multiple resident room PTAC units had air filters heavily caked with dust and debris during room tours. The housekeeping director said staff cleaned resident rooms but were not responsible for PTAC filter cleaning, and the DOM said each unit had two filters that should be cleaned on a monthly basis. He also stated the maintenance logs only showed the month cleaned, not the specific date, and confirmed the filters should have been cleaned more frequently.
Inaccurate PASRR Level I Screenings: The facility failed to complete accurate PASRR Level I screenings before admission for four residents. The records showed qualifying SMI/MI diagnoses for residents with conditions including depression, anxiety, bipolar disorder, schizoaffective disorder, psychotic disorder, dementia, and Parkinsonism, but no Level II was submitted for consideration; one Level I was also inaccurate because the primary dx of dementia was not checked. An RN/MDS nurse stated she had been instructed that if a resident was not having symptoms, a Level II PASRR was not needed.
The facility failed to maintain infection control practices related to respiratory equipment storage and hand hygiene before meals. Multiple residents had uncovered nebulizer masks, CPAP masks, oxygen tubing, or other respiratory items left at the bedside, on the floor, or in a shared bathroom, despite staff stating such items should be bagged and covered when not in use. During meal service, residents were not offered hand hygiene before trays were passed, and staff and the DON acknowledged that hand hygiene was not routinely being provided.
Missing Discharge Planning Care Plan: A resident admitted for short-term rehab had no care plan problem area or interventions related to discharge planning, despite stating a goal to complete therapy and discharge to an ALF. The resident was cognitively intact and independent with most ADLs, but staff confirmed there was no current discharge planning care plan and no documentation addressing it.
Failure to provide ADL care, including bathing and nail care: Three residents had missed or inconsistent showering and unmet nail care needs. A resident with severe cognitive impairment was observed with long, soiled fingernails and had limited showers documented despite a set schedule. Another resident with HF, respiratory failure, and weakness reported no help with fingernails or showers, and a family member of a third resident stated staff did not shower the resident as scheduled and the family had to cut the nails. Records and staff interviews showed care plans called for assistance with personal hygiene, bathing, and nail care, but documentation and care delivery were inconsistent.
Missing Hearing Aids Not Properly Managed: A resident admitted with bilateral hearing aids later had one aid missing and then both aids lost. Staff notes showed hearing aids being placed in before breakfast at times, but the family reported the devices were missing, and the facility's grievance investigation found they could not be located. The record also noted the hearing aids were not added to the inventory sheet and there was no order in the system.
A resident with dementia, major depressive disorder, and mood disorder was prescribed multiple psychotropic medications, including Depakote, paroxetine, lorazepam PRN, donepezil, and Zunveyl. The care plan and psychiatry notes required monitoring for side effects and behaviors every shift, but staff could not produce behavior monitoring documentation, and the DON acknowledged that behaviors were not documented daily. The PMHNP stated the resident’s behaviors were expected to be monitored every shift because the resident was very confused.
Medication administration errors resulted in a 38.46% error rate. A resident received nebulizer treatment without the ordered pre-treatment respiratory assessment, and another resident had multiple scheduled meds given late because an LPN was completing discharge paperwork for another resident. Facility policy required meds to be given safely, timely, and within 1 hour of the ordered time unless otherwise specified.
Unattended Medications Left at Resident Bedside: A resident with trouble swallowing solids and on a liquefied diet was observed with a cup of crushed morning meds mixed in pudding left at bedside. The RN confirmed she left the meds in the room and told the resident to let them melt before she returned, and the unit manager and DON stated residents should not be left alone with medications.
Failure to honor an ordered food texture and resident meal preference: A resident with dysphagia, malnutrition, and DM had an order for puree texture with all foods in bowls and liquified per request, but repeated meal observations showed breakfast items served in a lumped or non-liquified form. Meal tickets clearly listed the liquified requirement, and staff, the RDM, and the SLP confirmed the food was not prepared as ordered.
A resident with Parkinson’s disease and severe cognitive impairment had MAR entries showing scheduled meds documented at the same afternoon time on multiple days, despite orders for three daily doses. The family reported the resident said meds were only given twice daily, while an LPN said meds were given on time but charted later and progress notes were not updated. The DON stated meds must be documented when given and that there was no policy on medication administration documentation.
Surveyors found that appropriate care was not consistently provided for residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
A resident with hemiplegia and muscle weakness experienced ongoing issues with a malfunctioning call light, resulting in delayed staff response and unmet care needs. Despite reporting the problem and being provided with a bell as an alternative, the issue persisted for weeks, and staff did not always hear the bell. Maintenance efforts were insufficient, and documentation of resolution was lacking, indicating a failure in the facility's grievance process.
A resident experienced a malfunctioning call bell light that continuously flashed and sounded for several weeks. Despite being provided with bells to ring as an alternative, the resident reported delays in staff response, and a family member confirmed the ongoing issue. Maintenance attempted repairs, but the problem persisted, and there was no formal documentation of work orders for the call bell system.
Incomplete and Inaccurate Documentation of Foley Catheter Orders and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate documentation of physician orders and related care for a resident with an indwelling Foley catheter. The resident had a history of hemiplegia and hemiparesis following cerebral infarction, personal history of UTIs, neurogenic bladder, and an indwelling Foley catheter. Physician orders and the care plan included catheter care as ordered, monitoring for signs and symptoms of UTI, and a specific order to change the Foley catheter on the 15th of every month and as needed. Review of the January MAR showed an order to change the Foley catheter on the 15th, but the MAR entry for that date was blank, and there was no progress note documenting that the catheter was changed or explaining why it was not changed on that date. A progress note on 1/29/26 documented that the Foley catheter was changed, but did not provide a rationale for changing it on that day instead of the ordered date. In February, the MAR showed that the catheter was changed on 2/12/26 by one LPN and again on 2/15/26 by another LPN, despite the monthly order specifying the 15th and as-needed changes. There was no documentation in the progress notes explaining the rationale for changing the catheter on 2/12/26 or for changing it again on 2/15/26. Interviews with both LPNs confirmed they recalled changing the catheter but could not recall the reasons for the changes. The DON confirmed that the catheter was changed on both dates based on the MAR and stated that if a nurse did not receive information in nurse-to-nurse report, they might not have known it had already been changed, indicating a lack of clear documentation and communication regarding catheter changes. Additional documentation issues were identified with behavior monitoring and urine output orders. Behavior monitoring entries in February were mostly marked “No,” with no corresponding progress notes describing what behaviors, if any, were observed, despite the order requiring documentation of specific behaviors when present. For March, the order to “EMPTY FOLEY BAG RECORD OUTPUT every shift” was documented incorrectly with a “y” on several dates instead of recording the urine output in cubic centimeters, and one shift was left blank while another was marked “NA,” with no progress notes documenting the output on those dates. The DON acknowledged that the “y” entries were incorrect, that “NA” should not have been used, and that there was no documentation of urine output in the MAR, TAR, or progress notes as required by the physician order.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
Kitchen sanitation requirements were not met when surveyors observed multiple areas of disrepair and buildup during kitchen tours with the District Manager of Dining. The dishwasher area had debris, corrosion, and white buildup on the motor and hood, corrosion on the metal counter legs, brown buildup around pipes entering the floor, debris under the dishwasher, and a small tub of transparent liquid under the counter. The wall behind the metal counter was in disrepair with holes in three locations. In the chemical room, the outside wall had a square hole where the wall met the floor with crumbling drywall and missing, broken tile, and the inside of the wall was visible. The faucet above the floor sink was leaking and could not be shut off, live flying insects were observed, and the floor sink had discoloration and black streaks and buildup.
Kitchen Pest Control Lapses
Penalty
Summary
The facility failed to ensure the kitchen was free from pests in one of three pantries observed. During a tour of the kitchen with the District Manager of Dining, live insects were seen flying in the dishwasher room. On a later tour, when the District Manager moved an equipment cart near the eye washing station, a swarm of live insects flew up from the cart. In the kitchen pantry, a small clear plastic organizer described as a caddy was observed with honey-like yellow sticky substances in multiple areas, including the plastic drawers, along with black, red, and tan debris on the drawers and face of the caddy. Live insects were also observed flying and resting on shelves in the kitchen pantry, and the District Manager stated there should not be flies in the kitchen pantry. During interview, the District Manager stated not knowing whether the kitchen had ongoing pest control and monitoring, and a requested pest policy was not provided. Review of vendor pest control logs showed the facility did not treat for flies in 11/2025 and 12/2025. The Nursing Home Administrator stated not knowing live flying insects were in the kitchen and stated there were expectations of no pest in the kitchen; the Regional Vice President stated there was no pest control policy.
Soiled PTAC Air Filters Not Maintained
Penalty
Summary
The facility failed to ensure resident equipment was maintained and sanitary when multiple resident room wall-mounted Packaged Terminal Air Conditioner (PTAC) units were observed with air filters heavily caked with dust and debris. During room tours on 1/12/2026, 1/13/2026, and 1/14/2026, soiled filters were observed in resident rooms 201, 204, 206, 207, 209, 210, 211, 212, 213, 214, 302, 303, 304, 306, 311, 104, 106, 109, 110, 115, 119, 121, 122, 127, and 131. The observations showed that the PTAC filters in two nursing units were not maintained in a clean condition. During interview, the housekeeping director stated housekeeping staff were responsible for cleaning resident rooms, but not for cleaning or maintaining the PTAC air filters, and she did not know where the filters were located. The Maintenance Director stated each resident room had a PTAC unit with two air filters that should be cleaned and maintained, and that routine cleaning should occur within a one-month timeframe. He also stated staff had cleaned some filters the day before but was unsure which ones, and the monthly maintenance sheets only documented the month the filters were cleaned rather than the specific date. He confirmed the filters should have been cleaned more frequently. The facility policy stated the physical plant and equipment would be maintained through a program of preventative maintenance and prompt action to identify items in need of repair, and that the Director of Environmental Services would follow policies regarding routine periodic maintenance.
Inaccurate PASRR Level I Screenings
Penalty
Summary
The facility failed to ensure accurate PASRR Level I screenings were completed prior to admission for four residents reviewed. Resident #10 was admitted with diagnoses including major depressive disorder, anxiety disorder, schizoaffective disorder of the bipolar type, and Parkinsonism; the Level I PASRR dated 11/21/2024 identified qualifying diagnoses for SMI and/or MI, but a Level II was not submitted for consideration. Resident #21 was admitted and later readmitted with diagnoses including Parkinsonism, mood disorder, psychotic disorder, dementia, anxiety, depression, and neurocognitive disorder with Lewy Bodies; the Level I PASRR dated 2/26/25 also revealed qualifying diagnoses for SMI/MI, and no Level II was submitted. Resident #91 was admitted with diagnoses including bipolar disorder, anxiety, and depression, and the Level I PASRR dated 11/20/24 revealed qualifying diagnoses for SMI/MI without a Level II submission. Resident #41 was admitted and readmitted with diagnoses including dementia, major depressive disorder, and mood disorder; the Level I PASRR dated 1/13/26 showed the primary diagnosis of dementia was not checked, making the Level I PASRR inaccurate, and a Level II was not submitted for consideration despite qualifying diagnoses. During interview, the RN/MDS nurse stated she was instructed that if the resident is not having symptoms, submission for a Level II PASRR is not needed.
Infection Control Deficiencies in Respiratory Equipment Storage and Meal-Time Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program related to respiratory equipment storage and hand hygiene before meals. During observations, an oxygen mask was found on the floor in Resident #117’s room, and the resident’s record showed no orders for oxygen or nebulizer use. The Unit Manager stated she was unsure how the mask got on the floor and said the resident sometimes had visitors from other residents with oxygen. Multiple residents had respiratory items left uncovered or improperly stored. Resident #27 had an uncovered nebulizer mask, Resident #102 had a nebulizer mask left uncovered at the bedside, Resident #16 had nebulizer tubing on the floor with a date on it, Resident #50 had uncovered nasal cannula tubing wrapped around a wheelchair push bar in a shared bathroom, Resident #72 had an uncovered nebulizer mask on the bedside table, and Resident #1 had uncovered nebulizer and CPAP masks on the bedside table. Staff stated respiratory items should be bagged and covered when not in use, and the facility policy for nebulizers stated the entire unit should be placed in a bag and maintained in the resident’s room. During lunch meal service in the 100 unit, staff passed trays to residents without offering hand hygiene. A CNA stated staff do not usually offer to wash residents’ hands or provide any type of hand hygiene before meals. The DON stated hand hygiene should be offered prior to meals, and the Infection Preventionist stated she was aware hand hygiene was not being provided before meals and that the facility had started providing mini hand sanitizers to staff so they could offer hand hygiene to residents.
Missing Discharge Planning Care Plan
Penalty
Summary
The facility failed to develop a care plan with problem areas and interventions related to discharge planning for Resident #8. The resident was admitted for short-term rehabilitation and, during interview, stated he believed he was at the facility for short-term care but had not been spoken to about discharge planning. He said his goal was to complete rehabilitation and possibly move to an Assisted Living Facility, but he did not know when that would happen. Review of the medical record showed he was his own responsible party, had a BIMS score of 15 out of 15, and was independent with most to all ADL tasks. Record review showed the current care plans contained no problem area related to discharge planning, and there was no documentation in the chart related to discharge planning despite the resident having been in the facility for almost four months. During interviews, the MDS Coordinator, Care Plan Coordinator, and Social Service Director all confirmed there was not a current care plan problem area for discharge planning, and the Social Service Director stated the discharge planning care plan had been overlooked. The facility policy stated that the interdisciplinary team should develop a comprehensive plan of care within seven days after completion of the comprehensive assessment and include the resident’s needs, including social services, as applicable.
Failure to Provide ADL Care, Including Bathing and Nail Care
Penalty
Summary
The facility did not ensure ADL care was provided for three sampled residents, including assistance with bathing, personal hygiene, and nail care. Resident #12, who had diagnoses including cerebrovascular disease, heart failure, gait and mobility abnormalities, need for assistance with personal care, and cognitive communication deficit, was observed on 1/12/2026 and again on 1/15/2026 with long, soiled fingernails. The resident stated staff do not help with this care. The resident’s records showed a BIMS score of 4, severe cognitive impairment, and care plan interventions requiring assistance with personal hygiene and showering, yet the task report showed only six showers in the 30-day period reviewed, with many days marked not applicable. Resident #16, who had diagnoses including acute on chronic diastolic heart failure, generalized muscle weakness, chronic respiratory failure with hypercapnia, need for assistance with personal care, and gait abnormalities, stated staff had never assisted with fingernail or toenail care and that the nails were long and not as desired. Observation showed fingernails extending beyond the fingertips with jagged edges and a soiled appearance. The resident also stated they did not receive showers on scheduled shower days, including one scheduled shower day that was missed. The MDS showed a BIMS score of 14 and indicated the resident needed partial assistance with self-care and support for showering, while the care plan listed personal hygiene as supervision or touch assist and showering as dependent with one staff assist. Resident #57’s family member stated facility staff did not shower the resident as scheduled and that the family completed the task. The family member also stated the family cut the resident’s fingernails because the facility failed to assist. The resident’s task report showed a shower schedule of Monday, Wednesday, and Friday, with no shower recorded on 1/12/2026. The resident had diagnoses including Parkinson’s disease without dyskinesia, unspecified dementia, major depressive disorder, encephalopathy, and blindness in the left eye, and the MDS showed a BIMS score of 0 with severe cognitive impairment. Interviews with staff and review of shower sheets showed inconsistent documentation of nail care needs, including toenail-related entries but no fingernail information for some residents, and the facility policy stated fingernail trimming and cleaning were part of nail care and bathing was to be provided at least twice weekly and per resident preference.
Missing Hearing Aids Not Properly Managed
Penalty
Summary
The facility failed to ensure a resident's hearing aids were consistently available and used as needed to support communication, dignity, and quality of life. Resident #72 was admitted with right and left hearing aids documented on the admission screener, and early health status notes showed staff placing the hearing aids in before breakfast. However, a later note documented that the left hearing aid was in place while staff could not find the right hearing aid, and another note again documented both hearing aids being placed in before breakfast. By August 2025, the resident's family reported that the hearing aids were missing, and the facility's grievance investigation found the hearing aids could not be located. The investigation noted the hearing aids had not been added to the inventory sheet when brought in and that there was no order for hearing aids in the system. In October 2025, the facility emailed its audiology vendor asking to add the resident to an upcoming visit because she had lost her hearing aids and needed a new pair for a while. During interview, the resident's representative stated the facility acknowledged the loss but said it would not replace the hearing aids unless the resident enrolled in audiology services and obtained a new pair.
Failure to Document Required Psychotropic Behavior Monitoring
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following the clinical standard of practice for monitoring behaviors and medication side effects for a resident prescribed psychotropic medication. Resident #41 was admitted and later readmitted with diagnoses including dementia, major depressive disorder, and mood disorder. The resident’s care plan directed staff to administer antidepressant medications as ordered and to monitor and document side effects and effectiveness every shift. Psychiatry notes also stated that the resident was being monitored for potential adverse effects from medications, drug-drug and drug-disease interactions, and changes in daily functioning, social interaction, and ability to think or concentrate. The resident’s medication orders included Depakote, donepezil, lorazepam PRN, paroxetine, and Zunveyl, with prior orders for Paxil and Seroquel discontinued. Staff stated that behavior monitoring was documented in the MAR, behavior flow sheets, or progress notes, but they were unable to produce documentation showing daily behavior monitoring for the resident. The DON reviewed the record and acknowledged that no documentation of behavior monitoring was found for the past three months and that behaviors were not documented daily. The PMHNP stated that the resident’s behaviors were expected to be monitored every shift because the resident was very confused.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5.00%. During 26 observed medication administration opportunities, 10 errors were identified for two residents, resulting in a 38.46% medication error rate. One resident received Budesonide inhalation solution by nebulizer without the ordered pre-administration assessment of lung sounds, heart rate, and respirations. The respiratory therapist picked up a nebulizer mask stored uncovered on the bedside table, prepared the medication, and administered it before checking the resident’s lungs, and then shrugged when asked why the physician’s order was not followed. A second resident had multiple scheduled oral medications administered late by an LPN. Eight medications scheduled for 9:00 a.m. were given at 10:21 a.m., including Lactobacillus, Docusate Sodium, Coenzyme Q10, Ascorbic Acid, Biotin, Amiodarone, Isosorbide Dinitrate, Sennosides, and Polyethylene Glycol. The LPN stated the medications were late because she had to complete discharge paperwork for another resident. The facility policy stated medications are to be administered in a safe and timely manner and within one hour of the prescribed time unless otherwise specified.
Unattended Medications Left at Resident Bedside
Penalty
Summary
Medications were left unattended at a resident’s bedside during administration. On 01/12/2026 at 9:30 a.m., Resident #64 was observed sitting on his bed with a breakfast tray at bedside that included a plastic medication cup containing his morning medications mixed in pudding. The resident stated the nurse had left the medications there a while ago and said, “The meds are lumpy. I cannot swallow them.” The resident also stated he had trouble swallowing solids and was on a liquefied diet. During interview, the RN confirmed she had left the crushed medications in the room for the resident and stated she told him to let the medications melt first and that she would be right back. She acknowledged she should have supervised the resident during medication administration. The unit manager stated that at no time should a resident be left alone with medications and that the nurse must stay and watch the medication administration. The DON stated that no medications should be left unattended at a resident’s bedside. Facility policy stated medications are to be administered in accordance with prescriber orders and that residents may self-administer only if determined safe by the attending physician and interdisciplinary care planning team.
Failure to Honor Ordered Food Texture and Resident Meal Preference
Penalty
Summary
The facility failed to honor one resident’s meal form and dietary order by serving meals that were not prepared as ordered. Resident #64 had diagnoses including dysphagia, protein-calorie malnutrition, muscle weakness, and type 2 diabetes mellitus. The resident’s active diet order required dysphagia puree texture with regular/thin consistency, with all food in bowls and liquified per resident request. The resident stated that if the eggs were spread out with liquid, he could eat them, but not in a lump. During multiple meal observations, Resident #64’s breakfast trays contained food items that appeared to be pulpy, scooped, or applesauce-like, but the ordered liquified consistency was not followed. The meal tickets for the resident repeatedly stated that all foods were to be in bowls and all foods liquified, and the statement was highlighted for kitchen staff. Staff interviews confirmed that the tray line was expected to review and honor the ticket instructions, and the Regional Dietary Manager and Speech Language Pathologist both confirmed the resident’s specialized liquidized-solid order and that the observed meals did not meet that texture requirement. Staff also acknowledged that the eggs and sausage biscuit needed to be liquid with water and mixed/emulsified, but the plated food was observed without liquid added.
Incomplete and Late Medication Administration Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medication administration for one resident reviewed. The resident had diagnoses including Parkinson’s disease without dyskinesia, unspecified dementia, major depressive disorder, encephalopathy, and blindness in the left eye. The resident’s MDS showed a BIMS score of 0, indicating severe cognitive impairment. The care plan identified Parkinson’s disease with a risk for neurological problems and directed staff to give medications as ordered and to monitor and document side effects and effectiveness. Review of the medication audit and MAR showed that Entacapone 200 mg and Carbidopa-Levodopa 25-100 mg, both ordered for 0900, 1300, and 1700, were documented as administered at the same time in the afternoon on multiple dates. The resident’s family member stated the resident reported receiving medications only twice in one day even though they were ordered three times daily. An LPN stated medications were given at the right time but were not charted until later and confirmed progress notes were not updated on the days medications were documented late. The DON stated there was no way to determine the actual time medications were given if they were not documented at the time of administration, and also stated the staff cannot combine documentation for medications and that there was no policy on medication administration documentation. The facility policy stated medications are to be administered in a safe and timely manner and within one hour of the prescribed time unless otherwise specified.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Ensure Functioning Grievance Process and Timely Call Light Response
Penalty
Summary
The facility failed to ensure a functioning grievance process for a resident with hemiplegia and muscle weakness, who reported that his call light was not answered in a timely manner. Observations revealed that the call light in the resident's room was continuously flashing and sounding for an extended period, and the issue persisted despite maintenance attempts to repair it. The resident and his roommate were provided with bells to ring for assistance, but both the resident and his family member reported that staff did not always hear the bells, resulting in delays in receiving help. The family member also noted that the resident's clothing was soiled due to these delays, and that he had to intervene to get staff attention. Interviews with facility staff, including the Social Service Director and Maintenance Director, confirmed ongoing issues with the call light system in the resident's room. The Maintenance Director stated that repairs had been attempted, including replacing parts and installing a new box, but the problem recurred and was not fully resolved. Documentation of efforts to address the malfunction was lacking, and the resident's grievance was marked as resolved despite the ongoing issue. The facility's grievance policy required prompt resolution and follow-up within a specified timeframe, but the persistent malfunction and inadequate interim measures indicated a failure to meet these requirements.
Failure to Timely Repair Malfunctioning Call Bell System
Penalty
Summary
The facility failed to ensure the timely repair of a malfunctioning call bell light for one resident. Observations revealed that the call bell light above the resident's door was continuously flashing and sounding for an extended period, with the issue persisting from at least 07/21/2025 to 08/12/2025. The resident and their roommate were provided with bells to ring as an alternative, but the resident reported that staff sometimes did not hear the bells, resulting in delays in response. The resident also stated that the call bell light had been malfunctioning for about a month and a half, and a family member confirmed that the issue had been ongoing for weeks, causing the resident to wait for assistance and sometimes requiring them to go into the hallway to get staff attention. A grievance was filed by the resident regarding untimely responses to the call bell, and the Social Service Director acknowledged the malfunction and the interim use of bells. The Maintenance Director reported attempts to repair the system, including replacing parts and installing a new box, but the problem recurred shortly after. There was no documentation of work orders for the call bell issue, and the Maintenance Director relied on informal observation rather than formal tracking. The ongoing malfunction and lack of timely repair led to the deficiency cited in the report.
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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 Bradenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Braden River Rehabilitation Center Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Riviera Palms Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Greenbriar Healthcare Rehabilitation And Nursing C | 1.6 mi | ★★★★★ | 0 | 0 |
| Westminster Point Pleasant | 1.7 mi | ★★★★★ | 6 | 0 |
| Manatee Springs Rehabilitation And Nursing Center | 3.9 mi | ★★★★★ | 3 | 3 |
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