Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Brentwood during CMS and state inspections, most recent first.
A resident's representative was not promptly notified after the resident sustained a fall. Documentation showed missing contact information, and interviews confirmed that the family only learned of the incident after observing injuries during a visit and contacting the unit manager. Facility policy requires immediate notification of such events, but this was not carried out.
Two residents did not receive restorative nursing care as recommended by therapy upon discharge, due to the absence of a restorative nursing program. The DON and Rehabilitation Director confirmed the lack of restorative services, despite facility policy requiring such care to maintain or improve residents' range of motion and mobility.
A resident with diabetes and other complex conditions had a significantly elevated Hemoglobin A1C result, but there was no documentation that the physician was notified of this critical lab finding. Insulin management orders were made much later, and both the DON and physician confirmed the result was not communicated in a timely manner.
A resident receiving hemodialysis was not accurately documented as such in the MDS assessment, as Section O for special treatments was not checked. Both the DON and the MDS RN confirmed the resident was a dialysis patient and that the assessment should have reflected this.
A resident with physician-ordered parameters for Midodrine HCl to treat hypotension did not receive the medication despite blood pressure readings that met the criteria for administration. The MAR showed no documentation of the medication being given, and interviews with an LPN and other staff confirmed the omission and lack of adherence to the physician's order.
The facility did not maintain accurate or complete medical records for three residents, including incorrect fall risk assessment after a significant fall, missing documentation of wound care treatments, and incomplete records regarding medication administration and follow-up for a resident experiencing nausea. Interviews with the DON and nursing staff confirmed documentation lapses and inconsistencies.
A resident with multiple complex medical conditions was discharged home after insurance ended skilled service coverage. The case manager arranged for home health care but did not verify that services were initiated, failing to make the required follow-up call as outlined in facility policy. This resulted in the resident not receiving expected home health services post-discharge.
A resident with a PICC line was found with a dressing that had not been changed as per physician orders, which required a change within 24 hours of admission and weekly thereafter. Staff interviews confirmed the oversight, and the Treatment Administration Record showed the dressing was not changed every seven days as required. The DON acknowledged the expectation for timely dressing changes, which was not met.
The facility failed to enforce its smoking policy, allowing residents to possess vaping devices outside designated areas and times. Observations revealed that several residents had vaping devices in their rooms, contrary to the policy requiring storage by nursing staff. The DON acknowledged the issue, indicating ongoing efforts to address compliance.
The facility failed to refer two residents for a Level II PASRR evaluation despite their psychiatric diagnoses. One resident had unspecified psychosis and brief psychotic disorder, while another had pseudobulbar affect, delusional disorders, and unspecified psychosis. The Level I PASRRs did not document these conditions, incorrectly indicating that no further evaluation was needed. The DON acknowledged the inaccuracies.
The facility failed to ensure accurate assessments for residents, leading to discrepancies in records. A resident was discharged to an Assisted Living Facility, but the MDS inaccurately documented the discharge as to a hospital. Another resident's diet order was not correctly reflected in the MDS. Additionally, a resident's fall was not accurately recorded in the MDS, despite documentation of the incident. These errors were confirmed by the MDS Coordinator.
A resident with a forehead wound did not receive wound care as per physician's orders, with observations showing an unchanged bandage held by dried blood. The facility's policy requiring daily dressing changes was not followed, and documentation was missing for one day. Interviews confirmed the lapse in care.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in documentation and medication administration. One resident's MAR lacked documentation for the application of a prescribed barrier cream, while another resident received medication outside the prescribed time due to a transcription error. The DON acknowledged these issues, highlighting lapses in adherence to facility policies on documentation and physician orders.
A facility failed to ensure proper infection control during wound care for residents on enhanced barrier precautions. Staff did not consistently perform hand hygiene or use appropriate PPE, such as gowns, when providing care. Observations revealed that a Wound Care LPN did not perform hand hygiene between different stages of wound care and after touching potentially contaminated surfaces. The facility's policies require the use of gloves and gowns for high-contact care activities and emphasize hand hygiene, which were not followed, leading to a deficiency.
The facility did not maintain a clean and homelike environment in one of its main hallways, where a water leak and black substance were observed on the ceiling. A resident highlighted the issue, and the Maintenance Director confirmed the leak had been ongoing. The Resident Council President noted that concerns about the leak and mold had been reported to management for a long time. The facility's maintenance policy, which requires preventive maintenance and prompt repairs, was not followed.
The facility did not post nurse staffing information daily as required. On a Monday, it was found that the information displayed was from the previous Friday. The DON confirmed the lapse and noted that the weekend supervisor was responsible for updates. The facility lacked a specific policy for posting this information, relying on federal regulations.
Failure to Notify Resident Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident representative of a fall sustained by a resident. Record review showed that the resident experienced a fall, which was documented on an SBAR Communication form. The form indicated that the resident's representative was listed as the emergency contact, but no phone numbers were provided for either the representative or the resident's daughter, making it impossible to contact the family. The form was signed by an LPN, but there was no documentation that the family had been notified of the incident. Interviews revealed that the resident's granddaughter was not informed of the fall at the time it occurred. She discovered her grandmother's injuries upon visiting and subsequently contacted the unit manager via facetime, at which point she was informed of the fall. The LPN involved stated that she did not know about the fall until checking the computer after being contacted by the granddaughter. Another LPN could not recall if the family had been contacted. Facility policy requires prompt notification of the resident representative and attending physician in the event of accidents, but this procedure was not followed in this case.
Failure to Provide Restorative Nursing Services as Recommended by Therapy
Penalty
Summary
The facility failed to provide restorative nursing care and services as recommended by the therapy department for two residents. For one resident, the occupational therapy discharge summary recommended a restorative bed mobility program to maintain the current level of functioning, but there was no documentation in the clinical record indicating that restorative nursing was provided. The DON confirmed that the resident did not receive restorative nursing as recommended and acknowledged that the facility did not have a restorative nursing program in place at the time. For another resident, the physical therapy discharge summary indicated that the resident was discharged from therapy with a recommendation for a restorative nursing program due to ongoing risks such as knee buckling and fluctuating respiratory deficits. The resident reported not having therapy for a while and expressed interest in receiving it. The Rehabilitation Director stated that the resident was recommended for restorative care but was unaware that the facility lacked a restorative program. The DON confirmed that the facility had not had a restorative program for several months, despite facility policy stating that restorative nursing services should be provided to encourage and enable residents to be as independent as possible.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
The facility failed to take timely action on laboratory test results for one resident who was admitted with multiple complex diagnoses, including type 2 diabetes mellitus with hyperglycemia, anemia, chronic kidney disease, and a recent urinary tract infection. Upon admission, a physician ordered a Hemoglobin A1C test to monitor the resident's diabetes management. The lab result, reported two days later, showed a significantly elevated Hemoglobin A1C of 10.8. However, there was no documentation in the nursing progress notes that the physician was notified of this result. Subsequent physician orders for insulin management were made nearly two weeks after the lab result was available, with no evidence that the elevated A1C was communicated to the physician in a timely manner. During interviews, the DON acknowledged that the physician should have been notified of the results, and the physician could not recall being informed of the lab findings. This lack of timely notification and action on critical laboratory results constituted a deficiency in the facility's laboratory services for the resident.
Inaccurate MDS Assessment for Dialysis Patient
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident receiving dialysis. Record review showed that the resident had a physician's order for hemodialysis three times per week. However, the resident's quarterly MDS assessment did not indicate that dialysis was being received under Section O, which covers special treatments, procedures, and programs. During interviews, both the Director of Nursing and the MDS Registered Nurse confirmed that the resident was a dialysis patient and acknowledged that Section O should have been marked accordingly, in line with the RAI manual requirements.
Failure to Administer Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident did not receive blood pressure medication as ordered by the physician. The physician's order specified that Midodrine HCl 5 mg should be administered orally every 12 hours as needed for hypotension, specifically when the resident's systolic blood pressure was less than 110 mmHg and diastolic blood pressure was less than 60 mmHg. On a specific date, the resident's blood pressure readings were 105/54 mmHg and 102/50 mmHg, both meeting the criteria for medication administration. However, review of the Medication Administration Record (MAR) showed no documentation that the medication was given on that day. Interviews with facility staff revealed that the LPN responsible for the resident did not recall why the medication was not administered and stated that if it had been given, it would have been documented. The Advanced Practice Registered Nurse confirmed that the medication was available and that the parameters for administration were clear. The Director of Nursing also acknowledged that the medication should have been given according to the established parameters. Facility policy required review and adherence to physician orders, which was not followed in this instance.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for three residents. For one resident, an incident report documented a significant fall with injuries, including a laceration, hematoma, and fractures. However, the resident's subsequent fall risk evaluation incorrectly indicated no history of falls within the past six months, despite the recent incident. The Director of Nursing acknowledged the inaccuracy in the fall risk assessment. Another resident had multiple physician orders for wound care, including specific instructions for the sacrum and right lateral thigh. The Treatment Administration Records (TAR) for this resident showed several dates with missing documentation for wound care treatments. The wound care nurse noted that the resident sometimes refused care, but since the nurse had been providing care, there were no refusals. The Director of Nursing confirmed that treatment records should not have blanks and that refusals or care provided should be documented accordingly. A third resident's Medication Administration Record (MAR) indicated that aspirin was not administered due to nausea, but the progress note only mentioned that the medication was not on hand and that the provider would be contacted. Interviews with the DON and the nurse involved revealed inconsistencies in documentation regarding whether the provider was contacted and the resident's subsequent status. The DON stated that the nurse should have documented her follow-up actions, and the Regional Nurse Consultant noted the absence of a documentation policy.
Failure to Follow Discharge Follow-Up Policy for Discharged Resident
Penalty
Summary
The facility failed to follow its discharge policy for ensuring follow-up with discharged residents, as evidenced by the case of one resident who was discharged home after insurance discontinued payment for skilled services. The resident had multiple complex medical diagnoses, including sepsis, acute respiratory failure with hypoxia, type 2 diabetes with ketoacidosis and hyperglycemia, morbid obesity, and recent surgical aftercare. The case manager arranged for home health care through the resident's insurance company, which provided a reference number for services. However, it was later discovered that home health services had not been set up due to limitations in the resident's insurance plan. Despite the facility's policy requiring a follow-up call within 24 to 48 hours after discharge to verify that community services were in place, the case manager did not contact the resident post-discharge to confirm that home health services were being provided. The omission was acknowledged by the case manager, who stated that the follow-up call was simply forgotten. The Director of Nursing and Administrator both confirmed that the expectation was for follow-up contact to be made with discharged residents, but this did not occur in this instance.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and services for a PICC access device in accordance with professional standards of practice for a resident. The resident was re-admitted to the facility with a diagnosis that included intraspinal abscess, granuloma, osteomyelitis, and a urinary tract infection. Upon observation, the resident was found with a PICC line in the upper right arm, covered by a transparent dressing dated 2/9/2025. The resident reported that the dressing had only been changed once since admission, contrary to the physician's orders which required the dressing to be changed within 24 hours of admission and weekly thereafter. Interviews with facility staff revealed that the dressing change was overlooked. An LPN admitted to administering medication through the line without noticing the outdated dressing, and the Unit Manager confirmed the dressing had not been changed as required. The Treatment Administration Record for February 2025 corroborated that the dressing change was not completed every seven days as ordered. The Director of Nursing acknowledged the expectation for the dressing to be changed within 24 hours after admission and then weekly, which was not adhered to, resulting in the deficiency.
Failure to Enforce Smoking Policy for Vaping Devices
Penalty
Summary
The facility failed to adhere to its smoking policy, specifically regarding the use of vaping devices by residents. During observations, it was noted that several residents, identified as Resident #3, #15, #35, and #61, had vaping devices in their possession outside of designated smoking times and areas. Resident #3 had a vaping device in their room, which was not stored in the designated smoking box as required. Similarly, Resident #35 was observed with a vaping device on their bedside table and admitted to using it in their room, contrary to the facility's policy. Resident #15 also had a vaping device on their bed, which they handed over to the Director of Nursing (DON) upon request. Resident #61 initially refused to surrender their vaping device, stating they had not agreed to any policy restricting its possession. The facility's policy mandates that electronic cigarettes and related materials be stored by nursing staff and only used in designated smoking areas during authorized times. However, the observations and interviews revealed that these policies were not being enforced, as residents were found with vaping devices in their rooms and outside of designated smoking times. The DON acknowledged the issue, noting that the facility was aware of the problem and working towards compliance. The facility's failure to enforce its smoking policy resulted in residents having unrestricted access to vaping devices, which was against the established procedures.
Failure to Refer Residents for Level II PASRR Evaluation
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #38 and Resident #22, were referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination, as required. Resident #38 was admitted with a diagnosis of unspecified psychosis, and a psychiatry progress note later confirmed a diagnosis of brief psychotic disorder. However, the Level I PASRR completed by the facility staff did not document the resident's psychiatric diagnosis, incorrectly indicating that no Level II PASRR evaluation was required. Similarly, Resident #22 was admitted with diagnoses including pseudobulbar affect, delusional disorders, and unspecified psychosis. A psychiatry care plan note confirmed these diagnoses, yet the Level I PASRR also failed to document these conditions, again incorrectly stating that no Level II PASRR evaluation was necessary. During an interview, the Director of Nursing acknowledged that the PASRRs for both residents were inaccurate and needed correction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their records. Resident #102 was admitted and discharged to an Assisted Living Facility, but the Minimum Data Set (MDS) inaccurately documented the discharge as to a short-term general hospital. This error was confirmed by the MDS Coordinator during an interview. Similarly, Resident #2 had a physician's order for a Controlled Carbohydrate Diet with chopped meats, but the MDS inaccurately indicated that the resident did not require a mechanically altered diet. This was also verified by the MDS Coordinator. Additionally, Resident #10's records showed inconsistencies regarding fall incidents. Although the resident had a documented fall on April 24, 2024, the annual MDS inaccurately stated that there were no falls since admission. The resident's care plan indicated a risk for falls due to various health conditions, and the MDS Coordinator acknowledged the incorrect coding. These inaccuracies highlight the facility's failure to maintain accurate and up-to-date assessments for its residents, as required by their policy and procedure for MDS assessments.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care treatment in accordance with professional standards for a resident with a skin condition. During observations on two consecutive days, the resident was found with a bandage on her forehead that was not properly adhered, being held in place by dried blood from the wound. The bandage was dated for two days prior, indicating it had not been changed as per the physician's order, which required daily dressing changes. Additionally, there was no documentation of the wound care being administered on one of the days, as noted in the Treatment Administration Record. Interviews with the Director of Nursing and the Wound Care LPN revealed that the dressing was not changed on one of the days, and the system used to track wound care orders indicated that the dressing change had not been completed. The facility's policy on dressing changes, which mandates that a clean dressing be applied as ordered to promote healing, was not followed. This lapse in care was identified as a deficiency in the facility's adherence to professional standards of practice for wound care.
Deficiencies in Medical Record Accuracy and Medication Administration
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to deficiencies in documentation and medication administration. For one resident with a skin condition, the physician's order required the application of a house barrier cream to a sacral wound three times a day and as needed. However, the Medication Administration Record (MAR) showed multiple instances where the application was not documented over several months. The Director of Nursing acknowledged that the application was being done, but staff failed to document it in the MAR, which is expected when an order is present. Another resident had a physician's order for Midodrine HCl to be administered every eight hours, with specific instructions not to administer past 6 PM and to hold the medication if blood pressure exceeded 110. Despite this, the MAR indicated that the medication was administered at 10:00 PM on several occasions. The Director of Nursing identified this as a transcription error. The facility's policies on documentation and physician orders emphasize the importance of accurate and timely record-keeping, which was not adhered to in these cases.
Infection Control Deficiency in Wound Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for residents on enhanced barrier precautions. Specifically, staff did not consistently perform hand hygiene or use appropriate personal protective equipment (PPE) such as gowns when providing care to residents with open wounds. During an observation, a Wound Care LPN and a CNA entered a resident's room without enhanced barrier precautions signage or PPE available. Although they performed hand hygiene and donned gloves, they did not wear gowns. The LPN failed to perform hand hygiene between different stages of wound care, such as after removing gloves and before donning new ones, and after touching potentially contaminated surfaces like the resident's briefs. In another instance, the same LPN and CNA donned gloves and gowns before entering another resident's room. However, the LPN did not perform hand hygiene after removing gloves and before opening gauze packets, nor between different stages of wound care. The LPN acknowledged the failure to perform hand hygiene after cleaning wounds and when changing gloves. The Director of Nursing confirmed that staff are expected to don gloves and gowns for residents on enhanced barrier precautions and perform hand hygiene after cleaning wounds and when changing gloves. The facility's policies and procedures for enhanced barrier precautions, dressing changes, and hand hygiene were reviewed. These policies require the use of gloves and gowns for high-contact care activities and emphasize the importance of hand hygiene after contact with wounds or removal of gloves. The facility's failure to adhere to these protocols during wound care for residents on enhanced barrier precautions was identified as a deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its main hallways, as evidenced by a water leak and the presence of a black substance on the ceiling. This issue was observed in the hallway between the main dining room and the 400 Hall. A resident pointed out the black substance on the ceiling, indicating it should be cleaned off. The Maintenance Director confirmed the existence of a roof leak above the hallway, acknowledging it had been a persistent issue. Additionally, the Resident Council President reported that concerns about water leaks and mold in the hallway had been communicated to management for a long time. The facility's policy on maintenance, which includes preventive maintenance and prompt action to repair issues, was not adhered to, as daily rounds by the Director of Environmental Services failed to address the hazard.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis, as required by federal regulation. On Monday, August 12, 2024, at 5:59 AM, it was observed that the nurse staffing information displayed in the front lobby was outdated, showing details from Friday, August 9, 2024. During an interview on the same day at 7:00 AM, the Director of Nursing confirmed that the information had not been updated daily and attributed the responsibility to the weekend supervisor. Further, during an interview on August 14, 2024, at 12:02 PM, the Director of Nursing admitted that the facility did not have a specific policy for posting nurse staffing information, instead relying on federal regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lecanto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diamond Ridge Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Grove Healthcare And Rehabilitation Center And Reh | 1.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Citrus County | 2.5 mi | ★★★★★ | 10 | 0 |
| Crystal River Health And Rehabilitation Center | 6.4 mi | ★★★★★ | 26 | 0 |
| Cypress Cove Care Center | 7.7 mi | ★★★★★ | 2 | 0 |
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