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 Central Park during CMS and state inspections, most recent first.
A resident with multiple chronic conditions received pain medication outside the prescribed pain level parameters without physician or IDT notification. Nursing staff and record review confirmed that the required notifications were not made, despite facility policies mandating adherence to physician orders and communication when deviations occur.
Three residents with complex medical conditions were admitted or readmitted with documented code status orders, but baseline care plans reflecting these code statuses were not established within 48 hours as required. Staff interviews confirmed that the process for including code status in the baseline care plan was not consistently followed, resulting in delays in care plan documentation.
A resident with multiple complex medical conditions and a full code status experienced a cardiac arrest. During the emergency response, several staff members, including CNAs and LPNs, participated in CPR efforts. At least one CNA who performed chest compressions was not certified in CPR, and another CNA present was also not certified. The facility's policy required that only certified staff perform CPR, but this was not adhered to during the incident.
The facility failed to ensure a dignified dining experience for residents requiring assistance with eating. Observations showed staff standing while feeding residents, contrary to expectations. Interviews revealed confusion among staff about proper procedures, with some believing they should stand and others confirming they should sit. The Nursing Home Administrator acknowledged the lack of a specific policy on ADLs for dependent residents.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident did not receive a re-admission assessment, resulting in inadequate monitoring for pressure ulcers. Another resident's care plan lacked interventions for a stage III pressure ulcer, and they were observed without an air mattress. A third resident's care plan was incomplete, missing documentation for a stage IV pressure wound and necessary interventions. These failures contributed to the deficiencies in care.
The facility failed to provide adequate pressure ulcer care for two residents. One resident did not receive a re-admission assessment, leading to delayed treatment of pressure ulcers and a blister caused by a knee immobilizer. The care plan lacked interventions for these issues. Another resident with a stage III sacrum wound did not have an air mattress as required by policy, and the wound was not addressed in the care plan. The facility did not adhere to its skin and wound care policy, contributing to the deficiencies.
Failure to Notify Physician and IDT of Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that physician orders were followed regarding the administration of pain medication for a resident with multiple complex medical conditions, including chronic pain, coronary artery bypass graft, bilateral below the knee amputations, cardiogenic shock, acute respiratory failure, COPD, diabetes type 2, hypertension, and dyspnea. The resident had an order for Percocet 5-325 mg, to be administered every 6 hours as needed for moderate pain (pain level 4-7). However, the medication was administered on several occasions for pain levels of 8 and 10, which were outside the ordered parameters. There was no documentation indicating that the physician or the interdisciplinary team (IDT) was notified when the medication was given outside of the prescribed pain level range. Interviews with nursing staff and review of the resident's medical record confirmed that the physician was not notified when the medication was administered outside the ordered parameters. The facility's policies on pain management, care planning, and medication administration require adherence to physician orders and prompt notification of the physician when orders are not followed. Despite these policies, there was no evidence of follow-up or communication with the medical team regarding the deviation from the prescribed medication parameters.
Failure to Establish Baseline Care Plans for Code Status Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans addressing code status were in place within 48 hours of admission for three residents. Each of these residents had complex medical conditions, including chronic respiratory failure, COPD, diabetes, morbid obesity, altered mental status, hemiplegia, cerebral infarction, atrial fibrillation, pulmonary embolism, and chronic kidney disease. Physician orders documented the code status for each resident—either full code or do not resuscitate (DNR)—at the time of admission or readmission. However, review of the care plans revealed that none of the three residents had a baseline care plan for code status established within the required 48-hour timeframe, with delays ranging from several days to over a week. Interviews with facility staff, including the Social Service Director, Assistant Director of Nursing, and Nursing Home Administrator, confirmed that the process for reviewing and documenting code status was not consistently followed. The admitting nurse was expected to review code status with the resident or their representative and include it in the baseline care plan, but this step was missed for the residents in question. The facility's policy required an individualized, person-centered baseline plan of care to be developed within 48 hours of admission, including code status, but this was not adhered to for the affected residents.
Failure to Ensure Qualified Staff Provided CPR According to Resident's Plan of Care
Penalty
Summary
The facility failed to ensure that all nursing staff providing care had the necessary skills, knowledge, and certification to perform cardiopulmonary resuscitation (CPR) according to each resident's written plan of care. A resident with multiple complex medical conditions, including chronic respiratory failure, COPD, diabetes, morbid obesity, and congestive heart failure, was admitted as a full code, indicating that all resuscitative measures should be taken in the event of cardiac arrest. However, the resident's care plan did not include a specific plan for code status, and during a cardiac arrest event, not all staff involved were certified in CPR. During the code event, a CNA discovered the resident unresponsive and called for assistance. Several staff members, including LPNs and CNAs, responded and initiated CPR. Interviews revealed that at least one CNA who performed chest compressions was not certified in CPR, and another CNA present was also not certified. The facility's policy required that CPR be performed by staff with appropriate certification, and the expectation was that licensed nurses would provide CPR. Despite this, unqualified staff participated in the resuscitation efforts. The deficiency was further evidenced by the lack of documentation of CPR certification for one CNA in the employee record and the admission by the Nursing Home Administrator that the CNA should not have performed chest compressions. The facility's policy outlined that CPR should be provided to all residents without a DNR order and specified procedures for verifying code status and initiating resuscitation, but these procedures were not fully followed during the incident.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for four residents who required assistance with eating. Observations revealed that staff members were standing while assisting residents with meals, which is contrary to the facility's expectations. For instance, a speech therapist was observed standing next to a resident's bed with a utensil in hand, and a CNA was seen standing between a privacy curtain and a resident's bed, feeding the resident while their face was level with the staff member's mid-torso. Another CNA was observed feeding two residents simultaneously, sitting on one resident's bed to assist with eating. Interviews with staff, including a Registered Nurse and CNAs, indicated confusion regarding the proper procedure for assisting residents with meals. While some staff believed they were supposed to stand, others confirmed that they should sit while assisting residents. The Nursing Home Administrator acknowledged that staff should not stand while assisting residents with eating and noted the absence of a specific policy regarding Activities of Daily Living (ADLs) for dependent residents. The facility's policy on Resident Rights emphasized the importance of making residents and their representatives aware of their rights and ensuring staff are knowledgeable about these rights, with ongoing training as required by regulations.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. For Resident #2, the facility did not perform a re-admission assessment upon the resident's return from the hospital, resulting in a lack of skin assessment and subsequent care planning for pressure ulcers and blisters. The resident, who had a history of falls and a right femur fracture, was not adequately monitored for skin integrity, and the care plan did not address the necessary interventions for pressure ulcers and brace care. Resident #3's care plan did not include interventions for a stage III sacrum pressure ulcer, despite the wound being documented in the resident's medical records. The resident was observed without an air mattress, which was expected for a stage III or higher pressure wound. The facility's failure to update the care plan and provide appropriate pressure-relieving devices contributed to the deficiency in care for this resident. Resident #4's baseline care plan lacked documentation related to a stage IV sacrum pressure wound and the use of IV antibiotics for an infected sacrum pressure wound. The care plan also did not include interventions for transfers, which were necessary given the resident's medical conditions, including dementia and a history of cerebral infarction. The facility's failure to complete a comprehensive care plan upon admission and to address the resident's needs in the care plan led to the identified deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice related to pressure wounds/ulcers for two residents. Resident #2, who was readmitted to the facility after a hospital stay, did not receive a re-admission assessment, which resulted in a lack of skin assessment upon return. This oversight led to a delay in identifying and treating pressure ulcers on the resident's buttocks and a blister on the right leg caused by a knee immobilizer. The care plan for Resident #2 did not include interventions for the pressure ulcer or blister, and there was no documentation of monitoring the right lower leg and brace fitting. Resident #3, who had a history of cerebral infarction with hemiparesis, diabetes, and chronic pain syndrome, was found to have a stage III sacrum wound that was not addressed in the care plan. The facility's policy required an air mattress for residents with stage III or higher pressure wounds, but Resident #3 did not have an air mattress, as confirmed by a CNA. The facility's failure to include the sacrum pressure ulcer in the care plan and provide an air mattress as per policy contributed to the deficiency. The facility's policy on skin and wound care outlined the need for baseline skin condition evaluation upon admission or re-admission, weekly skin evaluations, and documentation of skin impairments. However, these procedures were not followed for Residents #2 and #3, leading to inadequate care and management of their pressure wounds. The lack of adherence to the facility's policy and the absence of appropriate interventions in the care plans were significant factors in the identified deficiencies.
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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 Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Center For Rehabilitation And Healing Of | 0.5 mi | ★★★★★ | 0 | 0 |
| Aviata At Oakfield | 0.9 mi | ★★★★★ | 23 | 0 |
| Victoria Crossing Rehabilitation Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 9.7 mi | ★★★★★ | 10 | 0 |
| Whispering Oaks | 9.9 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.