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 Countryside during CMS and state inspections, most recent first.
A resident with a history of self-exposure and sexual behaviors did not have an updated care plan to address these issues. Despite documented behaviors and psychiatric assessments indicating a pattern, the care plan lacked specific interventions to prevent future incidents. Staff interviews revealed a lack of communication and awareness, contributing to the deficiency.
A resident with a history of self-exposure was involved in an inappropriate act with another resident, but the care plan was not updated to include specific interventions. Despite documented behaviors, the care plan only included general strategies, lacking individualized interventions to prevent future incidents. Staff interviews revealed a lack of awareness and communication about the resident's history, contributing to the deficiency.
The facility failed to implement an effective infection control program, with issues such as improper PPE use by visitors, inadequate hand hygiene by staff, and improper storage of respiratory masks. Additionally, contact precautions were not timely implemented for a resident with ESBL, and dirty meal trays were stored with clean ones, posing an infection risk.
The facility failed to update advance directives for two residents according to their wishes. One resident wanted CPR withheld, but the document was unsigned by the physician, leaving a full code status in place. Another resident had a DNR order despite requesting CPR. Staff interviews revealed communication breakdowns between social services and nursing, resulting in unupdated orders.
A survey identified a 25% medication error rate in an LTC facility, involving four residents. Errors included incorrect dosages, late administration, and failure to check blood glucose levels before insulin administration. The facility's policies on timely and accurate medication delivery were not followed.
The facility failed to ensure proper storage and labeling of medications and medical devices. A medication cart was left unlocked and unattended, containing an undated bottle of Latanoprost. Expired urinary catheters were found in the medication room. Medications were improperly stored in resident rooms, contrary to facility policy, as confirmed by staff interviews.
A resident with missing and broken teeth experienced ongoing pain due to the facility's failure to coordinate dental services. Despite a care plan to address oral health, there was a lack of follow-up after initial dental consultations, partly due to a disconnect in vendor transitions. The resident's medical history included conditions like diabetes and COPD, and he continued to experience dental pain without appropriate follow-up care.
Failure to Update Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to include individualized interventions related to behaviors after a reported sexual event. The incident involved a resident who was observed performing a sexual act on another resident. Despite having a documented history of self-exposure, these behaviors were not added to the care plan prior to the incident. The care plan only included general interventions for reducing episodes of self-exposure, without specific measures to prevent future incidents of sexual behavior. The resident in question had a complex medical history, including diagnoses of muscle wasting, anxiety disorder, major depressive disorder, unspecified dementia, and cognitive communication deficit. Despite these conditions, the care plan did not reflect the resident's known behaviors of self-exposure and sexual acts. The psychiatric assessments and progress notes indicated a history of exposing himself to female residents, yet this information was not communicated effectively to the interdisciplinary team or incorporated into the care plan. Interviews with staff revealed a lack of awareness and communication regarding the resident's behaviors. The Advanced Practice Registered Nurse (APRN) was not informed of the resident's history of sexual behaviors prior to the incident. The Nursing Home Administrator (NHA) acknowledged that the care plan could be more meaningful and confirmed that no specific interventions were in place for the sexual act observed. The facility's policy required the care plan to be updated based on changing needs, but this was not adhered to, leading to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider for the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. F656 Develop/Implement Comprehensive Care Plan What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Facility updated Care Plan of resident #1 on How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: 1. An in-house quality review was completed to ensure residents exhibiting behaviors have accurate and updated care plans with a focus of ensuring a person-centered approach with resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment. Any outstanding issues or concerns were addressed as they were identified. What measures will be put in place or what systematic changes you will make to ensure that the practice does not recur: 1. The Regional Director of Clinical Services in-serviced the Interdisciplinary Team (IDT) on the components of this regulation and the facility policy regarding plans of care with an emphasis on person-centered care. 2. Facility staff were reeducated by the Assistant Director of Nursing/designee on Plans of Care policy and procedure with an emphasis on person-centered care. 3. Newly hired employees and contract staff will receive education during orientation. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: During Morning meeting, the Director of Nursing (DON) and/or designee will review occurrence of behaviors documented from the previous day, and/or post psychiatry documentation review, to ensure Care Plans are updated accordingly, daily 5 times a week for 4 weeks, then weekly for 4 weeks, then random Care Plans every other week, to ensure Care Plans are person-centered and accurate, until the QAPI committee finds that the facility has met substantial compliance. Date Certain:
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update the care plan for a resident following an incident involving inappropriate behavior. The resident, who had a history of self-exposure, was involved in an event where they were observed performing an inappropriate act on another resident. Despite this behavior being documented, the care plan was not updated to include individualized interventions to address these behaviors or prevent future incidents. The resident's medical history included diagnoses such as wasting and atrophy, major recurrent unspecified conditions, and unspecified severity without behavioral disturbance. The resident had documented behaviors of self-exposure that were not incorporated into the care plan prior to the incident. The care plan only included general interventions for self-exposure, such as encouraging appropriate expression of feelings and providing opportunities for positive interaction, but lacked specific strategies to address the recent event. Interviews with staff revealed a lack of awareness and communication regarding the resident's history of exposing themselves. The Advanced Practice Registered Nurse (APRN) was not aware of the resident's history of such behaviors prior to the incident. The Nursing Home Administrator (NHA) also admitted to not reviewing previous records that documented the resident's behavior. This lack of communication and failure to update the care plan contributed to the deficiency in addressing the resident's needs and ensuring their highest practicable well-being.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider for the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. **Develop/Implement Comprehensive Care Plan** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Facility updated Care Plan of resident #1 on How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: 1. On, in-house quality review was completed to ensure residents exhibiting behaviors have accurate and updated care plans with a focus of ensuring a person-centered approach with resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental needs that are identified in the comprehensive assessment. Any outstanding issues or concerns were addressed as they were identified. What measures will be put in place or what systematic changes you will make to ensure that the practice does not recur: 1. On, the Regional Director of Clinical Services in-serviced the Interdisciplinary Team (IDT) on the components of this regulation and the facility policy regarding plans of care with an emphasis on person-centered care. 2. Facility staff were reeducated by the Assistant Director of Nursing/designee on Plans of Care policy and procedure with an emphasis on person-centered care. 3. Newly hired employees and contract staff will receive education during orientation. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: During Morning meeting, the Director of Nursing (DON) and/or designee will review occurrence of behaviors documented from previous day, and/or post psychiatry documentation review, to ensure Care Plans are updated accordingly, daily 5 times a week for 4 weeks, then weekly for 4 weeks, then random Care Plans every other week, to ensure Care Plans are person-centered and accurate, until the QAPI committee finds that the facility has met substantial compliance. Date Certain:
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by multiple deficiencies observed during a survey. One significant issue was the failure to ensure that third-party vendors wore Personal Protective Equipment (PPE) appropriately for a resident under contact isolation. Despite clear signage indicating the need for PPE, visitors were observed entering the resident's room without wearing the necessary protective gear. This resident had been diagnosed with Enterocolitis due to Clostridium difficile, necessitating strict contact precautions. Another deficiency involved staff failing to conduct proper hand hygiene and don PPE while providing high-contact care activities. A registered nurse was observed administering medications without performing hand hygiene and assisting with resident repositioning without wearing a gown or gloves, despite the resident being under enhanced barrier precautions. Additionally, aides were seen providing incontinence care without PPE, further compromising infection control measures. The facility also failed to ensure proper storage of respiratory masks and timely implementation of contact precautions for residents with specific infections. A nebulizer mask was left uncovered on a nightstand, contrary to the facility's policy requiring storage in a respiratory bag. Furthermore, a resident with an active order for contact precautions due to ESBL in urine did not have the necessary signage or PPE at the door, indicating a lapse in implementing transmission-based precautions. Additionally, dirty meal trays were improperly stored with clean trays, posing an infection risk.
Failure to Update Advance Directives Per Resident Requests
Penalty
Summary
The facility failed to ensure that advance directives were updated according to the residents' requests, affecting two residents. Resident #406, who had chronic kidney disease and congestive heart failure, had expressed a wish to have CPR withheld, as documented in an Advance Directives Discussion Document. However, the document was not signed by the physician, and the resident's electronic medical record still indicated a full code status. The Director of Social Services acknowledged that the resident was aware the physician's signature was pending, but the delay in obtaining it meant that CPR would be administered if needed. Resident #455, diagnosed with spastic hemiplegia and respiratory failure, had an active DNR order despite having signed a form indicating a preference for CPR. Interviews with staff revealed that the code status on the dashboard was based on orders, and there was a lack of communication between social services and nursing staff to update the orders according to the resident's wishes. The Social Services Director confirmed the discrepancy but could not explain why the orders had not been changed. The Nursing Home Administrator and Assistant Director of Nursing acknowledged a breakdown in communication, as there was no documentation that physicians had been contacted to change the code status for either resident. The facility's policy required notification of the physician and documentation in the medical record upon completion of the Advance Directives Discussion Form, which was not followed in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 25% during the survey. Observations revealed multiple medication administration errors involving four residents. For Resident #59, a Registered Nurse (RN) dispensed an incorrect dosage of Folic Acid, initially providing two tablets instead of the prescribed one tablet of 1 mg. This error was identified during the medication administration process. Resident #55 experienced multiple issues, including the administration of insulin without checking the blood glucose level as required by the physician's order. Additionally, the resident did not receive the scheduled dose of Xanax due to unavailability, and the medication administration record showed the order had not been updated. The RN involved did not verify the blood glucose level before administering insulin, which was a deviation from the prescribed protocol. For Resident #44, the administration of Eliquis was delayed, and the RN had difficulty locating the medication. The resident was scheduled to receive Eliquis at 9:00 a.m., but it was administered late. Similarly, Resident #66's medications, including Vitamin B-12 and Polyethylene Glycol, were administered late. The RN confirmed dispensing the medications but did not adhere to the scheduled administration times. These observations indicate a failure to follow the facility's medication administration policies, which require timely and accurate medication delivery.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and medical devices, as observed in several instances. One of the medication carts, specifically the South Front cart, was left unlocked and unattended by Staff E, RN, who left the keys in the lock while speaking with another staff member. This cart contained an undated bottle of Latanoprost ophthalmic drops, which should have been dated upon opening. Additionally, the South unit medication room contained expired silicone and latex urinary catheters, which were not discarded as required. Further observations revealed that medications were improperly stored in resident rooms. In multiple rooms, medications such as hydrogen peroxide, soothing nerve pain spray, antifungal powder, wound cleanser, and multi-vitamins were found on residents' nightstands. Interviews with Staff H, RN, and the Director of Nursing confirmed that medications should not be left at the bedside, as per facility policy. The facility's policy on medication storage mandates that medications be stored in locked compartments accessible only to authorized personnel, and that expired or contaminated medications be properly managed.
Failure to Coordinate Dental Services for Resident
Penalty
Summary
The facility failed to coordinate dental services in accordance with professional standards of practice for a resident, leading to a deficiency. The resident, who had missing and broken teeth on the lower jaw, reported experiencing pain and stated that although he had seen a dentist months ago, no follow-up had occurred. The resident's medical history included conditions such as Normal Pressure Hydrocephalus, Type 2 diabetes, COPD, mild bipolar disorder, and joint pain. Despite having intact cognition, as indicated by a BIMS score of 13/15, the resident continued to experience dental pain without appropriate follow-up care. The resident's dental care plan aimed to ensure he was free of infection, pain, or bleeding in the oral cavity, with interventions including medication administration, dental care coordination, and mouth care. However, a review of dental service reports revealed a lack of follow-up after an initial consultation and a subsequent visit where no images were taken due to equipment malfunction. The Regional Social Service Director acknowledged a disconnect in vendor transitions, which contributed to the lack of follow-up care. The facility's policy required prompt referral for dental issues, but this was not adhered to, resulting in the resident's continued discomfort.
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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 Palm Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Clearwater | 0.7 mi | ★★★★★ | 0 | 0 |
| Westchester Gardens Health & Rehabilitation | 1.1 mi | ★★★★★ | 1 | 0 |
| Oakpark Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 13 | 0 |
| St Mark Village | 2 mi | ★★★★★ | 0 | 0 |
| Aviata At The Palms | 2.6 mi | ★★★★★ | 11 | 4 |
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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.