Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Englewood during CMS and state inspections, most recent first.
A resident with traumatic brain injury, moderate cognitive impairment, and a history of unpredictable behaviors became agitated and physically aggressive during transfer to bed. Despite the resident’s refusals and distress when a mechanical lift was brought in, two CNAs continued care. One CNA was reported to have grabbed the resident’s arm, twisted it, and forcefully slapped the same area of the forearm multiple times while laughing, after the resident kicked and hit staff. The resident later stated that nurses slapped his arm several times, and a family member reported being told that staff repeatedly tapped the resident’s arm while saying not to do that. Multiple staff, including CNAs and LPNs, observed redness and linear marks on the resident’s right forearm, and a provider note documented localized erythema with superficial linear markings consistent with a grab or excoriation-type injury. These events show that the resident was not protected from physical abuse by staff.
Infection control measures were not followed when multiple residents developed persistent rashes and itching with suspected scabies. A resident with stroke, diabetes, and kidney failure, another resident with COPD and heart disease, and a third resident with dementia all had ongoing skin symptoms and were treated with Permethrin, yet symptoms persisted and the DON said skin sweeps and isolation were not done until an investigator arrived. The infection preventionist reported that 29 residents and 15 staff were treated, including prophylactic treatment for roommates, and several residents remained symptomatic.
A resident with dementia, repeated falls, and multiple cardiac conditions fell from the bed during incontinent care after a CNA left her unattended while disposing of a brief and getting towels. The CNA said he did not know she required 1 to 2 staff assist and had not been trained to use the Kardex to find resident care needs. The fall caused a head laceration and subdural hematoma, requiring transfer to a higher level of care.
Failure to Supervise Resident With Repeated Falls: A resident with dementia, confusion, and poor safety awareness had multiple unwitnessed falls despite care plan interventions such as a low bed, fall mats, nonskid socks, toileting assistance, and frequent checks. Staff said the resident often got up on his own and did not reliably call for help, and the resident sustained a pubis ramus fracture, a head strike while on blood thinners, and later a displaced femoral neck fracture requiring hip surgery.
A resident who fell from bed was not properly assessed or monitored by an LPN, who failed to document the incident, initiate neurological checks, complete a post-fall evaluation, or notify the physician and resident representative. The fall was only discovered later when the resident reported symptoms, leading to hospital admission for a head injury. Facility leadership confirmed the LPN did not follow required post-fall procedures or communicate the event to the oncoming RN.
Two residents with urinary catheters were found with drainage bags lying on the floor, contrary to infection control policies requiring bags to be kept off the floor and covered for privacy. One resident was being treated for a UTI and required contact isolation, while the other had recent urinary retention and dementia. Staff acknowledged the infection control issue, and photographic evidence was obtained.
Resident Physically Abused by CNA During Agitated Care Episode
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by staff during the provision of care. The facility’s Abuse, Neglect, Exploitation & Misappropriation policy defines abuse as the willful infliction of injury, including physical abuse such as hitting, slapping, and punching, and states that such acts are strictly prohibited. Despite this policy, a CNA was reported to have intentionally struck a resident’s right forearm multiple times during care, resulting in visible redness and linear markings consistent with a grab or excoriation-type injury. The resident involved had a history of traumatic subdural hemorrhage, diffuse traumatic brain injury, ADHD, and a psychotic disorder with delusions, with a BIMS score indicating moderate cognitive impairment. The resident’s care plan documented mood problems related to traumatic brain injury, unpredictable behaviors, a potential for traumatization due to prior storm/hurricane evacuations, and communication problems requiring staff to allow adequate time to respond and not rush. The care plan also noted that the resident was dependent on staff for emotional, intellectual, physical, and social needs, with an intervention for all staff to converse with the resident while providing care. During the incident, the resident became agitated and physically aggressive while being assisted to bed, including kicking and hitting staff. Multiple staff interviews described the sequence of events leading to the abuse. One CNA reported that another CNA repeatedly tapped on the resident’s plate while insisting he finish his food, wiped his mouth aggressively when he refused and spit food out, and then proceeded with a transfer to bed despite the resident’s refusal and agitation when seeing the mechanical lift. During the transfer, the resident kicked one CNA and hit the other, after which the accused CNA allegedly grabbed the resident’s arm, twisted it so the forearm was exposed, and hit the same spot on the forearm four to five times while laughing and grinning. The reporting CNA, as well as other staff, observed a red mark on the resident’s right forearm, and photographic evidence documented these red marks. The resident stated that nurses slapped his arm multiple times, and a family member reported being told that someone had tapped his arm repeatedly while saying “don’t do that.” Additional staff, including LPNs, confirmed being told that the resident had been slapped on the arm and that they observed redness on the forearm. A primary care note documented localized erythema with superficial linear markings on the volar aspect of the right forearm, consistent with friction, a grab mark, or excoriation-type injury. Further interviews revealed that the accused CNA denied hitting the resident and instead alleged that the reporting CNA had pinched the resident’s feet during care. However, the reporting CNA stated she had previously seen the accused CNA smack residents’ hands in a manner similar to smacking a child, though not as aggressively as in this incident. Staff accounts also indicated that care was continued despite the resident’s verbal refusals and escalating agitation, and that one LPN, when informed of the incident and shown the resident’s arm, stated she did not want any part of it and left the room. Another LPN reportedly responded to the description of the incident and the redness on the arm by saying she hoped it would go away. These actions and observations collectively demonstrate that the resident was not kept free from physical abuse as required by the facility’s abuse policy.
Infection Control Failure During Suspected Scabies Outbreak
Penalty
Summary
The facility failed to follow infection control measures to prevent a potential outbreak of scabies after multiple residents developed persistent rashes and itching. The facility policy stated that infection prevention and control includes outbreak management, such as determining whether an outbreak is present, managing affected residents, preventing spread to other residents, documenting the outbreak, reporting to public health authorities, educating staff and the public, monitoring for recurrence, and reviewing care after the outbreak subsides. In this case, the DON stated that skin sweeps and isolation of symptomatic residents were not done until an investigator arrived to investigate a complaint of possible scabies in the facility. Resident #1 was admitted with diagnoses including stroke, spinal lesion, failure to thrive, diabetes, and kidney failure, and had intact cognition on MDS review. The resident was assessed for a rash under the thighs, treated with Permethrin 5% cream for rash, and later had a care plan for rash/scabies. On interview, the resident said he had had the rash for about a month, had received treatment since first reporting it, but did not want to repeat the treatment because it burned his skin. He remained itchy and was observed scratching his arms and legs, with noticeable bite marks on the arms and legs. Resident #2, who had COPD, heart disease, and chronic pain syndrome and intact cognition, was seen for vesicular lesions around the lips and later for a rash on the arms, hands, face, and neck. The APRN documented the areas appeared bite-like and less likely scabies because the rash was not disseminated, but the resident received one treatment of Permethrin with no improvement and continued to itch. Resident #3, who had dementia, cerebral infarction, and osteoarthritis, had an extensive ongoing rash to the hands, arms, trunk, and chest that was described as consistent with eczema/psoriasis versus fungal infection and not responding to multiple treatments. The resident was also placed on a care plan for rash/scabies and later seen by a dermatologist, who documented a rash present for months and diagnosed dermatitis. The infection preventionist reported that 29 residents and 15 staff members were treated for scabies, including 11 residents treated prophylactically because they were roommates of symptomatic residents, and 7 residents remained symptomatic and would be retreated.
Resident Fell From Bed During Incontinent Care
Penalty
Summary
The facility failed to protect a resident from neglect when staff left the resident unattended during incontinent care and did not adequately train staff on how to access resident care information. Resident #1 had diagnoses including heart failure, atrial fibrillation, repeated falls, hypothyroidism, obesity, hypertension, aortic stenosis with insufficiency, mood disorder, a cardiac pacemaker, and dementia, and a BIMS score of 5/15 indicating severely impaired cognition. The care plan required rolling the resident from side to side and side to back with dependent assistance from 1 to 2 staff members. During incontinent care, a CNA left the resident lying on her side at the edge of the bed to dispose of a brief and get towels. The CNA stated he assumed the resident was okay and was not aware she required 1 to 2 person assistance, and he said he had not been trained to look up resident information in the Kardex before the fall. The resident slid off the bed and fell to the floor, resulting in a head laceration and a subdural hematoma that required transfer to a higher level of care. The DON stated staff are supposed to ensure residents are in a safe position before leaving the bedside and could not verify the CNA had received Kardex training before the incident.
Failure to Supervise Resident With Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls with major injury for one resident who had repeated unwitnessed falls and poor safety awareness. The resident had five falls between 12/14/25 and 1/6/26, including a fall that led to a pubis ramus fracture after the resident was found on the floor and later showed an inverted and shortened left lower extremity. The resident also had an unwitnessed fall with a head strike while on blood thinner medication, another unwitnessed fall in the bathroom, and additional falls in the room and at the doorway, with one resulting in a small skin tear to the left knee. The resident’s record showed a history of dementia, confusion, forgetfulness, and non-compliance, and staff described the resident as very independent minded and as someone who tried to get up without assistance despite needing help. The care plan and CNA Kardex included interventions such as a low bed, fall mats, nonskid socks, frequent checks, toileting assistance, and a hand bell, but staff interviews indicated the resident still got up on his own and that checks were not documented. After continued complaints of hip and groin pain, imaging revealed a complete fracture of the left femoral neck with displacement and a pubis ramus fracture, and the resident later returned to the facility following left hip surgery.
Failure to Follow Post-Fall Protocol and Notification Procedures
Penalty
Summary
A resident experienced a fall from bed during the early morning hours, which was witnessed by the roommate. The roommate alerted a CNA, who then notified an LPN. The LPN arrived with another CNA, questioned the resident, and returned the resident to bed without performing an assessment. The LPN failed to document the fall in the medical record, did not initiate neurological checks, did not complete a Post Fall Evaluation form, and did not notify the resident's primary care physician or the resident's representative as required by facility policy. Additionally, the LPN did not communicate the incident to the oncoming RN during shift change. Later that day, the resident reported nausea and headache to the RN, who was then informed by the roommate about the earlier fall. The RN notified the APRN, who ordered medication and assessed the resident, ultimately directing a transfer to the hospital where the resident was diagnosed with a head injury/concussion. Facility leadership confirmed through their investigation that the LPN did not follow post-fall protocols, failed to document the incident, and did not notify appropriate parties as required.
Failure to Maintain Infection Control Standards for Urinary Catheter Care
Penalty
Summary
Surveyors identified that the facility failed to adhere to infection control standards for two residents with urinary catheters. For one resident with a history of urinary retention, obstructive and reflux uropathy, and sepsis, the urinary catheter drainage bag was observed lying on the floor next to the bed. The resident was being treated for a urinary tract infection at the time, and the care plan included interventions for infection control and contact isolation. A CNA confirmed that the drainage bag should not be on the floor due to infection control concerns and repositioned it appropriately. The facility's policy requires catheter bags to be covered for privacy and kept off the floor, but this was not followed in this instance. Another resident, admitted with diagnoses including urinary tract infection and dementia, was also observed with a urinary catheter drainage bag lying on the floor and without a privacy bag. Nursing documentation indicated recent urinary retention and Foley catheter insertion. The DON was notified of the issue and acknowledged the need to correct the placement of the drainage bag. These observations were supported by photographic evidence and demonstrated non-compliance with the facility's infection control and catheter care policies.
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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 Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Port Rehabilitation And Nursing Center | 9.1 mi | ★★★★★ | 0 | 0 |
| Sunset Lake Healthcare And Rehabilitation Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Port Charlotte Rehabilitation Center | 11.4 mi | ★★★★★ | 3 | 2 |
| Village On The Isle | 12.1 mi | ★★★★★ | 0 | 0 |
| Sun Harbor Healthcare | 12.1 mi | ★★★★★ | 0 | 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.