Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Lake Mary during CMS and state inspections, most recent first.
The facility failed to keep the exterior dumpster area sanitary. During a tour with the CDM, surveyors observed widespread food-related debris, trash, and used gloves scattered inside and around the dumpster enclosure, with litter extending beyond the fence line into the grass and gravel. Surveyors also found cigarette butts near the shut-off valve and grease trap, grease residue around the access point, and no No Smoking signage posted in the area.
Improper food storage and employee hygiene were observed in the kitchen dry storage area and tray service area. A clear cylindrical container was stored directly inside a bulk flour container with visible flour residue on the outside, and the CDM confirmed scoops and utensils were supposed to be stored outside dry goods. In the tray area, a Regional Kitchen Manager stood near uncovered ready-to-serve food without a beard cover and had close contact with kitchen staff, including hugging, while in the food service area.
Two residents with midline IVs had clear dressings dated after insertion that contained dried rusty brown substance on gauze underneath, and staff confirmed the dressings had not been changed since placement. Records showed no orders or documentation for IV site monitoring, dressing changes, assessments, or flushes, despite one resident receiving IV fluids and antibiotics and the other having a midline reinserted for wound infection treatment.
Failure to follow contact precautions: A resident with ESBL wound infection was on contact isolation, and the room door displayed signage requiring gown and gloves before entry. A Social Service Assistant entered without PPE, shook the resident’s hand, then touched the roommate with a bare hand before washing hands and leaving; the DON observed the event and the assistant said she had not noticed the isolation sign.
The facility failed to complete MDS Comprehensive Assessments within the required time frame for five residents. Delays ranged from two to twelve days, with one assessment remaining incomplete. The MDS Coordinator and Regional Director acknowledged the delays, citing challenges in completing specialized sections on time.
The facility failed to complete MDS Quarterly Assessments within the required time frame for two residents, with one assessment being 23 days late and another 7 days late. The MDS Coordinator acknowledged ongoing issues with timely completion, and the DON noted the absence of a Social Worker as a contributing factor. The facility's guidelines required assessments every three months, but these were not adhered to.
A facility failed to maintain adequate communication with a dialysis center and ensure post-dialysis assessments for a resident with ESRD. Despite receiving dialysis thrice weekly, multiple Dialysis Communication Records from January to June 2024 were incomplete or missing documentation from both the dialysis center and facility nurses. Interviews revealed that despite attempts to address the issue, communication forms continued to be returned incomplete, indicating a lapse in protocol adherence.
A resident with hypotension was improperly administered Midodrine 110 times over four months, despite orders to hold the medication if SBP was less than 110 mmHg. Nursing staff misunderstood the parameters, and the consultant pharmacist failed to identify the errors during monthly reviews.
The facility failed to prevent bacterial growth by improperly handling dishes. Observations revealed wet nesting of plastic pellet bases and improper air drying of cups and bowls. A Dietary Aide noted that bases were stacked wet, and the Dietary Manager recognized the need for better storage methods to ensure proper airflow and drying.
The facility failed to administer oxygen therapy as per physician orders for two residents. One resident received oxygen at a higher rate than prescribed, while another did not receive oxygen despite a continuous order. Staff acknowledged the discrepancies, and the facility's policy required regular review and documentation of oxygen therapy.
Unsanitary Exterior Waste Area and Cigarette Debris
Penalty
Summary
The facility failed to maintain the exterior waste areas in sanitary condition for 1 of 1 waste-handling locations reviewed. During an exterior tour with the Certified Dietary Manager, widespread litter and food-related debris were observed around the dumpster enclosure, including sugar packets, salt packets, powdered creamer packets, paper towels, used disposable gloves, graham crackers, and condiment packets scattered across the concrete inside the enclosure and throughout the surrounding ground. The debris extended 15-20 feet beyond the enclosure and over the fence line into the grass and gravel, and some of the trash appeared weathered, indicating it had accumulated over time. A few minutes later, thirteen cigarette butts were observed behind the building near the shut-off valve and grease trap, along with grease staining and residue around the grease trap access point. No No Smoking signage was posted in that area, and the Certified Dietary Manager confirmed the findings and stated the area was not acceptable per facility expectations.
Improper Food Storage and Employee Hygiene in Kitchen Areas
Penalty
Summary
Food was not stored and handled in a sanitary manner in the kitchen dry storage area and tray service area. During a tour of the kitchen with the Certified Dietary Manager (CDM), a clear, large cylindrical container was found stored directly inside the bulk flour container, with the container in direct contact with the flour and visible flour residue on the outside. The CDM confirmed that containers were not supposed to be stored inside bulk flour and stated that utensils and scoops were required to be stored outside of dry goods to prevent cross-contamination. In the tray service area, a Regional Kitchen Manager was observed standing at the tray cart with uncovered food items nearby while not wearing a beard cover over his facial hair. He was in close proximity to exposed, ready-to-serve food and engaged in close physical contact with kitchen staff, including hugging, while in the food service area. The Regional Kitchen Manager stated he had just arrived and confirmed he should have donned a beard guard before coming into the kitchen. The CDM acknowledged that all staff, including regional and visiting staff, were required to follow facility hygiene and PPE policies and that beard covers were required when handling or being near exposed food.
Midline IV Catheters Not Properly Monitored or Maintained
Penalty
Summary
The facility failed to ensure appropriate care and monitoring of midline IV catheters for 2 residents receiving parenteral fluids/IV therapy. Resident #16 was admitted with a diagnosis of urinary tract infection and had a midline IV with a clear dressing dated 4/18/26 that contained a small piece of gauze with dried rusty brown-colored substance underneath it. The resident was observed with the IV running and stated he did not recall staff changing the dressing since the IV was placed a few days earlier. The medical record showed orders for normal saline flushes and IV antibiotics, but no orders for midline IV catheter care, assessment, dressing changes, or IV fluids, and the TAR contained no documentation of dressing changes, assessments, or catheter care. Staff later confirmed the dressing had not been changed since insertion and that there was no documentation of monitoring or care of the IV catheter. Resident #4 was admitted with diagnoses including ESBL Klebsiella pneumoniae wound infection to both heels and had a midline IV reinserted with a clear dressing dated 4/17/26 that also contained rusty brown-colored substance on gauze underneath the dressing. The record showed no physician orders for midline IV care other than the re-insertion order, and the April 2026 TAR had no documented care, assessment, dressing changes, monitoring, or flushes for the catheter. An LPN confirmed the dressing had not been changed since insertion, and the LPN and Staff Development Coordinator confirmed there were no orders or documentation for care or monitoring of the midline IV site. The DON stated nurses should place orders for newly placed IVs to include site monitoring, dressing changes after the first 24 hours, weekly and as-needed dressing changes, and flushes. The facility policy stated the insertion site should be observed every shift and with dressing changes, with the initial dressing changed within 24 hours and then every five to seven days or as needed.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices related to transmission-based precautions for a resident on contact isolation for ESBL in bilateral heel wounds. The resident was admitted with diagnoses including Extended-Spectrum Beta-Lactamase (ESBL), Klebsiella pneumoniae wound infection to both heels, and the current physician orders placed the resident on contact isolation every shift for ESBL in the heel wounds. A sign on the room door indicated contact precautions and specified that gown and gloves were required before entering the room for the resident in bed A. While the resident was awake and alert in bed, a Social Service Assistant entered the room without donning a gown or gloves, despite the posted contact precaution signage. The assistant went to the resident’s bedside, shook the resident’s hand while speaking with her, then approached the roommate in a wheelchair near the window and patted the roommate on the shoulder with a bare hand before going to the bathroom, washing hands, and exiting the room. The DON observed the assistant enter without PPE and later confirmed the event, and the assistant stated she had not noticed the resident was on contact isolation until directed to the sign on the door.
Facility Fails to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) Comprehensive Assessments within the regulatory time frame for five residents. Resident #82's Annual MDS assessment was completed four days late, while Resident #88's Significant Change MDS assessment was two days late. Resident #227's Admission MDS assessment was nine days late, and Resident #228's Admission MDS assessment was twelve days late. Resident #233's Admission MDS assessment was incomplete and seven days late at the time of review. The MDS Coordinator acknowledged the delays and explained that the facility's process involved daily reviews of the MDS in progress list with the Interdisciplinary Team (IDT) to remind them of due dates and incomplete sections. The Regional Director of Clinical Reimbursement noted that the facility was behind and faced challenges in completing specialized sections on time. The facility's standards and guidelines require comprehensive assessments at least every three months, following the CMS Resident Assessment Instrument (RAI) guidelines.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Quarterly Assessments were completed within the regulatory time frame for two residents. Resident #63's Quarterly MDS assessment was completed 23 days late, and Resident #111's assessment was completed 7 days late. The MDS Coordinator acknowledged the late completion of these assessments and noted that there had been ongoing issues with timely completion since she started working at the facility. The facility's process involved reviewing the list of due assessments each morning with the Interdisciplinary Team (IDT), but this process did not prevent the delays. The Director of Nursing (DON) confirmed awareness of the ongoing issue with late MDS assessments and mentioned the absence of a Social Worker as a contributing factor. The Regional Director of Clinical Reimbursement also identified multiple additional incomplete and late assessments. The facility's job description for the MDS Nurse-LPN emphasized the importance of completing required documentation accurately and timely, and the facility's standards required assessments to be conducted no less than every three months. Despite these guidelines, the facility did not adhere to the required timelines for MDS assessments.
Inadequate Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to maintain adequate communication with the dialysis center and ensure post-dialysis assessments were completed for a resident with end-stage renal disease (ESRD) who required dialysis. The resident, who had intact cognition and no behavioral symptoms, received dialysis treatments three times a week. However, a review of the Dialysis Communication Records from January to June 2024 revealed multiple instances of missing or incomplete documentation from both the dialysis center and the facility's nurses. Out of 29 forms reviewed over five months, only 8 forms had all sections completed, indicating a significant lapse in communication and documentation. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the 100 hall Unit Manager (UM), revealed that the facility's protocol involved sending a communication form with the resident to the dialysis center, which was to be completed by both the facility and the dialysis center. Despite attempts by the UM to address the issue through emails and phone calls to the dialysis center, the communication forms continued to be returned incomplete. The UM acknowledged the incomplete records and stated that the expectation was for nurses to complete the documentation upon the resident's return and to inform the dialysis center when records were not completed. The facility's policy required the nursing staff to review and complete the communication forms and coordinate with the resident's physician and other departments as needed, which was not consistently followed in this case.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to properly administer Midodrine, a medication used to treat low blood pressure, to a resident over a four-month period. The resident, who had multiple diagnoses including hypotension, was prescribed Midodrine with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, the medication was administered 110 times when it should have been held, as the nurses did not adhere to the physician's parameter orders. This oversight was not identified by the nursing staff or the consultant pharmacist during their monthly reviews. Interviews with the nursing staff revealed a lack of awareness and understanding of the medication's purpose and the specific parameters for its administration. Several nurses, including RNs and LPNs, admitted to administering Midodrine without holding it as ordered, due to misunderstandings about the correct SBP threshold. The consultant pharmacist also failed to identify these errors during her reviews and did not report any discrepancies. The Director of Nursing confirmed the oversight and acknowledged that the pharmacist should have detected the errors during the monthly drug regimen reviews.
Improper Dish Drying Practices
Penalty
Summary
The facility failed to ensure that dishes were handled in a manner to prevent bacterial growth. During a kitchen tour, it was observed that plastic pellet bases were wet nesting, and cups and bowls were inverted on trays in a way that did not allow them to completely air dry. A Dietary Aide mentioned that the bases were kept stacked on top of each other next to the tray line for service, and when one base was removed, it was noted to be wet. The Dietary Manager acknowledged the need for liners between dishes and trays and a different storage method to prevent wet-nesting, emphasizing the importance of airflow to prevent bacterial growth.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders for two residents. Resident #327, who was admitted with diagnoses including heart failure and shortness of breath, had a physician order for continuous oxygen at 2 liters per minute. However, observations revealed the oxygen concentrator was set at 4.5 liters per minute. The LPN acknowledged the discrepancy but could not explain who set the oxygen at the incorrect rate. The Unit Manager and Director of Nursing confirmed the expectation that nurses should verify and ensure the correct oxygen flow rate as per physician orders. Resident #90 had an order for continuous oxygen at 2-4 liters per minute, but observations showed the oxygen was not being administered, and the nasal cannula was not connected. The LPN stated the resident's oxygen saturation was 94, and the resident was known to pull out the nasal cannula. Despite this, the oxygen was not administered, and the order was later changed to as-needed oxygen. The RN acknowledged the resident did not receive oxygen as ordered, and the electronic MAR indicated oxygen was signed off as provided, despite it not being administered.
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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 Lake Mary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Island Lake Center | 4.3 mi | ★★★★★ | 11 | 0 |
| Longwood Health And Rehabilitation Center | 4.9 mi | ★★★★★ | 2 | 0 |
| Village On The Green | 5.6 mi | ★★★★★ | 0 | 0 |
| Healthcare And Rehab Of Sanford | 6.5 mi | ★★★★★ | 5 | 0 |
| Life Care Center Of Altamonte Springs | 6.7 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.