Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Palm Bay during CMS and state inspections, most recent first.
A resident was discharged from an LTC facility without receiving the necessary medications as ordered by the physician. Despite a discharge plan indicating a safe transition home, the resident's daughter found that the medications were not sent to the local pharmacy or available at home. The facility staff acknowledged the oversight, citing incomplete discharge planning and holiday timing as contributing factors. The prescriptions were not called into the pharmacy until three days post-discharge.
A resident with multiple medical conditions did not have a required urinalysis and culture performed due to a failure in the facility's specimen collection process. An LPN could not recall collecting the specimen, and the lab confirmed it was never received. The facility's logs were incomplete, and the DON acknowledged the expectation for timely collection and communication, which was not met.
A resident with cognitive impairments and a history of wandering eloped from a facility due to inadequate supervision. Despite being under 1-to-1 supervision, the resident removed a security screw from his window and left the facility unnoticed. Staff failed to conduct regular checks, contributing to the incident. The resident's mother located him nearby after being informed of his disappearance.
The facility failed to complete a PASARR for a resident later diagnosed with major depressive disorder and schizophrenia. Despite significant behavioral issues and new diagnoses, the facility did not update the PASARR as required, leading to conflicting information in the resident's medical records and MDS assessments.
The facility failed to ensure accurate PASARR completion for three residents, leading to missed evaluations for serious mental illnesses. One resident's PASARR did not reflect a bipolar disorder diagnosis, another's did not include anxiety and psychotic disorder diagnoses, and a third's Level II PASARR was delayed. The Social Services Director acknowledged these inaccuracies.
A female resident with a complex medical history, including encephalopathy, cognitive communication deficit, dementia, and mobility issues, exited the facility unsupervised and walked 0.3 miles down a heavily trafficked highway before being found by her daughter. The resident had been assessed as a high elopement risk, but the facility did not implement appropriate preventive measures such as a wander prevention device or increased supervision. Multiple staff members were aware of the resident's exit-seeking behaviors and high elopement risk, yet safety interventions were not timely implemented, resulting in Immediate Jeopardy.
A female resident with a complex medical history, including dementia and mobility issues, eloped from the facility despite being assessed as a high elopement risk. The admitting RN did not implement necessary preventive measures, and the receptionist allowed the resident to exit unsupervised. Nursing staff, including an LPN and Discharge Planner LPN, did not take appropriate elopement precautions despite observing exit-seeking behavior.
The facility failed to ensure an appropriate discharge process for two residents, leading to actual harm. One resident was discharged without a wheelchair and necessary home health services, resulting in a fall and hospital readmission. Another resident was discharged with an abdominal wound and did not receive required wound care services due to insurance issues, leaving her in pain and without assistance.
The facility failed to notify residents or their representatives of discharges in a timely manner and did not submit notices to the State LTC Ombudsman. One resident was informed verbally the day before discharge, another's son felt pressured to take her home, and a third learned of her discharge on the same day. The facility's staff had conflicting understandings of their responsibilities, and the policy requiring written notifications was not followed.
The facility failed to implement policies for thorough monitoring and tracking of discharge notifications, leading to repeated deficiencies. Despite re-education and quality monitoring plans, the Social Services Director did not ensure appropriate notification to the Ombudsman, and the Administrator was unaware of the lapse.
A cognitively intact resident's alimony checks were erroneously received and cashed by the facility without her consent, and the facility deducted an amount owed without obtaining written authorization to manage her personal funds. The checks were deposited into the facility's operating account, and the facility's policy was to cover any outstanding balance before issuing a refund.
Failure to Provide Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary discharge medications as ordered by the physician. The resident, a cognitively intact female with multiple medical conditions including cerebrovascular disease, atrial fibrillation, and a history of stroke, was discharged home without her prescribed medications. The discharge plan indicated that the resident would have a safe discharge with medications provided, but upon returning home, the resident's daughter discovered that the medications were neither sent to the local pharmacy nor available at home. The Social Services Director and the Director of Nursing (DON) acknowledged the oversight, noting that the discharge planning process was incomplete due to the departure of the former Unit Manager and the timing of the Christmas holiday, which complicated the situation. The resident's daughter had to retrieve leftover medications from the facility, but only a limited supply of Coumadin was available. The facility's APRN did not call in the prescriptions to the pharmacy until three days after the resident's discharge. Interviews with facility staff and the resident's community pharmacist confirmed the delay in providing the necessary medications. The facility's standards and guidelines for discharge planning were not adequately followed, resulting in the resident being discharged without the required medications, which could have posed a significant risk given her medical history.
Failure to Collect and Submit Laboratory Specimen
Penalty
Summary
The facility failed to ensure a laboratory specimen was obtained and submitted per physician's orders for a resident. The resident, a female with multiple medical conditions including left-side paralysis, cerebrovascular disease, and a urinary tract infection, was supposed to have a urinalysis and culture performed on specific dates. However, the specimen was not collected and submitted as required, leading to a lack of test results. The deficiency occurred when a Licensed Practical Nurse (LPN) took a verbal order for a urinalysis and culture due to the resident's altered mental status but could not recall if the specimen was collected. The Treatment Administration Record indicated that the specimen was marked as uncollected, and the laboratory confirmed that no specimen was received. The Director of Nursing (DON) and other staff were unable to locate the necessary logs to verify the collection and submission of the specimen. The facility's process for handling laboratory specimens involved entering orders into the computer, printing requisitions, collecting specimens, and storing them in the refrigerator for pickup. However, the process was not followed correctly, as evidenced by the missing specimen and incomplete logs. The DON acknowledged the expectation for timely collection and communication of specimen status, but the failure to adhere to these procedures resulted in the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a history of traumatic brain injury, psychosis, and cognitive impairment. The resident, who was moderately cognitively impaired and had a history of wandering and agitation, was supposed to be under 1-to-1 supervision and equipped with an electronic wander alarm device. However, on the night of the incident, the resident managed to remove a security screw from his window and eloped from the facility without being noticed by the staff. The resident's mother was informed of his disappearance and was able to locate him in a nearby parking lot. She expressed concern that the facility staff did not check on her son frequently enough, as he was physically independent. The staff, including a CNA and an RN, admitted to not checking on the resident as often as required, with the CNA last seeing the resident at around 11:00 PM and the RN at 10:00 PM. The facility's guidelines required staff to check on residents at least every two hours, but this was not adhered to in this case. The facility's investigation revealed that the staff failed to conduct regular rounds throughout the night, which contributed to the resident's ability to elope. The resident had been upset due to a failed transfer to an assisted living facility, which may have exacerbated his behaviors. The facility's standards and guidelines for elopement risk were not effectively implemented, as the resident was not identified as being at risk for elopement until after the incident occurred.
Failure to Complete PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a resident who was later identified with a Mental Illness (MI). The resident was admitted with diagnoses including hypertension, type 2 diabetes, and dementia, and had a Level I PASARR completed in the hospital, which indicated that a Level II PASARR evaluation was not required. However, after the resident was diagnosed with major depressive disorder and schizophrenia, the facility did not repeat the Level I PASARR or refer the resident for a Level II evaluation. This oversight was evident in the medical records and Minimum Data Set (MDS) assessments, which showed conflicting information regarding the resident's mental health status and the completion of PASARR evaluations. The resident's medical records indicated significant behavioral issues, including physical behaviors directed toward others and rejection of care, which were documented in the MDS assessments. Despite these behaviors and the new diagnoses, the facility did not update the PASARR as required. Interviews with the Social Service Director confirmed that a new diagnosis should have triggered a review and possible update of the PASARR. The facility's policy and procedure for PASARR also emphasized the importance of ensuring that residents with serious mental illness or intellectual disability receive appropriate care and services, highlighting the facility's failure to adhere to its own guidelines.
Failure to Ensure Accurate PASARR Completion
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed for three residents. Resident #92 was admitted with diagnoses including bipolar disorder, depressive disorder, dementia, and anxiety. However, the PASARR form did not reflect the serious mental illness (SMI) of bipolar disorder. The Social Services Director confirmed that the Level I PASARR was inaccurate and should have been re-done to include the bipolar disorder diagnosis, which would have determined the need for a Level II PASARR evaluation. The Regional nurse also verified that it was the responsibility of the facility's Social Service Department to ensure the PASARR was accurate and re-assessed if necessary. Resident #21 was admitted with diagnoses including cerebral infarction, anxiety disorder, alcohol abuse, brief psychotic disorder, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment indicated severely impaired cognitive skills, and the medical record revealed behaviors of screaming at staff. The Social Service Director acknowledged that the Level I PASARR submitted did not include the anxiety and psychotic disorder diagnoses, making it inaccurate. Another Level I PASARR should have been submitted with the correct diagnoses. Resident #66 was admitted with diagnoses including major depressive disorder, schizoaffective disorder, and type 2 diabetes. The medical record showed a care plan for antipsychotic therapy and behaviors of refusing insulin, food, and medications. The Social Service Director verified that the Level I PASARR completed triggered a Level II PASARR, which had not been submitted until the day of the survey. The facility's policies and procedures required that all SMI and intellectually disabled residents receive appropriate pre-admission screening, and it was the responsibility of Social Services to coordinate and ensure the screenings were conducted and results obtained prior to admission.
Elopement Incident Involving High-Risk Resident with Cognitive Impairments
Penalty
Summary
The facility failed to protect a vulnerable resident, identified as resident #1, from elopement, leading to a deficiency in ensuring the resident's right to be free from neglect. Resident #1, a [AGE] year old female with a complex medical history including encephalopathy, cognitive communication deficit, dementia, and mobility issues, was admitted to the facility from the hospital with a documented high risk of wandering unsafely without 24-hour supervision. Despite being assessed as a high elopement risk, the facility did not implement appropriate preventive measures to mitigate the risk of elopement. On 12/30/23, resident #1 was allowed to exit the facility unsupervised and walked approximately 0.3 miles down a heavily trafficked highway before being found by her daughter at a nearby pharmacy. The facility was unaware of the elopement until the resident was returned. The failure to provide adequate supervision and implement safety interventions for a resident known to be at high risk for elopement resulted in Immediate Jeopardy, placing not only resident #1 but all residents who wandered at risk of serious harm or injury. The deficiency was further highlighted by the facility's lack of timely implementation of safety precautions, including the failure to use a wander prevention device or increase supervision despite clear indications of the resident's elopement risk. The deficiency in protecting resident #1 from elopement was exacerbated by the facility's failure to initiate appropriate interventions despite multiple staff members acknowledging the resident's exit-seeking behaviors and high elopement risk. The lack of implementation of safety measures, such as a wander prevention device or increased supervision, demonstrated a systemic failure in ensuring the safety and well-being of residents with cognitive impairments and mobility issues.
Elopement Incident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent elopement for a vulnerable resident, identified as resident #1 in the report. Resident #1, a [AGE] year-old female with a complex medical history including encephalopathy, cognitive communication deficit, dementia, and mobility issues, was admitted to the facility from the hospital with a documented risk of wandering unsafely without 24-hour supervision. Despite being assessed as a high elopement risk upon admission, appropriate safety interventions such as an electronic wander prevention device or increased supervision were not implemented. This failure led to resident #1 eloping from the facility by walking out of the front entrance when the receptionist unlocked the door for her, ultimately reaching a local retail pharmacy where she was found by law enforcement. The report highlighted various missed opportunities to prevent the elopement of resident #1. The admitting Registered Nurse (RN) failed to implement the necessary preventive measures despite identifying the resident as a high elopement risk. The facility's Receptionist allowed resident #1 to exit unsupervised after unlocking the door, believing she was leaving with a group of visitors when, in fact, she was alone. Additionally, the facility's nursing staff, including the Licensed Practical Nurse (LPN) and Discharge Planner LPN, did not implement elopement precautions such as an electronic wander prevention device or increased supervision, despite observing signs of restlessness and exit-seeking behavior in resident #1.
Inadequate Discharge Planning Leads to Harm
Penalty
Summary
The facility failed to ensure an appropriate discharge process for two residents, leading to actual harm. Resident #21, who had multiple medical conditions including type 2 diabetes, a right below-knee amputation, and chronic heart failure, was discharged home without the necessary equipment and services. Despite being non-ambulatory and requiring substantial assistance, she was sent home without a wheelchair and did not receive the ordered home health care services. This resulted in her falling at home, being readmitted to the hospital, and receiving intravenous antibiotic therapy for a urinary tract infection that was not communicated to her before discharge. Resident #29, who had undergone surgery and had chronic conditions such as rheumatoid arthritis and chronic obstructive pulmonary disease, was also discharged without proper coordination of home health services. She was sent home with an abdominal surgical wound and did not receive the necessary wound care services. The home health agency did not accept her insurance, and she was left without the required assistance, leading to her lying on her couch in pain, unable to change her wound dressing due to her blindness. The facility's discharge planning process was inadequate, as evidenced by the lack of communication and coordination with home health agencies and the failure to ensure that residents had the necessary equipment and services before being sent home. The interdisciplinary team did not adequately address the residents' needs, and the discharge planner did not follow up to confirm that services were in place. This resulted in unsafe discharges and actual harm to the residents involved.
Failure to Notify Residents and Ombudsman of Discharges
Penalty
Summary
The facility failed to notify residents or their representatives of a facility-initiated discharge in a timely manner and in writing, and did not submit a copy of the notice to the State Long-Term Care (LTC) Ombudsman for three residents. Resident #21 was verbally informed of her discharge the day before she went home and was not provided with information on how to appeal the decision or the Ombudsman's contact details. She signed a discharge form as she was being wheeled out of the facility without receiving copies of the documents. Resident #28's son was informed that the insurance did not approve her stay and was not given the option to appeal. He felt pressured to take her home due to her weak condition and was unaware of the LTC Ombudsman's services. Resident #29 learned of her discharge on the same day she was sent home, with no written notification provided to her or her representative. The facility's records showed no evidence of notification to the LTC Ombudsman for any of these residents, and the staff were unclear about the processes for non-Medicare residents and the responsibilities for sending notifications. The Social Services Director (SSD) and the Medical Records Coordinator had conflicting understandings of their responsibilities regarding discharge notifications. The SSD believed the Medical Records Coordinator was responsible for sending notifications to the Ombudsman, while the Medical Records Coordinator thought it was the SSD's responsibility. The facility's policy required that residents and their representatives be notified in writing before a transfer or discharge, and a copy of the notice be sent to the Ombudsman. However, this policy was not followed, leading to the deficiencies identified in the report.
Failure to Implement Policies for Discharge Notifications
Penalty
Summary
The facility failed to ensure the implementation of policies for thorough monitoring of previously identified areas of concern and adequately track performance to ensure prior improvement measures for discharge notifications were realized and sustained. The facility was cited at F623, Notice Requirements Before Transfer/Discharge, during the last complaint survey conducted on 6/07/23. The Plan of Correction (POC) included re-education of the Social Services Director (SSD) and quality monitoring of discharges to ensure appropriate notification to the Ombudsman. However, during the current survey, F623 was again identified with no continued oversight of the previous citation. The Administrator stated that she was ultimately responsible for overseeing the operation of the facility and explained that audits and monitoring processes were performed to remain in compliance. Despite this, the SSD was responsible for the Ombudsman notification, and the Administrator was unaware that this was not being done as required. This indicates a failure in the facility's internal monitoring and communication processes, leading to repeated deficiencies in discharge notifications.
Failure to Obtain Written Authorization for Managing Resident's Personal Funds
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for a resident who was cognitively intact and made all decisions for her care. The resident was admitted with diagnoses including a history of falls, pathological fracture of the right humerus, osteoporosis, and muscle weakness. After her discharge, the facility erroneously received and cashed her alimony checks totaling $1500.00 without her consent. The facility returned the money minus $116.18, which they claimed the resident owed them, but did not obtain her written consent to manage her personal funds or deduct the amount owed. The Business Office Manager (BOM) and her assistant confirmed that the checks were deposited into the facility's operating account and that the facility's policy was to deduct any amount owed before issuing a refund. The BOM acknowledged that the checks were payable to the resident and not the facility, and that they should not have cashed them. The Administrator stated that it was their policy to cover any outstanding balance before processing a refund. The Admission Agreement signed by the resident indicated that the facility would refund any overpayment and that the resident must sign an authorization form for the facility to manage personal funds, which was not done in this case.
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What surveyors actually found near you
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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 Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anchor Care & Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Palm Bay | 1.2 mi | ★★★★★ | 0 | 0 |
| Atlantic Shores Nursing And Rehab Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Melbourne Terrace Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Avante At Melbourne Inc | 4.5 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.