Below 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 Palma Sola Bay during CMS and state inspections, most recent first.
A resident in an LTC facility did not receive critical medications for seven days due to a failure in the admission process, leading to serious harm. The resident, with a history of Multiple Sclerosis and other medical conditions, was admitted without her medications being entered into the electronic medical record. This oversight resulted in a hospital readmission with exacerbated symptoms and a hematoma. The error was attributed to a lack of communication between nursing staff during the admission process.
The facility failed to maintain complete and accurate medical records, leading to significant medication errors for two residents. One resident did not receive prescribed medications for a week, and an ineffective antibiotic was administered multiple times. Another resident did not receive Methadone for 77 hours, causing pain and withdrawal symptoms. These deficiencies resulted in worsened conditions and the likelihood of serious injury or death.
A resident experienced a serious change in condition due to bleeding from multiple wounds, which was not addressed in a timely manner by the facility staff. Despite being on blood thinners, the resident's condition was not reported to the physician, leading to a delayed hospital transfer and subsequent death from sepsis and DIC. Additionally, another resident was improperly restrained in a Geri-chair, limiting his movement.
The facility failed to provide timely care and monitoring for three residents, leading to significant deficiencies. One resident experienced a delay in treatment for bleeding wounds and died from sepsis and DIC after not being sent to the hospital promptly. Another resident did not receive vital signs monitoring as ordered, resulting in an unresponsive state and CPR initiation. A third resident's hypotension was not recognized or addressed in a timely manner, despite low blood pressure readings and continued administration of antihypertensive medications.
The facility failed to ensure competent nursing staff, leading to inadequate care for three residents. A resident on anticoagulant therapy experienced unmanaged bleeding, resulting in death due to sepsis. Another resident with respiratory issues was found unresponsive, with vital signs not documented as ordered. A third resident experienced a significant change in condition, with delayed physician notification and emergency care. These deficiencies highlight failures in monitoring, documentation, and communication among staff.
A resident on anticoagulant therapy experienced significant bleeding and vomiting, but the facility failed to conduct a thorough investigation into a neglect allegation. The DON received a complaint about delayed hospital transfer, but the investigation found no care issues. Staff interviews revealed inadequate monitoring and communication with the PCP, who was not informed of the resident's condition, leading to a lack of timely medical intervention.
A resident with severe cognitive impairment and a history of falls was consistently placed in a noisy area by the nurses' station, despite his preference for a quiet environment. The use of a geriatric chair, intended to prevent falls, was not ideal and restricted the resident's movement, as noted by the Director of Rehabilitation and acknowledged by the DON.
A resident with dementia and other health issues was observed with a poorly positioned sling, leading to swelling in her left hand. The facility's care plan did not address the sling use or swelling management. Staff interviews revealed confusion about the resident's condition and treatment, with no referral to a lymph specialist or discussion on treatment changes.
The facility failed to implement an effective infection prevention and control program, as evidenced by the absence of enhanced barrier precaution signage for two residents with indwelling medical devices. Despite care plans indicating the need for precautions, signage and PPE supplies were not provided. Staff interviews revealed reliance on door signage for infection control measures, underscoring the importance of proper signage. The infection preventionist admitted to oversight, acknowledging that precautions should have been implemented upon admission.
Failure to Administer Medications Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors, resulting in serious harm. Upon admission, the resident's physician-ordered medications were not entered into the electronic medical record, leading to a seven-day period where the resident did not receive critical medications such as Prednisone, Amiodarone, Gabapentin, Ferrous Sulfate, and Wellbutrin. This oversight was not discovered until the resident was readmitted to the hospital with a hematoma and exacerbated symptoms of Multiple Sclerosis, including paralysis in her hands, confusion, and low hemoglobin levels requiring a transfusion. The resident, who had a history of multiple medical conditions including Multiple Sclerosis, paraplegia, and major depressive disorder, was admitted to the facility from an acute care setting. Despite having a comprehensive list of medications to be administered, only two out of fifteen medications were ordered by the facility. The failure to administer these medications was attributed to a lack of communication and follow-through between nursing staff during the admission process. The admitting nurse did not complete the medication reconciliation and assumed the oncoming nurse would finish the task, leading to a critical lapse in care. Interviews with the resident, her family member, and facility staff revealed that the resident experienced significant confusion and a decline in her condition during her stay at the facility. The family member expressed concerns about the resident's altered mental status, which was not her baseline, and the lack of treatment for her MS flare-up. The Director of Nursing acknowledged the error and identified a breakdown in the admission process, where the medications were not reconciled or entered into the medical record, resulting in the resident not receiving her prescribed medications.
Medication Errors Due to Incomplete Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, leading to significant medication errors. For one resident, the facility did not complete the medication reconciliation upon admission, resulting in the resident not receiving prescribed medications for a week. Additionally, an ineffective antibiotic was administered multiple times, and two different antibiotics were given simultaneously without consulting the physician. This lack of proper documentation and communication among staff led to the resident experiencing confusion and a decline in their condition. Another resident did not receive their physician-ordered Methadone for approximately 77 hours, causing them to suffer from pain and withdrawal symptoms. The facility staff failed to clarify the physician's order for Methadone in a timely manner, and there was no documentation of contact with the physician to reconcile the discharged medications. This oversight resulted in the resident experiencing significant discomfort and withdrawal symptoms during their stay at the facility. The deficiencies in documentation and medication administration created a situation that resulted in a worsened condition for the residents and the likelihood of serious injury or death. The facility's failure to maintain accurate medical records and ensure proper communication among staff led to the determination of Immediate Jeopardy, which was later removed after corrective actions were taken.
Failure to Respond to Change in Condition and Improper Use of Restraint
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse and neglect by not responding to a serious change in condition in a timely manner. A resident experienced a change of condition due to bleeding from multiple skin wounds, which required several dressing changes over 17 hours. Despite the resident being on blood thinners, the nursing staff did not notify the physician of the multiple dressing changes or the resident's vomiting of blood. The resident was eventually transferred to the hospital, where he died from sepsis and disseminated intravascular coagulation (DIC). Interviews with staff revealed that the resident's bleeding was not adequately addressed. A Licensed Practical Nurse (LPN) changed the resident's dressings multiple times due to saturation but did not notify the physician or document the changes as a change of status. The resident's family member reported the bleeding and vomiting to the nursing staff, but the staff did not take immediate action to send the resident to the hospital. The Primary Care Physician stated that if he had been informed of the bleeding and vomiting, he would have sent the resident to the hospital sooner. Additionally, the facility used a Geri-chair as a restraint for another resident, limiting his movement. The resident was observed in the Geri-chair multiple times, and staff confirmed that the resident could not independently get out of the chair. The use of the Geri-chair was not an ideal intervention for fall prevention, and the Director of Nursing acknowledged that the restriction on the resident's movement was not considered.
Removal Plan
- Resident (#404) was discharged from the facility to the hospital.
- Residents with a BIMS of 10 or greater interviews were initiated to ensure no other allegations of abuse were not reported and investigated. And residents/responsible parties with a BIMS of 9 or less a skin evaluation will be initiated by a licensed nurse.
- Licensed Nurses received education on following a change in condition, proper documentation, monitoring, and communication and reporting of a change in condition in a timely manner.
- Center Personnel received education on ab
Failure to Provide Timely Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice, resulting in significant deficiencies for three residents. For one resident, there was a failure to communicate a significant change in condition to other licensed nurses and the physician, leading to a delay in treatment. This resident experienced bleeding from multiple skin wounds, which required several dressing changes over 17 hours. Despite being on blood thinners, the resident was not sent to the hospital until the following morning, where they subsequently died from sepsis and disseminated intravascular coagulation (DIC). Interviews revealed that the nursing staff did not notify the physician of the multiple dressing changes or the resident's vomiting of blood, which contributed to the delay in receiving appropriate care. Another resident did not receive vital signs monitoring as ordered by the physician. The resident was admitted with several respiratory conditions, including COPD and emphysema, and had an order for daily vital signs monitoring. However, the facility failed to document vital signs from the date of admission until the resident was found unresponsive and CPR was initiated. The lack of vital signs monitoring and documentation was confirmed by the Director of Nursing, indicating a failure to implement physician orders and monitor the resident's condition effectively. A third resident experienced a failure in recognizing and responding to a change in condition related to hypotension. The resident, who had a history of hypertension and other medical conditions, had a documented low blood pressure reading during the day. Despite this, the resident's antihypertensive medications were administered as scheduled. Later, the resident was found to have an altered level of consciousness and a significantly low blood pressure, prompting a call to 911. The facility's policy on notification of change in condition was not followed promptly, contributing to the delay in addressing the resident's hypotensive state.
Inadequate Nursing Competency and Monitoring
Penalty
Summary
The facility failed to ensure competent staff were available to provide necessary nursing services, compromising the safety and well-being of three residents. Resident #404, who was on anticoagulant therapy, experienced multiple episodes of bleeding from skin tears, which were not adequately managed or reported by the nursing staff. Despite the resident's condition and the presence of blood thinners, the staff failed to notify the physician promptly about the bleeding and vomiting episodes. The lack of documentation and communication among the staff led to a delay in sending the resident to the emergency room, ultimately resulting in the resident's death due to sepsis with complications. Resident #94, who had a history of respiratory issues, was found unresponsive and without vital signs. The facility failed to document vital signs as ordered, which could have provided critical information about the resident's condition leading up to the event. The lack of adherence to physician orders and inadequate monitoring of the resident's respiratory status contributed to the failure to identify and address the resident's deteriorating condition in a timely manner. Resident #401, with a history of hypertension and other medical conditions, experienced a significant change in condition, including altered consciousness and hypotension. Despite the resident's declining condition, there was a delay in notifying the physician and initiating emergency care. The facility's failure to monitor vital signs as ordered and to document changes in the resident's condition contributed to the inadequate response to the resident's medical needs, resulting in the resident being transferred to a higher level of care.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect concerning a resident who was on anticoagulant therapy and had multiple wounds. The Director of Nursing (DON) acknowledged receiving a family member's complaint on social media about the resident not being sent to the hospital promptly. The resident, who was on Eliquis, a blood thinner, had been experiencing bleeding and had saturated dressings on his arms. Despite these issues, the DON stated that the investigation did not find any problems with the care provided. Interviews with staff revealed inconsistencies in the care and monitoring of the resident. A Registered Nurse (RN) mentioned that the resident had been sent to the hospital for bleeding, but she did not participate in the investigation. A Licensed Practical Nurse (LPN) reported that the resident had multiple skin tears and was bleeding, but the dressing used was not appropriate for the amount of bleeding. The LPN notified the physician about the bleeding, but the physician was not informed of multiple dressing changes or the resident vomiting blood, which would have prompted a hospital evaluation. The Primary Care Physician (PCP) stated that he was not adequately informed about the resident's condition, including the bleeding and vomiting episodes. The PCP indicated that if he had been aware of these issues, he would have sent the resident to the hospital. The investigation conducted by the previous Nursing Home Administrator was based on chart reviews and staff interviews, but the complete investigation notes were not available. The facility's policy on abuse and neglect requires thorough investigations, but this was not adequately followed in this case.
Failure to Honor Resident Preferences for Quiet Environment
Penalty
Summary
The facility failed to honor the preferences of a resident with severe cognitive impairment, who was consistently placed in a noisy area by the nurses' station despite his preference for a quiet environment. The resident, who has a history of traumatic brain injury, Parkinson's Disease, dementia, and seizures, expressed a desire to rest in his bed rather than being seated in a geriatric chair facing the nurses' station. The care plan for the resident, initiated due to a fall with minor injury, included placing him in common areas, which led to his placement in the noisy environment. Interviews with staff revealed that the use of a geriatric chair was intended to prevent falls, as the resident was considered a fall risk. However, the Director of Rehabilitation noted that geriatric chairs could decrease resident function and were not ideal for fall prevention. The Director of Nursing acknowledged that the restriction imposed by the geriatric chair was not ideal and had not been considered. Despite these concerns, the resident was repeatedly observed in the geriatric chair facing the nurses' station, indicating a failure to accommodate his preferences for a quieter resting area.
Deficiency in Comprehensive Care Plan for Sling Use
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident regarding the use of a sling for her left arm. The resident, who has a history of dementia, COPD, metabolic encephalopathy, and muscle weakness, was observed multiple times with a sling that was improperly positioned, resulting in her left hand being swollen and resting on her thigh. Despite the presence of a care plan addressing the resident's risk for mood and behavior changes, there was no specific intervention related to the use of the sling or management of the swelling. Interviews with staff revealed a lack of clarity and consistency in the management of the resident's condition. Staff members, including a CNA and an RN, were unsure of the reasons for the resident's arm swelling and the effectiveness of the sling. The RN mentioned that therapy was involved but was unaware of any specific treatment for edema. The DON acknowledged the lack of a referral to a lymph specialist and the absence of a discussion on treatment changes. The MDS Coordinator was aware of the swelling but did not have information on the use of a compression sleeve, indicating a gap in communication and care planning.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement an effective infection prevention and control program, as evidenced by the absence of enhanced barrier precaution signage on the doors of two residents. Resident #297, who was admitted with an intravenous (IV) port and dressing, did not have the required signage or a storage bin with personal protective equipment (PPE) supplies outside their door. Despite having a care plan indicating the need for enhanced barrier precautions due to the use of an indwelling medical device, there was no physician order for these precautions, and Resident #297 was not listed on the facility matrix for enhanced barrier precautions. Similarly, Resident #81, who had a percutaneous endoscopic gastrostomy (PEG) tube, Foley catheter, and colostomy, also lacked the necessary enhanced barrier precaution signage on their door. The care plan for Resident #81 indicated the need for enhanced barrier precautions due to the use of indwelling medical devices and chronic wounds, but the signage was not in place. Interviews with staff members revealed that they rely on door signage to determine the necessary PPE for infection control, highlighting the importance of proper signage for effective infection prevention. The facility's infection preventionist acknowledged the oversight, stating that enhanced barrier precautions should have been implemented for both residents upon admission due to their medical conditions. The infection preventionist admitted to missing the placement of signage and PPE bins, which should have been done by the Director of Nursing or unit manager in her absence. The facility's policy requires enhanced barrier precautions for residents with wounds and/or indwelling medical devices, and signage should be posted to indicate the type of precautions and PPE required.
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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 Bradenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park Health Center By Harborview | 1.2 mi | ★★★★★ | 6 | 0 |
| Surrey Place Healthcare And Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Inn At Freedom Village, The | 1.4 mi | ★★★★★ | 2 | 0 |
| Casa Mora Rehabilitation And Extended Care | 1.5 mi | ★★★★★ | 8 | 3 |
| Westminster Point Pleasant | 3.8 mi | ★★★★★ | 6 | 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.