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 Sarasota during CMS and state inspections, most recent first.
A resident with a history of digestive surgery and cardiac/vascular procedures reported feeling unwell with ongoing bowel movements and later was found hunched over on the toilet, prompting an LPN to call a Code Blue and 911, resulting in transfer to the hospital. A Change in Condition assessment documented unresponsiveness, and a Transfer Assessment was initiated, but both lacked documentation that the resident’s representative was notified, despite facility policy requiring prompt notification and documentation for significant changes and transfers. The DON later learned from the hospital that the representative had been contacted by the hospital during the night, and the LPN Unit Manager stated she informed the representative the next morning but did not document this communication in the medical record.
The facility failed to timely report an allegation of neglect after a resident’s representative stated to the DON and Administrator during a phone call that the resident should have been transferred to the hospital sooner, following the resident’s transfer and subsequent death. Facility policy requires the Executive Director, as abuse coordinator, to ensure allegations are reported promptly to appropriate officials, yet the allegation—recognized by the DON as neglect—was not submitted to the Agency until the following day, after the DON and Administrator delayed reporting while gathering additional information.
A resident with significant mobility impairments sustained a burn after spilling reheated coffee that had not been checked for safe temperature, as required by facility policy. Staff involved were unaware of the policy mandating temperature checks with a thermometer before serving reheated food or beverages, leading to the incident and subsequent injury.
A resident admitted with serious infections did not receive five doses of prescribed IV Oxacillin because the admitting order lacked clarification on dose, frequency, and route. The Unit Manager did not obtain the necessary clarification from the physician, resulting in the medication not being ordered or administered as required by facility policy.
A LTC facility failed to protect residents from medication misappropriation, resulting in missing or improperly administered controlled drugs. In one case, a resident's Hydrocodone was unaccounted for, and the facility's investigation was inconclusive. Another incident involved medications signed out for residents who did not receive them, with the investigation unable to determine if diversion occurred. Additionally, a resident reported receiving a Mucinex tablet instead of his prescribed pain medication. The facility's QAPI meetings lacked documentation of these issues, and the Pharmacy Consultant was not informed.
The facility did not have a system to accurately reconcile and account for controlled substances. The DON described a process involving two nurses signing for narcotics and storing discontinued medications in a locked drawer. However, the DON could not reconcile the medications without manually checking count sheets and medication cards, indicating a lack of systematic accounting.
A LTC facility failed to ensure accurate medication administration for 17 residents, resulting in significant errors. Controlled drugs were signed out for residents who did not request or receive them, and discrepancies were found in narcotic count sheets. An LPN documented administering medications that residents denied receiving, and the facility's investigation was inconclusive. The errors were linked to a nurse experiencing personal issues, and the DON did not provide staff education, considering it an isolated incident.
A resident's wheelchair was in disrepair, with a broken back support and frayed armrests, leading to safety concerns. Despite multiple requests for a replacement, the issue was not addressed until the Regional Nurse Consultant and Director of Nursing were informed. The facility lacked a proper system for logging maintenance concerns, contributing to the delay.
The facility failed to maintain a safe and clean environment, with issues such as stained and torn carpets, non-functioning lights, and improper storage of personal care items. Staff were confused about the new electronic system for reporting maintenance issues, leading to continued use of an outdated maintenance book. Observations also revealed urinals improperly stored and missing toilet tank tops, indicating a lack of proper housekeeping and maintenance procedures.
A facility failed to conduct PASARR Level I and II screenings for a resident with serious mental illness prior to admission. The resident had multiple psychiatric diagnoses and was on antipsychotic medications. The Social Services Director and Administrator confirmed the absence of PASARR documentation, which was the nursing team's responsibility to ensure upon admission.
The facility failed to create comprehensive care plans for two residents with pacemakers, neglecting necessary monitoring and maintenance. Staff interviews revealed a lack of awareness and documentation regarding the pacemakers, and the MDS Coordinator confirmed the absence of care plans for these devices.
A resident with acute vision changes and broken glasses was not assisted in accessing necessary vision services due to insurance issues and lack of follow-up. Despite recommendations for further ophthalmologic evaluation, no appointment was arranged. The Social Service Director faced difficulties scheduling due to insurance, and the Director of Nursing was unaware of the glasses' condition.
A resident with a history of neuromuscular dysfunction of the bladder was found with an unsecured urinary catheter, despite the availability of catheter straps. The care plan did not include securing the catheter, and staff were unaware of the issue, leading to a deficiency in catheter care.
The facility failed to post nurse staffing information daily, with lapses on two consecutive days and inaccuracies on two additional days. Staffing records showed discrepancies in the number of CNAs working compared to what was posted. The weekend supervisor was responsible for updates, but the process failed, leading to non-compliance with federal requirements.
An LPN stored unidentified pills in a medication cart drawer, labeled only with room numbers, due to residents being absent from their rooms. Additionally, a resident was found with medications and an inhaler on his bedside table and in his nightstand drawer without an order to self-administer.
The facility's pest control program was ineffective, leading to flying insects and roaches in residents' rooms. Two residents with intact cognition reported seeing insects and roaches, with one resident noting the issue for over a year. The Director of Maintenance cited air conditioner unit issues as a cause, and documentation lacked evidence of recent pest treatments.
Failure to Notify Resident Representative of Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s representative of a significant change in condition and transfer to the hospital, as required by facility policy. The facility’s policy N-105, “Notification of Change in Condition,” directs nursing staff to promptly notify the resident, attending physician, and resident representative when there is an accident, significant change in physical, mental, or psychosocial status, need to significantly alter treatment, or a transfer or discharge, and to document this notification in the medical record. The resident involved was admitted with diagnoses including surgical aftercare following digestive system surgery, disruption or dehiscence of an internal surgical wound, and a history of cardiac and vascular surgery with an aortocoronary bypass graft. A recent MDS showed the resident had normal cognition and required supervision or touching assistance for transfers and ambulation. On the evening in question, a progress note documented that the resident reported not feeling well for a couple of days, with ongoing bowel movements and feeling too unwell to go out to smoke. After the LPN checked the medication cart for GI-related orders, a CNA urgently summoned her; the resident was then found on the toilet, hunched over and being held up by another CNA. The LPN called a Code Blue, activated 911, and the resident was transferred to the hospital. A Change in Condition assessment completed after midnight documented “Unresponsiveness” but left the section for family representative notification blank, and a Transfer Assessment initiated the same date was also blank. There was no documentation in the clinical record that the resident’s representative was notified of the change in condition or transfer. The DON later stated that the hospital had informed the resident’s nephew (the representative) during the night, and that the nephew called the facility the next morning to ask what had happened. The DON acknowledged the Change in Condition form did not indicate emergency contact notification, and the LPN Unit Manager reported she verbally informed the representative the following morning but did not document this, leaving no record of timely notification at the time of the event.
Failure to Timely Report Allegation of Neglect Related to Resident Death
Penalty
Summary
The facility failed to timely report an allegation of neglect that involved a resident who later died. Facility policy N-1265, effective 11/30/2014 and revised 11/16/2022, states that once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to the proper officials in accordance with Federal and State regulations. According to the facility’s investigation, on 12/26/25 at approximately 8:03 p.m., during a phone conversation with the DON and the Administrator, the resident’s representative stated that he felt the resident should have been transferred to the hospital sooner. The investigation documented that the Administrator became aware of this concern at that time. The DON reported that the resident had been transferred to the hospital on a prior date and that the resident’s representative informed her on the morning of 12/26/25 that the resident had passed away. Later that day, the representative began asking more questions about what had occurred at the facility before the transfer and, during a three-way call with the DON and Administrator, expressed that the resident should have been sent to the hospital sooner. The DON stated she considered this an allegation of neglect. However, the allegation was not reported to the Agency until 12/27/25 at 3:29 p.m., and the DON acknowledged this delay, explaining that she and the Administrator were trying to gather more information and determine if there was anything to add to the report before submitting it.
Resident Burned by Unchecked Hot Beverage Temperature
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis, following a cerebral infarction, suffered a burn injury after spilling reheated coffee on his lap. The incident resulted in a blistered area on the resident's upper right thigh, with medical records confirming a partial thickness burn. The resident did not report pain at the time, but the injury required wound care and follow-up by medical staff. The facility's policy required staff to reheat resident food and beverages to a temperature not exceeding 140 degrees Fahrenheit and to verify this with a thermometer before serving. However, staff involved in the incident were unaware of this policy at the time. The coffee was reheated by a staff member who did not check the temperature, and the beverage was subsequently handed to the resident without verifying its safety. The CNA who assisted the resident was also unaware of the temperature-check requirement and only learned of the burn after the resident reported it the following day. Interviews with staff and review of facility procedures revealed that the policy regarding reheating and temperature checks was not communicated or enforced prior to the incident. Staff members, including the CNA and the individual who reheated the coffee, confirmed they had not received education on the policy before the event. The lack of staff awareness and failure to use the required equipment to ensure safe serving temperatures directly contributed to the resident's burn injury.
Failure to Clarify and Administer Admitting IV Antibiotic Order
Penalty
Summary
The facility failed to ensure that an admitting order for an intravenous antibiotic (Oxacillin) for a resident with diagnoses including septic arterial embolism, bacteremia, and methicillin-susceptible Staphylococcus aureus infection was clarified by the resident's primary care physician upon admission. The facility's Medication Reconciliation policy required that all discrepancies in medication orders, including dosage, frequency, and stop date, be reviewed and clarified with the physician and documented in the resident's medical record. Upon admission, the discharge reconciliation document from the hospital had a question mark next to the Oxacillin order, indicating the need for clarification. However, the Unit Manager did not obtain the necessary clarification, resulting in the medication not being ordered or administered as prescribed. As a result of this failure, the resident missed five doses of the prescribed IV antibiotic. The issue was identified when the DON reviewed new admissions and noted the missing medication on the resident's MAR. Staff interviews confirmed that the nurse responsible for the admission relied on the Unit Manager to complete the paperwork and obtain clarification, but the clarification was not obtained, and the medication was not administered until the error was discovered. The deficiency was directly related to the lack of timely clarification and transcription of the antibiotic order during the admission process.
Medication Misappropriation and Administration Errors in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, leading to several incidents where medications were unaccounted for or improperly administered. In one instance, a resident's Hydrocodone-Acetaminophen tablets were reported missing, and the facility's investigation was inconclusive. The medication was initially signed as received by an LPN, but later could not be located in the medication carts or rooms. The Director of Nursing (DON) confirmed that the medication was eventually found, but there was no documentation to support this claim. The facility's policy required two nurses to sign for controlled drugs, but this procedure was not consistently followed, contributing to the discrepancy. In another incident, controlled medications were signed out for three residents who reported not receiving them. An RN discovered that medications were signed out for residents who typically did not request them, raising suspicions of medication diversion. The DON conducted an audit and interviewed the involved staff and residents, but the investigation was inconclusive. The nurse involved in the incident did not return for her scheduled interview or shift, and the facility could not determine if the medications were diverted or administered incorrectly. Additionally, a resident reported receiving a medication that was not his prescribed pain medication. The resident identified the pill as a Mucinex tablet, which he did not have an order for, instead of his Hydrocodone-Acetaminophen. The facility's investigation into this incident was also inconclusive, and the DON did not provide education to the staff as it was considered an isolated situation. The facility's Quality Assurance Performance Improvement (QAPI) meetings did not document discussions or corrective actions regarding these medication discrepancies, and the Pharmacy Consultant was not informed of the incidents.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to implement a system for periodic reconciliation and disposition of controlled substances, as required by their policy. The Director of Nursing (DON) described the process for handling narcotic medications, which involved two nurses signing when narcotics are received and when the medication is discontinued or the medication card is empty. The DON collects discontinued medications weekly, signs the declining count sheet with a nurse, and stores the medications in a double-locked drawer. However, the DON admitted that she could not reconcile the controlled medications currently stored in the locked drawer without opening it and manually checking the count sheets and medication cards. This indicates a lack of a systematic process to provide an accurate accounting of the medications kept in the locked drawer.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of medication administration for 17 residents, resulting in significant medication errors. The errors were identified through a review of clinical records, facility policies, and interviews with residents and staff. The facility's policy required controlled drugs to be delivered in a sealed container, with two nurses responsible for opening and reconciling the contents. However, discrepancies were found, including medications being signed out for residents who did not request or receive them. For instance, a resident was documented to have received Tramadol and Hydrocodone within an hour, despite not requesting or receiving them. Further investigation revealed that an LPN documented administering medications that residents denied receiving. One resident reported receiving a pill that did not match their prescribed medication, raising concerns about the accuracy of medication administration. The facility's investigation into these incidents was inconclusive, with the DON unable to determine whether the medications were administered correctly or if they were taken by the nurse. The errors were attributed to a nurse who was experiencing personal issues and admitted to having a difficult night. The facility's investigation also uncovered discrepancies in the declining narcotic count sheets, with medications missing or incorrectly documented. Despite the facility's policy for handling controlled drugs, the errors persisted, affecting all residents on the nurse's assignment. The DON acknowledged the errors but did not provide education to the staff, considering it an isolated incident. The lack of clarity in the investigation and the absence of corrective actions highlight the facility's failure to maintain accurate medication administration records.
Failure to Provide Safe Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that a resident had a wheelchair in good working condition, which compromised the resident's safety and comfort. The resident's wheelchair was observed to have a broken back support, frayed armrests covered in black tape, and a torn seat. The resident expressed concerns about the wheelchair being dangerous and not providing adequate support, fearing a potential fall. Despite multiple requests for a new wheelchair, the resident had not received one. The facility's policy required that wheelchairs be maintained in a safe operating condition and that staff notify the rehabilitation department for repairs or replacements. However, the Regional Nurse Consultant and the Director of Nursing were unaware of the wheelchair's condition until it was brought to their attention. The Maintenance Director confirmed that the resident had reported the issue but was instructed to go to therapy, as the wheelchair was beyond repair. The lack of a proper logging system for maintenance concerns contributed to the delay in addressing the resident's needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. A large brown stain and a tear in the carpet were noted in the living room area adjacent to a resident's room, caused by an air conditioner leak. The Maintenance Director acknowledged the issue but faced challenges in obtaining approval for repairs. Additionally, a resident reported that the light over her bed had not been working since she moved into her room months ago, and there was confusion among staff about the new electronic system for reporting maintenance issues, with some staff still using the outdated maintenance book. Further observations revealed multiple issues in various rooms, including missing toilet tank tops, wash basins on the floor, personal care items improperly stored, and urinals hanging from trash cans. In one instance, a urinal with urine was found inside a trash can, and oxygen tubing was lying across it. Staff interviews indicated a lack of awareness and understanding of proper maintenance and housekeeping procedures, contributing to the facility's failure to provide a clean and safe environment for residents.
Failure to Conduct PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Pre-Admission Screening and Resident Review (PASARR) Level I and Level II for a resident diagnosed with serious mental illness prior to their admission. The resident, who was admitted from a general hospital, had multiple psychiatric diagnoses including major depressive disorder, psychophysiologic insomnia, and later developed psychotic disorder with delusions and anxiety disorder. Despite these conditions, there was no evidence of a PASARR Level I or Level II screening in the resident's medical record, as confirmed by the Social Services Director and the Administrator. The resident's medical record showed active orders for antipsychotic medications, and a psychiatric consultation recommended against a gradual dose reduction due to the risk of instability. The Social Services Director admitted to not finding any PASARR documentation and acknowledged that he was not qualified to perform the screening. The Administrator confirmed that it was the nursing team's responsibility to ensure PASARR documentation was present upon admission, but it was missing in this case.
Deficiency in Pacemaker Care Planning
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for two residents with implanted cardiac pacemakers, leading to a deficiency in ensuring proper functioning and maintenance of these devices. The facility's policy required nursing services to coordinate and assist with pacemaker checks, but this was not implemented for the residents in question. Resident #9, who had a history of atrial fibrillation and a pacemaker, was admitted to the facility without a care plan addressing the pacemaker's maintenance. The resident's care plans for nutrition, advanced directives, and terminal prognosis did not include any interventions for the pacemaker, and there was no remote cardiac monitoring device in the resident's room. Interviews with staff revealed a lack of awareness and documentation regarding the residents' pacemakers. The health care surrogate for Resident #9 was unaware of any scheduled pacemaker checks or cardiology appointments, and the LPN was not informed about residents with pacemakers. The MDS Coordinator confirmed the absence of a care plan for the pacemaker and acknowledged the need for one. The DON expected to see physician's orders for cardiology follow-up and maintenance, but these were not present in the resident's records. Similarly, Resident #22's medical record did not include a care plan for the pacemaker, despite the presence of a diagnosis indicating its existence. The resident's care plans for heart-related conditions did not address the pacemaker's care and maintenance. The MDS Coordinator confirmed the lack of a care plan for the pacemaker, indicating a systemic issue in the facility's care planning process for residents with such devices.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident in gaining access to necessary vision services, resulting in a deficiency. The resident, who had diagnoses including morbid obesity, type 2 diabetes, and acute vision changes, was observed with broken glasses taped together. Despite multiple requests to see an eye doctor, the resident was told to wait due to insurance issues. The resident had been sent to the hospital for severe eye pain, and the discharge summary recommended further ophthalmologic evaluation, suspecting conditions like hypertensive or diabetic retinopathy. However, there was no documentation of a follow-up appointment being arranged. Interviews with facility staff revealed that the Social Service Director (SSD) was responsible for scheduling in-house eye doctor appointments but faced difficulties finding a physician to accept the resident's insurance. The SSD was aware of the broken glasses and was waiting for new ones to arrive. The Director of Nursing (DON) mentioned that the resident's insurance had changed, and the new plan did not include vision coverage. Despite the facility offering to pay for the appointment, the resident insisted on going to the emergency room. The DON was unaware of the extent of the damage to the resident's glasses, and the SSD was responsible for handling routine eye visits and appointments for eyeglasses.
Failure to Secure Urinary Catheter
Penalty
Summary
The facility failed to ensure that a urinary catheter for a resident was properly secured, which is necessary to allow free flow of urine and prevent movement and pulling of the catheter line. This deficiency was identified through observation, interview, and record review. The resident, a female with a history of spinal cord compression, intervertebral disc degeneration, neuromuscular dysfunction of the bladder, major depressive disorder, anxiety disorder, severe protein malnutrition, and constipation, was observed on multiple occasions with an unsecured catheter line. The resident confirmed that a catheter strap had not been used to secure the catheter for an entire week. The facility's care plan for the resident included the goal of preventing catheter-related trauma but did not specify securing the catheter to prevent movement and pulling. Additionally, the Kardex, a communication tool for aides, did not include instructions for catheter care or securing the catheter. Interviews with staff revealed that catheter straps were available, but the registered nurse was unaware that the resident's catheter was not secured. The central supply aide confirmed the availability of catheter straps, indicating a lapse in communication and implementation of proper catheter care procedures.
Failure to Post Accurate and Timely Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal requirements for posting nurse staffing information daily. On two consecutive days, the facility did not post any staffing information, and on two additional days, the posted information was inaccurate. Specifically, on 12/9/24, the last posted staffing information was dated 12/6/24, indicating a lapse in daily updates. Furthermore, a review of staffing records for 11/16/24 and 11/17/24 revealed discrepancies between the posted number of Certified Nursing Assistants (CNAs) and the actual number working. The postings inaccurately listed 13 CNAs for both morning and evening shifts, while records showed only 12 CNAs on 11/16/24 and 12 CNAs in the morning and 11 in the evening on 11/17/24. During an interview on 12/11/24, the Staffing Coordinator explained that the weekend supervisor was responsible for updating the postings on weekends, as the coordinator did not work during those times. This indicates a failure in the facility's process for ensuring accurate and timely updates to staffing information, leading to non-compliance with federal posting requirements.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely and in accordance with professional principles. During an observation of the North medication Cart #2, an LPN was found to have stored three clear, plastic medication cups with unidentified pills in the top drawer of the cart. One of the cups contained crushed medications in applesauce, and the other two cups were stacked on top of each other with unidentified pills. The medication cups were labeled with room numbers, and the LPN admitted to placing them in the drawer because the residents were not in their rooms at the time. Additionally, a resident was observed with a medication cup containing a whole white pill and a half of a white pill on his bedside table, along with an unidentified and unlabeled inhaler. Further observation revealed that the resident had three medications stored in his nightstand drawer, including a Symbicort inhaler, Fluticasone Propionate nasal spray, and Besivance antibiotic eye drops. The clinical record review indicated that the resident did not have an order to self-administer these medications.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects and roaches in residents' rooms. Observations revealed small insects flying around the bed of a female resident with no cognitive deficits, who reported seeing these insects for at least two weeks and noted roaches entering her room through the air conditioner. Similarly, a male resident with intact cognition reported seeing roaches in his room and observed flying insects around his trash can for the past year. The Director of Maintenance acknowledged the ongoing issue of pests entering the building, attributing it to stripped-out sleeves around air conditioner units that leave openings for insects. Documentation provided by the Director of Maintenance only included a pest control report for November 2024, lacking evidence of treatment for flying insects in residents' rooms. Additionally, the pest control logbook indicated that the pest control company last visited on December 9, 2024, but did not list the affected rooms for treatment.
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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 Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sarasota Point Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Sarasota Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Aviata At Beneva | 1.9 mi | ★★★★★ | 16 | 4 |
| Birchwood Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 8 | 0 |
| Pines Of Sarasota | 2.6 mi | ★★★★★ | 2 | 0 |
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