Above 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 Spring Hill during CMS and state inspections, most recent first.
The facility did not ensure accurate MDS assessments for three residents. One resident's discharge status was incorrectly recorded as a discharge to home instead of a hospital transfer. Another resident's use of antidepressant medication was not documented in the MDS, and a third resident's active diagnosis of hypertension was omitted from their assessment. Staff confirmed these discrepancies during interviews.
The facility did not accurately complete PASRR screenings for three residents with documented mental health diagnoses, including schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. Despite physician orders and psychiatric notes confirming these conditions and ongoing treatment, the PASRRs failed to reflect the residents' mental illnesses, as confirmed by the DON.
A resident with COPD, heart failure, and a cardiac pacemaker was receiving PRN oxygen therapy and permitted to self-administer medications, but the facility did not develop a care plan addressing oxygen administration or self-administration. Staff confirmed the absence of a care plan despite documented use of oxygen and facility policy requiring individualized care planning.
Two residents received wound care without physician orders, and dressings were not consistently dated or initialed as required by facility policy. Staff and DON interviews confirmed that wound care was performed without proper orders and documentation.
Two residents received oxygen therapy without proper physician orders specifying flow rate or administration, contrary to facility policy. One resident received oxygen at a set flow rate with only a general comfort order, while another received oxygen with no order for administration at all. Staff interviews confirmed that orders should include specific details to ensure safe respiratory care.
A resident receiving hemodialysis did not have pre- and post-dialysis vital signs or observations documented on multiple occasions, and several required communication records were missing. Interviews revealed that staff were not consistently educated or following the facility's policy for dialysis assessment and documentation.
Surveyors found that medications, including antifungal and medicated powders, were left unsecured at the bedside of two residents, and an IV fluid bag and tubing for a resident were not properly dated. Staff confirmed that medications should not be left unsecured and that IV bags and tubing must be labeled according to facility policy.
Several residents receiving insulin therapy had incomplete or inaccurate medical records, including missing documentation of blood glucose levels, insulin administration, and provider notifications when insulin was held or refused. Staff interviews confirmed that insulin was sometimes given or withheld without proper documentation, and required communications with providers were not always recorded, contrary to facility policy.
A resident was prescribed Erythromycin Ophthalmic Ointment for an eye infection without a specified end date, and the antibiotic order remained active without clear duration. Staff interviews confirmed that antibiotic orders should have a stop date, and facility policy required this, but the order was left open-ended while awaiting provider evaluation.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the progress notes indicated an emergent transfer to the hospital, but the MDS discharge status was incorrectly coded as a discharge to home/community. This discrepancy was confirmed by both the MDS RN and the Director of Nursing during interviews. Another resident had a physician's order for daily Sertraline for depression, but the quarterly MDS did not reflect the use of antidepressant medication. Additionally, a third resident had an active physician's order for Atenolol to manage hypertension, yet the quarterly MDS did not indicate hypertension as an active diagnosis. In each case, staff interviews confirmed the inaccuracies in the respective MDS sections.
Failure to Accurately Complete PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure accurate completion of the Preadmission Screening and Resident Review (PASRR) for three out of five residents reviewed for mood and behavior disorders. For one resident admitted with schizoaffective disorder and major depressive disorder, the PASRR did not document any mental illness, despite physician orders and psychiatric notes confirming these diagnoses and ongoing treatment with psychotropic medications. The Director of Nursing (DON) acknowledged that the PASRR screening was not reviewed until about seven days after admission and confirmed that the screening needed revision to include the resident's mental health diagnoses. Similarly, two other residents with documented diagnoses of major depressive disorder and, in one case, generalized anxiety disorder, had PASRR screenings that failed to reflect their mental illnesses. Both residents were receiving medications for their conditions, and psychiatric notes indicated ongoing management of their mental health needs. The DON confirmed that the PASRRs for these residents were also inaccurate, indicating a pattern of incomplete or inaccurate preadmission screenings for residents with mental health diagnoses.
Failure to Develop and Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical diagnoses, including COPD, heart failure, and a cardiac pacemaker, who was receiving oxygen therapy. The resident's admission record and physician orders indicated the use of oxygen as needed via nasal cannula and permission for self-administration of medications. However, review of the resident's care plan revealed no focus or interventions related to oxygen administration or self-administration of medications, despite documented use of oxygen on multiple occasions. Observations showed the resident managing their own oxygen therapy, with the oxygen tubing found lying on the ground, and the resident reporting self-directed use of oxygen. Interviews with facility staff, including the MDS RN and DON, confirmed the absence of a care plan addressing these needs. Facility policy requires individualized, person-centered care plans to be developed and updated to reflect resident needs, but this was not done for the resident in question.
Failure to Provide Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide appropriate wound care according to physician orders and facility policy for two residents. For one resident, observations revealed a dressing on the left forearm that was changed and re-dated over several days, but there was no physician order for wound care to that area. Staff interviews confirmed that wound care was being performed without an order, and the Director of Nursing acknowledged that staff are not permitted to provide wound care without a physician's order and that dressings should be dated and initialed. For another resident, a gauze-wrapped dressing was observed on the right arm over multiple days, but the dressing was not dated or initialed, and there was no physician order for wound care to that area. Staff interviews confirmed that wound care dressings should be dated and that orders are required for wound care. Review of facility policy indicated that a physician's order is required for dressing application and that dressings should be labeled with the date and initials, which was not followed in these cases.
Failure to Ensure Proper Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who were receiving oxygen therapy. For one resident, observations showed that oxygen was administered via nasal cannula at 2 liters per minute on multiple occasions, but the physician's order only stated 'Oxygen For comfort' without specifying a flow rate. The Director of Nursing confirmed that the order should have included the flow rate, and the LPN interviewed stated that a specific flow rate is expected, especially for residents with COPD, to avoid hyper-oxygenation. For the second resident, observations also showed oxygen being administered at 2 liters per minute via nasal cannula, but there was no physician order for oxygen administration, only an order for oxygen tubing changes. The DON acknowledged the absence of an oxygen order, and a registered nurse stated that orders should be present in the system when a patient is on oxygen. The facility's policy requires that physician orders for oxygen therapy include the administration modality, flow rate, and specific guidelines for use, which was not followed in these cases.
Failure to Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis was properly assessed before and after dialysis treatments. Record reviews showed that on multiple occasions, there was no documentation of pre- and post-dialysis vital signs or observations for the resident. Additionally, there were several dates where no hemodialysis communication documentation was present in the resident's records, despite physician orders specifying the need for regular dialysis treatments. Interviews with facility staff revealed a lack of awareness and education regarding the requirement to complete pre- and post-dialysis assessment forms. The DON acknowledged not having educated nurses on the process, and a LPN described the expected procedure, which was not consistently followed. The facility's own policy required completion of dialysis communication forms and coordination with the dialysis center, but these procedures were not adhered to, resulting in incomplete documentation and assessment for the resident undergoing dialysis.
Failure to Secure and Label Medications and IV Fluids
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly secured and labeled according to professional standards. Specifically, antifungal powder (Miconazole Nitrate 2%) and medicated body powder containing menthol were found unsecured on the bedside tables of two residents over multiple days. Interviews with the residents confirmed that the powders were used daily, and staff interviews revealed that medications are not permitted at the bedside unless the resident has been evaluated for self-administration, in which case the medication must still be locked. Facility policy requires all medications to be stored in locked compartments accessible only to authorized personnel. Additionally, an observation revealed that a resident receiving Dextrose 5% intravenous (IV) fluids had an IV bag and tubing that were not dated, contrary to facility policy. Staff interviews confirmed that both the IV bag and tubing should be dated, initialed, and timed. The facility's policy on intravenous administration specifies that solution containers must be labeled with the start time and approximate completion time, and that labels or tape should be used rather than writing directly on the bag.
Failure to Maintain Accurate Medical Records for Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents who were receiving insulin therapy for diabetes management. For one resident, there were discrepancies in the Medication Administration Record (MAR), including missing or inaccurate documentation of blood sugar levels and insulin administration, as well as a lack of documentation regarding physician notifications when insulin was held or when the resident declined insulin. Staff interviews revealed that insulin was sometimes administered without proper documentation, and in some cases, staff did not record communications with physicians as required by facility policy. Another resident's records showed missing entries for insulin administration and blood sugar monitoring, with no documentation of provider notification when insulin was held due to low blood sugar. Staff interviews indicated that insulin was sometimes held based on clinical judgment, but the required documentation and provider communication were not consistently recorded in the medical record or progress notes. The physician expected to be notified when insulin was held, but there was no evidence of such notifications in the records reviewed. Additional residents had similar issues, including failure to document provider notifications when blood glucose readings exceeded parameters outlined in physician orders, and instances where insulin was administered or held without appropriate documentation or explanation. Facility policy required immediate documentation of medication administration or refusal, as well as documentation of any communication with providers regarding changes in medication administration. These requirements were not consistently followed, resulting in incomplete and inaccurate medical records for the residents involved.
Failure to Monitor Antibiotic Use per Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective antibiotic stewardship program to monitor antibiotic use for one resident. Specifically, a resident was prescribed Erythromycin Ophthalmic Ointment for an eye infection, with the physician order lacking a specified end date. The order was active and ongoing, and the resident had been using the ointment continuously, including prior to admission. Observations showed the resident's left eye was not red or drooping, and no drainage was visible at the time of the survey. Interviews with facility staff, including an LPN, the DON, and the Infection Preventionist, revealed that antibiotic orders typically require a stop date, and the facility was awaiting further evaluation by the provider before assigning an end date to the resident's antibiotic ointment. The facility's own policy required that all antibiotic orders include a duration of treatment, either as a start and stop date or a specified number of days. The lack of a stop date for the antibiotic order was inconsistent with facility policy and standard practice.
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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 Brooksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Woods | 0.2 mi | ★★★★★ | 0 | 0 |
| Oak Hill Health & Rehabilitation | 1.6 mi | ★★★★★ | 2 | 0 |
| Brooksville Healthcare Center | 7.3 mi | ★★★★★ | 10 | 0 |
| Northbrook Center For Rehabilitation And Healing | 7.9 mi | ★★★★★ | 1 | 0 |
| Aviata At Brooksville | 9.3 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.