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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At The Harbor during CMS and state inspections, most recent first.
Failure to Honor Guardian Advocate Communication Rights: A resident with multiple chronic conditions, including MRSA, stage 3 pressure ulcers, and spina bifida, had a Guardian Advocate authorized to consent to medical treatment, but the facility did not document notifying the representative about repeated refusals of wound care, meds, assessments, labs, or behavioral changes. The family member reported repeated unanswered requests for updates, no informed consents for psychotropic meds, and that she had to personally intervene when the resident became lethargic and not at baseline.
A resident with a court-appointed Guardian Advocate and multiple medical diagnoses was given psychotropic meds, including Buspar, Seroquel, Trazodone, Ativan, and Hydroxyzine, without proper guardian involvement or completed informed consent in the record. The guardian was listed as the emergency contact and had authority to consent to medical treatment, but the facility used resident signatures on consent forms, left the responsible party section blank, and did not produce consent forms for some meds. The NHA said he reviewed the guardianship paperwork but believed an incapacity decision was needed before involving the guardian.
Failure to develop a baseline care plan for advance directives and person-centered care. A resident admitted with multiple complex diagnoses, including MRSA, chronic pain, spina bifida, and stage 3 pressure ulcers, had guardianship documents on file showing a family member could consent for medical treatment. However, the electronic care plan had no advance directives focus area, and staff could not locate the baseline care plan; the NHA said he reviewed the guardian paperwork but did not seek legal guidance, and the MDS Coordinator confirmed the baseline plan was not in the system.
A resident with highly impaired hearing and hearing aids had no care plan focus or interventions for hearing impairment or hearing aid management. The resident stated both hearing aids were missing, the hearing aid case was empty, and staff interviews showed the NHA, LPN, and CNA were unaware the devices were gone; the chart also contained special instructions to remove and charge the hearing aids nightly, but there was no documentation that this was done.
The facility failed to maintain proper food storage and sanitation standards. The walk-in refrigerator was out of service, leading to overpacking of a reach-in refrigerator, which could not maintain safe temperatures for cold foods. Temperature logs were incomplete, and a microwave was found dirty. Staff interviews confirmed the refrigerator issue and expectations for daily log completion. Observations showed cold food items above safe temperatures, requiring disposal.
A facility failed to deliver oxygen according to physician orders for a resident with a tracheostomy, with discrepancies in FIO2 settings and incomplete emergency supplies at the bedside. Another resident also lacked essential emergency tracheostomy supplies, with staff unable to access necessary equipment promptly. The facility's lack of clear policies and staff training contributed to these deficiencies.
The facility failed to ensure safe medication storage, with an inhaler found unsecured on a resident's bedside table, an unlocked treatment cart accessible to residents, and a medication room with improper refrigerator temperatures. Medication carts contained expired medications and personal items, indicating lapses in protocol adherence. A resident with COPD and dementia had an inhaler without an order to self-administer, highlighting deficiencies in medication management.
The facility failed to serve food at appetizing temperatures, as reported by several residents who expressed dissatisfaction with the quality and temperature of meals. A test tray confirmed the food was served below the expected temperature, and the Nursing Home Administrator acknowledged the issue.
The facility failed to implement an effective infection control program, particularly regarding Enhanced Barrier Precautions (EBPs) and PPE use. Observations showed staff did not consistently wear gowns, masks, and gloves during high-contact care activities. Residents with MRSA and gastrostomy tubes reported inadequate PPE use, and staff were often unaware of the required precautions. The facility's policies on EBPs were not followed, leading to inconsistent infection control practices.
The facility's smoking area was found to have significant structural hazards, including bowing wooden planks and beams, overgrown plant-like substances, and a missing light fixture cover. Additionally, a drainage area had an exposed section, and the vertical foundation beams were cracked and splintered. These issues were observed while two residents and family members were present, highlighting a failure to maintain a safe environment.
A facility failed to maintain a medication error rate below 5%, resulting in an 11.43% error rate. Observations revealed that an LPN was unable to provide prescribed medications due to unavailability and administered an incorrect dosage of Guaifenesin. Interviews with staff indicated a lack of clarity and communication regarding medication availability and ordering, and the facility's procedures for handling medication shortages were not effectively followed.
Failure to Honor Guardian Advocate Communication Rights
Penalty
Summary
The facility failed to ensure the rights of a resident representative, appointed as Guardian Advocate and authorized to consent to medical treatment, were honored in relation to communication about the resident’s health status. The resident’s family member reported that she had been appointed Guardian Advocate in October 2025 and had provided the paperwork to the Admissions Director at admission, but she repeatedly contacted the facility for updates and did not receive return calls. She also stated she had not signed any informed consents for psychotropic medications and that, after visiting the facility and finding the resident lethargic and not at baseline, she requested transfer to the hospital, after which the resident received care. The resident was admitted on 04/23/2026 and later discharged. The clinical record identified the same family member as Emergency Contact and Guardian, and the guardianship paperwork appointing her as Guardian Advocate with authority to consent to medical treatment was scanned into the record on admission. The resident had diagnoses including malfunction of a continent urinary stoma, muscle weakness, MRSA infection, neuromuscular bladder dysfunction, fibromyalgia, chronic pain syndrome, stage 3 pressure ulcers, and spina bifida. The care plan contained no advance directive care plan. Nursing progress notes documented repeated refusals of wound care, medications, assessments, vital signs, labs, and evaluations, along with behavioral episodes such as screaming, combativeness, and refusal of care on multiple dates, but there was no documentation that the Guardian Advocate was notified of these refusals, behavioral changes, or other concerns. The NHA stated he reviewed the guardian paperwork at admission but believed the facility needed a determination of incapacity and had not contacted legal for guidance.
Failure to Involve Court-Appointed Guardian in Treatment and Psychotropic Consent
Penalty
Summary
The facility failed to ensure that the legally appointed Guardian Advocate was notified of and involved in health care decisions for one resident, including decisions related to psychotropic medications. The resident’s court-appointed Guardian Advocate had authority to consent to medical treatment, and the guardianship paperwork was scanned into the chart on 04/23/2026. The resident’s face sheet also listed the same family member as the emergency contact/guardian with phone number and email, but the family member reported they were not contacted for updates, did not sign any informed consent forms for psychotropic medications, and only became concerned after a visitor raised issues about the resident’s care. Record review showed the resident was admitted with multiple diagnoses, including malfunction of urinary tract stoma, neuromuscular dysfunction of the bladder, fibromyalgia, chronic pain syndrome, and pressure ulcers. The consent to treat form was signed by the resident, with the responsible party section left blank, and psychotropic medication consent forms for Buspar, Seroquel, and Trazodone were signed by the resident rather than the guardian. The MAR also showed Ativan IM doses and Hydroxyzine doses were administered without informed consent in the record, and the facility was unable to produce completed consent forms for those medications during the survey. The NHA stated he reviewed the guardianship paperwork at admission but believed an incapacity decision was required before involving the guardian.
Failure to Develop Baseline Care Plan for Advance Directives
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission to address Advance Directives and person-centered care for one resident. Resident #1 was admitted with diagnoses including malfunction of continent stoma of urinary tract, muscle weakness, MRSA infection, neuromuscular dysfunction of bladder, fibromyalgia, chronic pain syndrome, stage 3 pressure ulcers of the left hip and another site, and spina bifida. The resident’s record also contained Letters of Guardian Advocate, dated before admission, showing a family member had been appointed Guardian Advocate with authority to consent for medical treatment. Review of the electronic care plan system showed no advance directives care plan for the resident, and the facility could not locate a baseline care plan. The family member stated she had provided the guardianship documents to the Admissions Director at admission and reported repeated calls to the facility for updates without receiving return calls. The NHA stated he reviewed the guardian documentation at admission but thought an incapacity decision was needed and did not contact the facility’s legal department for guidance. The MDS Coordinator stated Social Services was responsible for the advance directives care plan and confirmed the baseline care plan, which would contain the information, was not available in the system.
Care Plan Missing Hearing Aid Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with hearing impairment and hearing aid management needs. The resident was observed sitting on the side of her bed, partially through breakfast, wearing a hospital gown, and stated that she had lost both hearing aids, with one missing for a while and the second now gone. A hearing aid case was present on the bedside table and was empty, and the resident could not recall when either device went missing. The resident’s record showed an inventory documenting one pair of hearing aids, and the MDS Coordinator confirmed that the resident’s assessments later indicated highly impaired hearing and, on the most recent quarterly assessment, hearing aids were present. Review of the care plan showed a focus on altered self-care performance related to emphysema, glaucoma, and dementia, with interventions for personal hygiene and upper body dressing, but no focus area or interventions addressing hearing impairment, hearing aid use, or staff support for the devices. Staff interviews showed that the NHA was unaware the hearing aids were missing, the LPN stated she did not place hearing aids in the resident’s ears and only learned they were missing after being asked by the Administrator, and the CNA stated he did not put them in and did not know they were missing. The MDS Coordinator stated the hearing-related care plan did not trigger because the full assessment did not capture the presence of hearing aids, and she confirmed the chart included special instructions to remove and charge the hearing aids every night, although the clinical record contained no documentation that nurses performed this task and hearing aid support was not included in CNA task lists.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards, as evidenced by several observations and interviews. The walk-in refrigerator was out of service, leading to all food being transferred to a three-door reach-in refrigerator, which was overpacked and unable to maintain safe temperatures for cold foods. Temperature logs for the freezer, reach-in refrigerator, and three-compartment sink were not completed for two consecutive days. Additionally, a microwave in the 200 Hallway Nourishment room was found to be dirty, with a sticky brown substance inside, indicating a lack of regular cleaning by the responsible staff. Interviews with staff revealed that the walk-in refrigerator had been non-functional since the previous day, and the issue was reported to administration. The Interim Dietary Manager and the new Dietary Manager both acknowledged the expectation for daily completion of temperature logs. Observations of food temperatures showed that several cold food items were above the safe temperature of 41 degrees Fahrenheit, necessitating their disposal. The facility's policies on food storage and preventing foodborne illness were not adhered to, as evidenced by the lack of temperature monitoring and unsanitary equipment.
Deficiencies in Oxygen Delivery and Emergency Tracheostomy Supplies
Penalty
Summary
The facility failed to ensure that oxygen was delivered according to physician orders for a resident with a tracheostomy tube. Resident #91 was observed receiving oxygen via a trach collar connected to an air compressor with varying FIO2 settings, which did not match the physician's order for continuous 2 liters per minute (LPM) of oxygen. The staff confirmed discrepancies in the oxygen delivery settings and acknowledged the absence of a physician order for the FIO2 settings. Additionally, the emergency tracheostomy supplies at the resident's bedside were incomplete, lacking a smaller trach size and a full oxygen tank. Another deficiency was identified regarding the availability of emergency tracheostomy supplies for Resident #83. During an observation, it was noted that essential emergency supplies, such as a bag-valve device, oxygen, and a tracheostomy device one size smaller, were not present at the resident's bedside. The DON stated that these items were available on the code carts in the hallway, but staff were unable to access them promptly during the observation. The facility's lack of a clear policy on emergency tracheostomy supplies and the inconsistent adherence to physician orders for oxygen delivery contributed to these deficiencies. Interviews with staff revealed uncertainty about the necessary supplies and settings for residents with tracheostomies, highlighting a gap in training and protocol adherence. The absence of readily accessible emergency equipment at the bedside poses a risk to residents requiring immediate respiratory intervention.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage of medications, as evidenced by multiple observations of improper medication handling and storage. An inhaler was found on a resident's bedside table without the resident present, indicating a lack of secure storage. Additionally, a treatment cart was observed unlocked in an area accessible to residents, with medications for wound care inside. The medication room on the west wing was found in poor condition, with a refrigerator temperature significantly higher than recommended, and a large piece of ice hanging inside, indicating improper maintenance and monitoring. Further deficiencies were noted in the handling of medication carts. A medication cart on the west wing contained a vial of Novolog past its expiration date, and another cart on the east wing had personal items mixed with medications, as well as insulin pens without proper documentation of opening dates. These observations highlight a lack of adherence to protocols for medication labeling and storage, which are critical for ensuring resident safety and compliance with professional standards. Resident #38, who has a primary diagnosis of COPD and secondary diagnoses including dementia and chronic respiratory failure, was found to have an inhaler on their bedside table without an order to self-administer medication. The resident's care plan did not include a focus area for self-administration of medications, further indicating a lapse in the facility's medication management practices. The facility's pharmacist had previously noted issues with the medication room's refrigerator, but these concerns were not adequately addressed, contributing to the observed deficiencies.
Deficiency in Food Service Temperature and Quality
Penalty
Summary
The facility failed to serve food at an appetizing temperature for five residents, as observed during a survey. Resident #90 expressed frustration with the lack of fresh fruits and vegetables, and the repetitive, over-processed meals. He reported that the food was often cold, and he had difficulty obtaining alternatives from the Always Available Menu. Despite voicing his concerns to the facility, no changes were made, and he continued to receive meals that were not to his satisfaction, such as cold scrambled eggs without toast. Resident #95, who is diabetic, reported not receiving a proper diabetic diet and described the food as having a chemical taste, being cold, and contributing to his weight loss and acid reflux. His weight records showed a significant decrease from June to July. Resident #18 also complained about the food quality, stating that the hot food was cold and the cold food was hot. Similarly, Resident #29, another diabetic resident, mentioned that the food was often not what was on the menu, was burned, and served at incorrect temperatures. Resident #51 echoed these sentiments, describing the food as unappetizing and repetitive. A test tray was requested to assess the food temperature, but it was delivered late and to the wrong location. The Food Service Director measured the food temperatures, which were below the expected 140 degrees Fahrenheit, with items like pork loin and pinto beans being cool to the touch. The Nursing Home Administrator acknowledged that the test tray food was not palatable or at appetizing temperatures, confirming the residents' complaints.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to ensure an effective infection control program, particularly concerning Enhanced Barrier Precautions (EBPs) and the use of personal protective equipment (PPE). Observations revealed that staff did not consistently wear gowns, masks, and gloves when required, particularly during high-contact resident care activities. For instance, Resident #203, who had a gastrostomy tube, reported that staff did not wear gowns during her care, and there was no signage indicating EBPs were in place. Similarly, Resident #202, who was on contact isolation due to MRSA, noted that staff rarely wore the necessary PPE, despite having a PICC line and a wound vac. Further observations highlighted that staff members, including a Licensed Practical Nurse (LPN) and the Activities Director, entered rooms without the required PPE. The LPN administered medication to Resident #83 without proper gown and gloves, acknowledging the mistake. The Activities Director was unaware of the PPE requirements when entering Resident #202's room, indicating a lack of training and communication regarding infection control protocols. The facility's policies on EBPs, revised in August 2022, require specific PPE use during high-contact activities and proper signage to indicate the type of precautions needed. However, the facility did not adhere to these guidelines, as evidenced by the absence of EBP signage for Resident #203 and inconsistent PPE use by staff. Interviews with the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant confirmed discrepancies in the facility's infection control practices, with the ADON needing to review guidelines to determine proper isolation measures.
Structural Hazards in Smoking Area
Penalty
Summary
The facility failed to ensure a safe environment free from potential accident hazards in the designated smoking area. During an observation, it was noted that two residents and two family members were present under a gazebo with structural issues. Specifically, two wooden planks in the gazebo ceiling were not connected to a foundation beam and were bowing down onto the smoking patio. Additionally, other beams above the table used by residents during smoking times were also bowing, though they appeared to be connected to a foundation beam. The gazebo was overgrown with plant-like substances on numerous beams, and three light foundations were similarly affected, with one light fixture missing a cover. A family member expressed surprise that the structure had not already collapsed. Further observations revealed additional hazards, including a drainage area in the center of the gazebo with a metal grate that had an exposed area approximately one to one and one-half inches wide and about one inch in height. The vertical foundation beams were observed to have numerous cracks and splintered wood. Despite these observations, the facility's policy was not provided during the survey, indicating a lack of documentation or adherence to safety protocols.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by an 11.43% error rate observed during a medication administration review. Thirty-five medication administration opportunities were observed, and four errors were identified for one resident. The errors included the unavailability of prescribed medications such as B12, Lansoprazole, and Metoprolol, as well as the incorrect dosage of Guaifenesin being administered. During the medication administration observation, it was noted that the Licensed Practical Nurse (LPN) was unable to provide certain medications as they were not available in the medication cart. The LPN stated that requests for refills had been made, but the medications were still unavailable. The facility's pharmacist confirmed that the pharmacy supplier had received requests for these medications, but there was a delay in delivery. Additionally, the LPN administered an incorrect dosage of Guaifenesin, giving 5 ml of a 200mg/10ml solution instead of the prescribed 200mg/5ml solution. Interviews with facility staff, including the Director of Nursing (DON) and other nursing staff, revealed a lack of clarity and communication regarding the availability and ordering of medications. The facility's policies and procedures for handling medication shortages and errors were reviewed, highlighting the need for immediate action when medications are unavailable. However, the staff did not follow these procedures effectively, leading to the medication errors observed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 359 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Safety Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Oaks Health Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Westchester Gardens Health & Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
| Aviata At Oldsmar | 2.8 mi | ★★★★★ | 0 | 0 |
| Advanced Care Center | 3 mi | ★★★★★ | 5 | 0 |
| Palm Garden Of Clearwater | 3 mi | ★★★★★ | 2 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aviata At The Harbor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.