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 The Palms during CMS and state inspections, most recent first.
Surveyors found extensive environmental deficiencies, including a cluttered maintenance shed and exterior grounds with discarded equipment, a broken resident-room window, wasp nests, and fallen gutters left unaddressed. Inside, several cognitively intact residents reported persistent roaches and other pests in their rooms, with observations of dead and live insects, pest debris, large holes in drywall and baseboards, and messy conditions contributing to infestation. One visually impaired resident described fear of unseen pests, while surveyors noted multiple roaches, pest traps behind the toilet, and a large bottle of bug spray on the bedside table. Staff interviews revealed inconsistent use of pest sighting logs, lack of awareness of reporting procedures by some CNAs, and acknowledgment by leadership that toilets, lighting, pest control practices, and scattered items did not meet policy expectations for a safe, clean, and homelike environment.
The facility failed to document and act on grievances raised during resident council and food committee meetings. A cognitively intact resident reported that concerns voiced in council meetings were recorded but never resolved, leading to the same issues being repeated. Meeting minutes showed multiple complaints about housekeeping not cleaning rooms daily, poor customer service, staff using personal cell phones and headphones, maintenance problems without follow-through, and housekeeping moving personal items and using ill-fitting sheets. Food committee minutes documented concerns about tray accuracy, missing condiments, lack of nighttime snacks, overcooked food, dislike of canned fruit, overly strong juice, cold plates, and hard-to-chew canned fruit. None of these concerns appeared on the grievance logs, despite a facility policy requiring staff to initiate grievance forms, log complaints, and complete follow-up, and the NHA acknowledged ongoing challenges and lack of follow-through with grievances from these meetings.
The facility failed to follow professional standards for tracheostomy and oxygen therapy for two residents. One resident with chronic respiratory failure and a trach was observed on humidified O2 via trach mask without a physician order, with visible dried blood and heavy secretions in the mask, undated tubing, water in the oxygen tubing, and missing bedside emergency trach supplies; record review showed missed or undocumented trach tie changes and dressing changes despite standing orders and a care plan requiring oxygen as ordered. Another resident with acute and chronic respiratory failure and a trach was receiving continuous O2 via trach mask with undated tubing and an old-dated bag, had drainage at the trach site, and lacked documented orders for trach care, suctioning, and emergency supplies at the bedside, even though staff acknowledged expectations for every-shift trach care, dating of tubing, and keeping emergency trach equipment at the bedside.
The facility failed to ensure that nursing staff had verified competencies for IV therapy and tracheostomy care. HR records showed most LPN IV certifications as expired or undocumented, yet LPNs administered multiple IV antibiotic and flush doses to two residents without documented IV competency. Two residents with tracheostomies were observed with undated oxygen and trach tubing, missing or inaccessible emergency trach supplies, and visible secretions, while staff could not locate required physician orders for humidified oxygen or trach care details. Documentation on treatment records showed missed or unrecorded trach tie changes, suctioning, and dressing changes, and HR and the DON could not provide evidence of completed trach care competency assessments for nursing staff, despite a facility policy requiring ordered, individualized trach care.
A resident with severe cognitive impairment, total dependence for ADLs, and constant bowel and bladder incontinence was observed sitting in a wheelchair with a blanket over the head, wearing sweatpants soaked through from an unchanged brief and with paper towels soaked in yellow body fluid in the lap. Documentation showed the resident required staff to anticipate needs and be checked routinely for toileting and hygiene. The assigned CNA admitted not performing initial rounds and being unaware of the resident’s condition, while the LPN stated CNAs are expected to complete bedside rounds at shift start and indicated the prior shift likely had not checked on the resident. The DON reported incontinent residents should be checked at least every 2 hours and that this resident should have been changed by the start of the current shift, and facility policy required cleaning after each incontinence episode.
A resident with type 2 DM on sliding-scale insulin had numerous blood sugar readings above the ordered notification threshold over several months, yet there was no documentation that the physician was notified as required. The MAR showed repeated BSLs greater than 400 mg/dL, while the insulin order directed staff to notify the MD for values above this level. In interview, the DON acknowledged that nurses should have notified and documented physician contact for these out-of-parameter results, and that the existing orders still required notification despite an increase in the sliding scale range, contrary to the facility’s own notification-of-change policy.
A resident with functional quadriplegia, right-sided impairments, and a right-hand contracture was repeatedly observed in bed with the hand tightly flexed into the palm and no splint or support in place, and a positioning neck pillow not in use as intended. Records showed the resident had diagnoses including a healed right humerus fracture and Type 2 DM, and had been approved for PT/OT minutes, but staff interviews revealed that nursing, rehab, and restorative therapy each believed another discipline was responsible for managing the contracture and providing ROM. The resident was not on restorative caseload, had not been screened by rehab for the contracted hand, and was not receiving ROM from nursing, despite a facility policy requiring evaluation for contracture prevention on admission/readmission and ROM to inactive extremities as part of daily care.
A resident with severe dementia, dysphagia, and an ordered pureed diet was given the wrong meal consistency and choked during lunch, requiring the Heimlich maneuver. Staff observations and interviews showed the resident was not consistently upright and 1:1 meal supervision was not in place, despite care plan and ST directions for supervised feeding and 90-degree positioning. The resident later had chest x-ray findings consistent with early atelectasis or pneumonia.
Incorrect Diet and Inadequate Meal Supervision: A resident with dementia and dysphagia was supposed to receive a puree diet with 1:1 feeding assistance and upright positioning, but he was observed eating in a reclined Geri-chair without the required supervision. Staff provided the wrong meal consistency, and the resident choked, requiring the Heimlich maneuver. Interviews showed confusion over tray checks and that no nurse was present in the dining room during the meal.
A resident with advanced dementia, severe cognitive impairment, and swallowing difficulty was ordered a controlled carbohydrate diet with pureed texture and thin liquids, but he was served a regular consistency lunch tray instead. He choked in the dining room and staff performed the Heimlich maneuver to dislodge the food. Interviews showed conflicting accounts about whether dietary or unlicensed staff made the error, but staff confirmed the resident received the wrong tray and that the meal ticket and ordered diet did not match.
Failure to Follow Diet, Positioning, and Feeding Assistance Requirements: A resident with dementia and dysphagia was served the wrong diet and choked during lunch, requiring the Heimlich maneuver. Records showed the resident was supposed to receive a pureed diet with thin liquids, upright positioning, and 1:1 feeding assistance, but he was observed eating while reclined and without the required assistance. Staff interviews described confusion about tray accuracy and meal supervision, and no nurse was present in the dining room at the time of the choking event.
The facility failed to follow physician orders for wound care and splint application for three residents. One resident's dressings were not changed as required, leading to soiled and undated dressings. Another resident did not receive the necessary dressing change for a leg wound, and a third resident's wound care orders were not implemented. Additionally, a resident's wrist splint was not applied as ordered, with inconsistent documentation of its use.
The facility failed to ensure the Dietary Manager met the minimum qualifications, as the current manager was not a Certified Dietary Manager (CDM) and lacked Servsafe certification. The Corporate Area Support Manager, who held the certification, was not a full-time employee and only visited occasionally, leaving the facility without a qualified full-time Dietary Manager.
A resident's right to self-determination was not honored as the facility failed to assist him out of bed despite his repeated requests. The resident, with intact cognition and healed wounds, remained in bed over several days due to staff's inability to coordinate the use of a Hoyer lift. The resident's care plan required assistance with transfers, which was not provided, leading to a deficiency in honoring his choices and rights.
A resident's request to change their code status to Full Code was not honored, despite discussions with the DSS and confirmation from the APRN. The resident's medical records incorrectly indicated a DNR status, and the DSS claimed no knowledge of the request. The facility's policy on Advanced Directives was not followed, leading to a deficiency.
The facility failed to maintain a clean and homelike environment in two resident rooms due to leaking air conditioning units. Despite work orders being created, the issues persisted for weeks, resulting in wet linen and musty odors. Staff interviews indicated that maintenance issues were reported electronically, but the NHA was unaware of the problems until the survey. The facility's policy for prompt maintenance action was not followed, leading to the deficiencies.
The facility failed to ensure accurate PASRR screenings for three residents with mental health diagnoses, resulting in the omission of necessary Level II evaluations. Despite having conditions like schizophrenia and dementia, the PASRR Level I Screens incorrectly indicated no need for further assessment. The Social Services Director confirmed the errors, and no Level II PASRRs were submitted, contrary to facility policy.
A resident admitted after a motor vehicle accident experienced inadequate discharge planning, with minimal assistance from the Social Service Director (SSD) and lack of coordination for necessary services. The resident had to personally manage insurance appeals and was discharged with insufficient preparation, leading to a return to the hospital. Facility documentation and policy indicated a failure to effectively execute interdisciplinary discharge planning.
The facility did not follow the pharmacist's recommendations for behavior monitoring for two residents on psychotropic medications. Despite care plans requiring monitoring for medication-related behaviors and side effects, the necessary actions were not taken. The DON acknowledged the oversight, which was contrary to the facility's policy on consultant pharmacist services.
Pest Infestation, Structural Disrepair, and Cluttered Grounds Undermine Safe, Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, sanitary, pest‑free, and homelike environment in multiple areas inside and outside the building. Surveyors observed the maintenance shed full of debris and discarded items, including a toilet, garbage-filled bin, bathroom commode, wheelchair, an opened safe, industrial portable air conditioning units with visible bio growth, multiple garbage cans, and carts. Additional clutter and discarded items, such as a wheelchair, empty plastic bins, a shop vacuum, garbage can lids, and plastic trays, were found outside the kitchen door. The grounds inspection also revealed a large broken resident-room window, wasp nests between windows and screens, and fallen gutter pieces not properly disposed of. A maintenance assistant reported that the shed was full and they were waiting for direction from the Maintenance Director on what to do with the items. The facility also failed to maintain resident rooms in a clean, pest‑free, and well‑repaired condition. One resident reported waking up to a broken window in January and stated they had informed staff and maintenance since the day it occurred, but the repair had been slow. Another resident, admitted with multiple rib fractures, a history of falling, and chronic pain syndrome and assessed as cognitively intact, had a dead insect on the closet floor, a large hole at the ground corner of the window wall with broken drywall and crumbling baseboard, and small pests under the bed. This resident stated they always see roaches and bugs in the room and on the bed and that staff do nothing about it. A CNA confirmed roaches in the closet and under the bed and, when the bed was moved, multiple pest debris and dust were observed; the CNA stated pests are found in rooms that are untidy or have a lot of food or in rooms with men, and was unaware of the pest sighting log. Another cognitively intact resident’s room was observed to be messy, with scattered shoes, stacked cups, a pest in the resident’s personal care pack, and a large hole of crumbling drywall under the window next to the bed; the resident stated no one cares to fix the room and that roaches are always present. A CNA identified the pest as a roach and stated the room tends to have roaches because of its constant condition. A further cognitively intact resident with highly impaired vision reported living in terror of pests crawling on them in bed, especially because they cannot see them. Surveyors observed multiple pests crawling under this resident’s bedside table, pest traps behind the toilet, and a large gallon bottle of pest killer on the bedside table that the resident stated was brought in by family due to the severity of pests in the room. The resident also reported that the light above the bed only worked halfway and that they had reported this for months without resolution, and that the toilet could not be flushed again for at least 20 minutes after one flush and had been reported to nursing without action. During a room observation with the NHA, Director of Maintenance, and Regional Vice President Officer, multiple roaches were found crawling on the wall and floor after the bedside table was moved, and more roaches were found behind items hanging on the wall. The Transportation Director, who visits the resident daily on angel rounds, stated they had not asked the resident about bugs, had not noticed the large bottle of bug spray, and that bug spray is never to be left in resident rooms due to safety concerns. Staff interviews revealed inconsistent use of the pest sighting log, lack of awareness of the log by some CNAs, and acknowledgment by the Director of Maintenance and NHA that pest traps should not be in resident rooms or the kitchen and that the presence of pests, holes in walls, and scattered items on the grounds were unacceptable. Facility policies on maintenance and pest control required daily rounds to identify hazards and prompt reporting and treatment of pest sightings, which were not consistently followed as evidenced by the observed conditions and staff statements.
Failure to Log and Resolve Resident Council and Food Committee Grievances
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without discrimination or reprisal and to make prompt efforts to resolve those grievances, as required by its own grievance policy. A cognitively intact resident, confirmed by a BIMS score of 15 on a recent MDS assessment, reported that concerns raised during resident council meetings were written down but not followed through or resolved, resulting in the same old and new business concerns being repeated each month. The Activities Assistant stated she handwrote resident council minutes and then gave them to the Activities Director to be typed and placed in a binder, but she did not know what happened to the minutes after that point. Surveyors reviewed resident council minutes for several months and found multiple documented concerns that were not entered into the grievance system. In one resident council meeting, residents reported that housekeeping was not cleaning rooms daily and that there was poor customer service. In another meeting, residents voiced concerns about staff using personal items such as cell phones and headphones, maintenance issues and lack of follow-through or resolution with reported issues, and housekeeping staff moving resident items and not returning them, as well as fitted sheets being too small. The facility was unable to provide resident council minutes for one of the months reviewed, further limiting documentation of concerns raised. Similarly, review of food committee meeting minutes showed repeated food- and service-related concerns that were not documented as grievances. Residents reported issues with meal ticket and tray accuracy, lack of condiments on trays, and snacks not being offered at night. Additional concerns included overcooked food, dislike of canned fruit, juice tasting too strong, plates not being hot, canned fruit being too hard to chew, and snacks not consistently available. Despite these documented concerns in both resident council and food committee minutes, the facility’s grievance logs for the corresponding months did not contain entries for these group or individual concerns. The Nursing Home Administrator acknowledged that grievances could come from anyone and should be documented on the grievance log, but stated he was still learning the resident council process and described challenges and lack of follow-through regarding concerns voiced in resident council and food committee meetings, which conflicted with the facility’s written grievance policy requiring initiation, logging, follow-up, and documentation of all complaints/grievances.
Failure to Follow Tracheostomy and Oxygen Therapy Standards for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and services in accordance with professional standards of practice for residents with tracheostomies and oxygen therapy. For one resident with chronic respiratory failure with hypoxia, dementia, dysphagia, aphagia, and tracheostomy status, surveyors observed the resident in bed with a trach mask delivering 2 L/min of oxygen at 28% humidity, despite there being no physician order for humidified oxygen via trach mask in the medical record. The trach mask contained red specks appearing to be dried blood, and large amounts of tannish white secretions were leaking from the trach mask onto a wash cloth. Free water was observed in the lower portion of the oxygen tubing prior to the water collection bag, which was placed on its side in the bed, and there was condensation on the compressor and water on the table below the equipment. Oxygen and trach tubing were not dated as required by the resident’s orders. Further review of this resident’s records showed multiple ordered tracheostomy-related treatments were not documented as completed. The TAR showed no entries for ordered daily trach tie changes on several day shifts, no documentation of as-needed trach suctioning to clear the airway, and missed documentation of tracheostomy site dressing changes on specified day shifts. The care plan for this resident included a focus on risk for respiratory complications related to tracheostomy and an intervention to administer oxygen as ordered, but staff were unable to locate a corresponding oxygen order. Staff interviews confirmed that oxygen therapy requires a physician order, that trach care and suctioning should be documented in the medical record, and that emergency trach supplies, including an extra trach tube and artificial manual breathing unit, were expected to be kept at the bedside. However, staff could not locate a replacement trach tube in the resident’s room. A second resident with acute and chronic respiratory failure with hypoxia, anoxic brain damage, COPD, dysphagia, tracheostomy status, and dependence on supplemental oxygen was observed receiving 5 L/min of oxygen at 28% humidity via trach mask. The oxygen and trach tubing were not dated, and a bag at the bedside was dated more than two weeks earlier than the observation date. Later observation showed clear to white drainage at the trach site. The TAR contained an order to change and date oxygen tubing and bag cover weekly, and an order for continuous oxygen at 5 L/min via trach mask with 28% humidified air, but there were no orders or treatments documented for trach tubing, trach care, suctioning, or emergency trach supplies at the bedside. Staff confirmed that trach care and suction should be provided every shift and as needed, that tubing should be dated when changed, and that emergency trach supplies, including a trach tube, should be at the bedside, yet the replacement trach tube was not readily accessible and was reported to be kept in central supply. The facility’s tracheostomy care policy required trach care to be performed only with a physician order and in accordance with the resident’s individualized plan of care, which was not consistently followed for these residents.
Lack of Verified IV and Tracheostomy Care Competencies and Missing Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies for IV therapy and tracheostomy care. Human Resources (HR) provided an employee list showing that 15 of 19 LPNs had IV certifications listed as expired on a specific date, and HR stated that only four LPNs’ IV therapy certifications could be verified with actual documentation. HR further explained that the remaining LPNs were given a uniform expiration date because there was no documentation of their IV therapy certification. The DON confirmed that HR was responsible for tracking and auditing IV therapy certifications, that the expectation was for LPNs to have IV therapy certification, and that a prior DON had completed an audit that was no longer accessible. Several LPNs interviewed stated they were IV certified, but the HR list showed their IV certifications as expired. For two residents receiving IV antibiotics, the facility did not have documentation that the LPNs administering IV medications had current IV competencies. One resident with cerebral palsy and osteomyelitis had orders for IV cefazolin and heparin/saline flushes; from the medication administration record, 24 of 35 IV cefazolin doses and 24 of 35 heparin/saline flushes were administered by multiple LPNs (Staff F, G, H, I, J, K) without facility documentation of IV competency. Another resident with quadriplegia, sepsis, MRSA carrier status, and a history of UTIs had IV cefepime ordered; 8 of 10 IV doses were administered by LPNs (Staff F, H, K) with no documentation of IV competency. The facility did not provide an IV therapy policy when requested. The facility also failed to ensure competent tracheostomy care and related documentation for two residents with tracheostomies. One resident with chronic respiratory failure with hypoxia, dysphagia, dementia, and tracheostomy status was observed with a trach mask delivering humidified oxygen, with red specks resembling dried blood in the mask, large amounts of tannish white secretions leaking onto a washcloth, free water in the lower tubing, and undated oxygen and trach tubing. Condensation was present on the compressor and water was on the table below the equipment. Repeated observations showed no changes, and staff could not locate a physician order for humidified oxygen via trach mask despite the resident receiving 2 L/min at 28% humidity. The resident’s MAR and TAR contained orders for trach ties, tubing changes with labeling and dating, suctioning with documentation in progress notes, trach dressing changes, and emergency trach supplies at the bedside, but there were multiple days with no documentation of trach tie changes, no entries for suctioning, and missing documentation of trach dressing changes. Staff were unable to locate an extra trach tube at the bedside as ordered. Another resident with acute and chronic respiratory failure with hypoxia, anoxic brain damage, COPD, dysphagia, tracheostomy status, and dependence on supplemental oxygen was observed with a trach mask delivering 5 L/min of oxygen at 28% humidity, with trach and oxygen tubing not dated. A bag on the side table was dated, but the replacement trach tube was not readily accessible. Later observation showed clear to white drainage at the trach site, and the LPN confirmed there were no dates on the tubing and that emergency supplies, including the trach tube, were kept in central supply rather than at the bedside. The TAR showed an order to change and date oxygen tubing and bag cover weekly and an order for continuous oxygen via trach mask, but the medical record contained no orders or treatments for trach tubing, trach care, suctioning, or emergency supplies at the bedside, despite the care plan stating the resident had a tracheostomy and required suctioning and trach care every shift and as needed. HR reported having no documentation of nursing competency assessments for tracheostomy care and suctioning, and the DON confirmed the expectation for documented competencies but was unable to provide a list of such competencies. The facility’s tracheostomy care policy required trach care to be performed only with a physician order and in accordance with the individualized plan of care, but the documented practices and missing orders did not align with these requirements.
Failure to Provide Timely Incontinence and ADL Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate ADL care to maintain grooming and personal hygiene for one resident who was totally dependent on staff for these needs. During an observation, the resident was seen sitting in a wheelchair with a blanket pulled over their head and face, wearing sweatpants that were soaked through from an overly wet brief that had not been changed since the prior shift or the start of the current shift. Paper towels soaked in yellow body fluid were found in the resident’s lap area, and the resident was unable to communicate their needs. The resident’s records showed severe cognitive impairment (BIMS score of 99), dependence for all functional abilities (GG score of 1), and always incontinent of bowel and bladder, with toileting not attempted due to medical or safety concerns. Progress notes documented that the resident was alert with confusion, dependent for most ADLs due to decreased cognitive function and mobility, and incontinent of bowel and bladder, wearing briefs changed by staff as needed. The care plan identified risk for decreased ability to perform ADLs, including toileting and personal hygiene, and noted communication problems requiring staff to anticipate and meet needs based on physical and non-verbal signs, with specific interventions to check the resident routinely and assist with toileting as needed. The CNA assigned to the resident admitted she had not completed initial rounds at the start of her shift and was unaware of the resident’s condition, stating the prior shift must not have changed the resident or informed her of the need. The LPN stated CNAs are supposed to perform bedside rounds at shift start to ensure residents are changed as needed and indicated that the prior shift CNA likely had not checked on the resident all day, noting similar past issues with that CNA. The DON stated incontinent residents should be checked at least every two hours, more frequently if unable to communicate, and that the resident should have been changed by the start of the current shift. The facility’s diarrhea and fecal incontinence policy required residents to be cleaned after each episode of incontinence, and a bladder incontinence/ADL policy was requested but not provided.
Failure to Notify Physician of Repeated Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of blood sugar levels (BSLs) that were outside the ordered parameters for one resident with type 2 diabetes mellitus with hyperglycemia and diabetic peripheral angiopathy on long-term insulin therapy. The resident had a Novolog sliding scale insulin order specifying insulin doses for BSLs from 150 to 450 mg/dL and explicitly directing staff to notify the physician if the blood sugar was less than 70 or greater than 400. Review of the Medication Administration Records (MARs) for November 2025 through January 2026 showed multiple BSL readings above 400, including specific values such as 420, 423, 409, 440, 450, 412, 408, 413, and 436 in January alone. In December, the resident had BSLs above 400 on 19 out of 120 tests, and in November, on 32 out of 120 tests. Despite these repeated out-of-parameter BSLs, the resident’s medical record from November 2025 to January 2026 did not contain documentation that the physician was notified as required by the insulin order. During interview, the DON acknowledged that nurses should have documented notification of BSLs above 400 and stated that although the physician had increased the sliding scale to 450 because the resident’s baseline was higher, the instruction to notify the physician for BSLs greater than 400 had not been changed. The DON confirmed that, given how the current orders were written, there should have been documentation of physician notification when BSLs were above or below parameters. This practice was inconsistent with the facility’s “Notification of Change” policy, which requires prompt notification of the attending physician and resident representative when there is a need to alter treatment significantly or an exacerbation of a chronic condition, and requires documentation of such notifications in the medical record.
Failure to Provide ROM and Contracture Management for Resident With Functional Quadriplegia
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion for a resident with a right-hand contracture and functional quadriplegia. On multiple observations throughout the same day, the resident was seen lying in bed with the right hand in a contracted position, fingers touching the palm, without any splint or support in place. The resident was unable to verbally communicate but could respond by shaking his head. A neck pillow ordered for positioning was observed lying on top of the sheet over the resident’s stomach rather than being used for its intended purpose. The resident’s records showed an admission with diagnoses including an unspecified displaced fracture of the surgical neck of the right humerus with routine healing, Type 2 diabetes mellitus, right-side involvement, and functional quadriplegia. The MDS documented impairments on one side of the upper and lower extremities and no mobility devices. A therapy funding verification form showed the resident had been approved for PT and OT minutes. Interviews revealed that no discipline had assumed responsibility for managing the resident’s contracted hand or providing ROM as part of daily care. An LPN stated the resident was not receiving ROM or routine care from nursing for the contracted hand and believed therapy was responsible for contractures, explaining that therapy would screen and either continue services or refer to restorative therapy. The restorative therapy staff member confirmed the resident was not on the restorative caseload and had never been referred. The Rehab Director stated he had not screened the resident’s contracted hand and believed nursing was responsible for managing it. The DON stated the resident was admitted with a right-hand contracture and that nursing could not do anything for a contracted hand until therapy evaluated and educated nursing on splint management. The facility’s “Contractures, Prevention” policy required that each resident be evaluated for contracture prevention procedures on admission, readmission, and as needed, and specified that residents with inactive extremities should receive ROM to those extremities as part of daily care, which was not occurring for this resident.
Wrong Diet and Inadequate Meal Supervision Led to Choking Episode
Penalty
Summary
The facility failed to ensure one resident was free from neglect when it did not provide the correct physician-ordered diet and did not ensure the resident was upright and supervised during meals. Resident #3 had diagnoses including unspecified dementia, generalized muscle weakness, anxiety, major depressive disorder, convulsions, and constipation. The resident’s MDS showed severe cognitive impairment, mechanically altered diet needs, and therapeutic diet needs. The care plan directed staff to provide the diet as ordered, set up trays, supervise, cue, and assist with meals as needed, and ensure the resident was upright for oral intake. On 11/9/25, the resident was observed in the dining room eating when he choked on food and staff performed the Heimlich maneuver. A physician note documented that nursing reported the resident had been given the wrong food consistency and that staff performed the Heimlich when he was unable to swallow. The note also ordered upright positioning for all PO intake and staff to ensure the resident received the correct food consistency. A chest x-ray later showed early changes of intrapillar atelectasis or pneumonia, with findings favoring atelectasis in the absence of leukocytosis. During later observations on 11/17/25 and 11/18/25, the resident was seen in the dining room seated in a Geri-chair at about 60 to 65 degrees while eating pureed food, and one-to-one supervision was not observed. Staff were observed setting up the tray, but the resident began eating without assistance and had difficulty handling the food on the fork. Interviews and record review showed conflicting accounts about the meal consistency provided, with staff describing that the resident received a regular diet tray instead of the ordered pureed diet. The resident’s speech therapy evaluation documented severe dysphagia, impaired cognition, close supervision for oral intake, and the need for 1:1 feeding assistance with upright positioning at 90 degrees during and after meals.
Incorrect Diet and Inadequate Meal Supervision
Penalty
Summary
The facility failed to ensure residents were free from avoidable accidents when it did not provide Resident #3 the correct physician-ordered diet and did not provide the level of supervision and positioning identified in his care plan and speech therapy evaluation. Resident #3 had diagnoses including dementia, generalized weakness, muscle wasting and atrophy, anxiety disorder, major depressive disorder, convulsions, and constipation. His quarterly MDS showed severe cognitive impairment, and his care plan directed staff to provide the ordered dysphagia puree diet, monitor for chewing and swallowing problems, and set up trays, supervise, cue, and assist with meals as needed. The speech therapy evaluation also documented severe swallowing impairment, impaired cognition, and the need for 1:1 feeding assistance with upright positioning at 90 degrees during meals. During lunch, Resident #3 was observed eating in a Geri-chair positioned at about 60 to 65 degrees on one occasion and about 60 degrees on another, rather than upright. He was observed eating without assistance on one observation and, on another, staff only set up the tray while he began eating unassisted. Staff noted he had difficulty seeing and handling the food on the tray. The resident later choked while eating in the dining room, and staff performed the Heimlich maneuver to dislodge the food. Progress notes and provider documentation stated he had not received the correct food consistency for the meal and that the choking episode involved food being abruptly dislodged. The investigation also showed breakdowns in meal tray verification and supervision in the dining room. A witness stated a new staff member gave Resident #3 a regular diet tray, and multiple staff interviews described confusion about who checked the tray and whether the correct diet was provided. Staff reported there was no nurse present in the dining room during the meal, and one CNA stated she was often the only staff member there. The nurse supervisor later confirmed she was not in the dining room at the time of the choking event and that the assigned nurse was on the floor, not in the dining room. The resident’s tray was later confirmed to have contained regular consistency items, including regular ham, black-eyed peas, and greens, rather than the ordered puree diet.
Wrong Diet Tray Led to Choking Episode
Penalty
Summary
The facility failed to ensure a resident received the physician-ordered therapeutic diet. The resident had advanced dementia, severe cognitive impairment, swallowing difficulties, and orders for a controlled carbohydrate diet with pureed texture and thin liquids. His care plan directed staff to provide the ordered diet, supervise meals as needed, and monitor for signs of aspiration. Records also showed a long history of texture-modified diet orders, including a pureed diet order in place before the incident. On the day of the event, the resident was in the dining room for lunch and was given a regular consistency meal instead of the ordered pureed diet. A staff member observed him choking on food, and staff performed the Heimlich maneuver to dislodge the food. The resident was removed from the dining room after the episode. A physician later documented that nursing reported the resident had not received the correct food consistency and that staff had performed the Heimlich maneuver when he was unable to swallow the food. Interviews and record review showed conflicting accounts about where the error occurred, but multiple staff confirmed the resident received the wrong tray or wrong food consistency. A CNA stated the resident received a regular diet tray and should have received pureed food. A receptionist who helped pass trays stated she did not know she had to check diet tickets and confirmed she gave the resident his tray. Dietary staff described the tray line process and acknowledged interruptions during meal service. The meal ticket for the resident reflected a dysphagia mechanical diet, while the resident’s active order was pureed texture with thin liquids. The facility’s investigation identified that dietary staff prepared the incorrect diet consistency and an unlicensed staff member served the incorrect meal tray.
Failure to Follow Diet, Positioning, and Feeding Assistance Requirements
Penalty
Summary
The facility failed to ensure nursing staff were competent to provide care for residents with swallowing needs, therapeutic diets, and positioning requirements. Resident #3 had diagnoses including dementia, generalized weakness, and dysphagia-related concerns, and his record showed a pureed, consistent carbohydrate diet with thin liquids, along with care plan interventions for meal setup, supervision, cueing, and assistance as needed. The speech therapy evaluation documented severe swallowing impairment, impaired cognition, and a recommendation for 1:1 feeding assistance, slow rate of intake, and upright positioning at 90 degrees during and after meals. On 11/9/25, Resident #3 was observed in the dining room eating lunch when he choked on food and staff performed the Heimlich maneuver. The physician note stated nursing reported he had not received the correct food consistency for his meal. A later interview with a cognitively intact resident who witnessed the event stated a new staff member gave Resident #3 a regular diet tray while he was in a recliner chair, and that no nurse was present in the dining room during lunch. Staff accounts also described the resident as being in a Geri-chair or recliner and not positioned upright when the choking occurred. Record review and interviews showed the resident’s diet orders, care plan, and speech therapy recommendations were not followed during meals. Observations on 11/17/25 and 11/18/25 showed Resident #3 seated at about 60 to 65 degrees while eating a pureed meal, and he was observed eating without assistance despite documentation that he needed setup, supervision, cueing, and 1:1 feeding assistance. Staff interviews also indicated confusion about tray-line responsibilities, meal ticket accuracy, and who was responsible for checking diets and assisting residents during meals. The report states these failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in Immediate Jeopardy.
Failure to Adhere to Physician Orders for Wound Care and Splint Application
Penalty
Summary
The facility failed to ensure proper dressing changes and adherence to physician orders for three residents. Resident #147 reported that his dressings on his hand and arm were not changed as required, leading to visibly soiled and undated dressings. The Treatment Administration Record (TAR) confirmed that several dressing changes were missed on specific dates, despite clear physician orders for daily care. Resident #47 also experienced a failure in receiving the necessary dressing change for a wound on his right lower leg, which was observed to be soiled and undated. The facility's policy required documentation of dressing changes, which was not adhered to in these cases. Resident #68's care was compromised as the facility did not implement the wound care orders provided by a Nurse Practitioner. The resident's right lower extremity, which had a venous wound, was observed without a dressing, and the prescribed treatment was not documented in the TAR. The facility's staff failed to apply the necessary dressings consistently, and the Director of Nursing acknowledged the lack of a PRN order for dressing changes, which should have been obtained. Additionally, the facility did not apply a wrist splint for Resident #37 as ordered. The splint was observed lying unused on the bedside dresser over several days, and the TAR showed inconsistent documentation of its application. The resident's care plan required the application of the splint to prevent complications from contractures, but there was a communication error regarding who was responsible for applying it. The Director of Nursing confirmed the lack of documentation on the resident's tolerance of the splint, indicating a failure to follow the prescribed care plan.
Dietary Manager Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the minimum qualifications for the position. During an interview, the Dietary Manager, identified as Staff B, admitted to not being a Certified Dietary Manager (CDM) and not having a Servsafe certification, although she planned to obtain it soon. Staff B had been working as the Dietary Manager since November 2023, but there was no verification of her qualifications for the role. The facility's records showed that Staff A, a Corporate Area Support Manager (CASM), held a Servsafe Certification, but he was not a full-time employee and was not listed on the facility's employee list as he worked for a contracting company and traveled between facilities. Interviews with the facility's Administrator and Human Service Director (HSD) revealed that Staff A, CASM, was not present daily and acted more as a problem solver, while Staff B was the designated Dietary Manager. The HSD could not confirm when Staff B officially became the Dietary Manager, noting that she was initially a cook when the HSD started working at the facility. This lack of clarity and failure to ensure the Dietary Manager met the necessary qualifications led to the deficiency identified by the surveyors.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not assisting Resident #81 out of bed despite repeated requests. Observations revealed that the resident remained in bed wearing a hospital gown over several days. Interviews with the resident indicated that he had asked for assistance to get out of bed daily, but staff did not comply, citing being too busy. The resident also expressed frustration over not being able to speak with the Director of Nursing as requested. The resident's cognitive status was intact, as indicated by a BIMS score of 15, and his care plan required assistance with transfers, which was not provided. Further investigation showed that the resident had been able to get out of bed with a Hoyer lift, but staff failed to coordinate this assistance. The Unit Manager confirmed that the resident was capable of getting out of bed and that his wounds had healed, yet the resident had not been assisted out of bed for the majority of the 14-day look-back period. The Regional Director of Operations acknowledged the difficulty in coordinating the Hoyer lift due to the absence of a Physical Therapy Assistant who could assist the resident alone. Despite the resident's ability to tolerate being out of bed for short periods, the facility did not facilitate this, resulting in a failure to honor the resident's choices and rights.
Failure to Honor Resident's Advance Directive Request
Penalty
Summary
The facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record. A resident expressed a desire to be a Full Code and to change their Health Care Surrogate (HCS) after returning from the hospital. Despite discussions with the Director of Social Services (DSS) and confirmation from the Advanced Practice Registered Nurse (APRN) that the resident was a Full Code, the resident's medical records still indicated a Do Not Resuscitate (DNR) status. The resident repeatedly checked with nurses about the changes, but the DSS claimed to have no knowledge of the request to change the code status. Interviews with staff revealed that the resident had been asking to be a Full Code since returning from the hospital, and the Licensed Practical Nurse (LPN) had informed the DSS of the resident's request. However, the DSS stated that the resident requested to change the HCS, which was completed, but denied knowledge of the request to change the code status. The Director of Nursing (DON) explained that the process for a code change should involve contacting the physician and ensuring all documents are in order. The facility's policy on Advanced Directives requires that such directives be honored and properly documented, but this was not adhered to in this case.
Failure to Maintain Clean and Homelike Environment Due to Leaking AC Units
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two resident rooms, as evidenced by observations of leaking air conditioning units. Work orders were created for these issues, but the problems persisted for several weeks. In one room, wet linen was observed under the Packaged Terminal Air Conditioner (PTAC), and the resident reported that the unit had been leaking for about a month. The room was described as muggy with a musty odor, and photographic evidence was obtained to document the conditions. Interviews with staff revealed that maintenance issues were reported through the facility's electronic building maintenance system. However, the Nursing Home Administrator (NHA) was unaware of the ongoing issues until they were brought to his attention during the survey. Despite the facility's policy requiring prompt action to address maintenance needs, the issues were not resolved in a timely manner, leading to the observed deficiencies in the residents' living environment.
Inaccurate PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) and obtain a Level II screening when appropriate for three residents. Resident #44 was admitted with multiple mental health diagnoses, including paranoid schizophrenia and major depressive disorder. Despite these diagnoses, the PASRR Level I Screen indicated no suspicion of a serious mental illness or intellectual disability, and a Level II PASRR was not conducted. Observations and a psychiatry note indicated that Resident #44 was experiencing hallucinations and delusions, suggesting a need for a Level II evaluation. Resident #11 was admitted with diagnoses including dementia and paranoid schizophrenia. The PASRR Level I Screen incorrectly marked that there was no serious mental illness or intellectual disability, and a Level II PASRR was not required. Observations showed Resident #11 in bed and later eating lunch, but the PASRR documentation failed to reflect the resident's mental health needs accurately. Resident #46, diagnosed with dementia and a psychotic disorder, also had a PASRR Level I Screen that did not indicate the need for a Level II evaluation. The Social Services Director later confirmed that the PASRRs for Residents #11, #44, and #46 were marked incorrectly, and no Level II PASRRs had been submitted. The facility's policy requires that if a Level II screening is indicated after admission, Social Services must coordinate the screening, which was not done in these cases.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was admitted after a motor vehicle accident. The resident expressed that her discharge was not properly arranged, and she had to personally follow up on her insurance appeals. The Social Service Director (SSD) provided minimal assistance, and the resident was informed of her discharge with little notice and without adequate preparation. At discharge, the resident had to borrow a walker and was advised to visit the emergency room for a leg wound, as the wound care orders had changed just before discharge. Despite repeated attempts to contact the SSD and the Nursing Home Administrator (NHA) for assistance, the resident did not receive a response until after she was readmitted to the hospital. The facility's documentation revealed that the resident was given a Notice of Medicare Non-Coverage, which she appealed. The discharge plan was for the resident to return home with her spouse, but it was contingent on her ability to navigate stairs. The discharge summary indicated that the resident understood the instructions and was grateful for the care received, yet there was a lack of coordination for Durable Medical Equipment (DME) and Home Health Care (HHC) services. The SSD acknowledged the resident's multiple appeals and the request for discharge but could not provide additional documentation or details about the discharge planning process. The facility's policy required discharge planning to begin at admission and involve interdisciplinary coordination, which was not effectively executed in this case.
Failure to Implement Pharmacist Recommendations for Behavior Monitoring
Penalty
Summary
The facility failed to follow the pharmacist's recommendations for behavior monitoring for two residents receiving psychotropic medications. Resident #76, diagnosed with bipolar disorder, was prescribed Trazodone 50 mg daily for depression. The resident's care plan, initiated on June 3, 2024, included monitoring for medication-related behaviors and side effects. However, the pharmacist's report dated June 7, 2024, recommended adding behavior monitoring for antidepressants, which was not implemented by August 7, 2024. Similarly, Resident #89, with diagnoses including major depressive, mood, and psychotic disorders, was prescribed multiple psychotropic medications, including Divalproex, Trazodone, and Citalopram. The care plan for this resident, initiated on August 6, 2024, also required monitoring for medication-related behaviors and side effects. Despite the pharmacist's recommendations, the facility did not initiate the necessary behavior monitoring by August 7, 2024. The Director of Nursing acknowledged that the pharmacist's recommendations for both residents were missed. The facility's policy on consultant pharmacist services, dated May 2022, outlines the requirement for regular and reliable pharmacist services, including assistance in identifying and evaluating medication-related issues.
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.
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What surveyors actually found near you
We read the 344 citations issued within 25 miles in the last 12 months — including the 21 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 Palm Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Mark Village | 0.6 mi | ★★★★★ | 0 | 0 |
| Oakpark Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 13 | 0 |
| Aviata At Countryside | 2.6 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Clearwater | 3.2 mi | ★★★★★ | 0 | 0 |
| Westchester Gardens Health & Rehabilitation | 3.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.