Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Venice during CMS and state inspections, most recent first.
Failure to Provide Ordered ADL Care and Hygiene Assistance: Staff did not consistently provide or document showers, oral care, toileting, and incontinence care for dependent residents whose care plans required assistance. Observations found poor hygiene, foul odors, dry lips, oral debris, long untrimmed nails, and wet/incontinent conditions, while CNA records showed multiple shifts with no care documented or marked N/A despite care plan directions and resident reports that help was delayed or not provided.
Failure to Provide Resident-Centered Activities: Two residents did not receive activities aligned with their preferences and care plans. One resident with dementia and depression repeatedly requested time outside but was rarely taken out, while staff said memory care residents did not go outside and the patio was not used. Another resident with severe cognitive and physical impairments was often observed in bed with the TV and radio off despite a care plan noting she enjoyed music and television, and activity records showed limited participation.
Failure to Timely Report Allegation of Neglect: A resident on a puree diet with honey-thickened fluids was served the wrong meal tray, and a piece of sausage became lodged in her throat, requiring a nurse to perform the Heimlich maneuver. Although the ED was notified the same day, the Federal Immediate report was not filed until 20 days later, and the facility later verified the allegation of neglect.
A resident with a feeding tube, dysphagia, and moderate cognitive impairment was repeatedly observed lying completely flat while tube feeding was infusing at 70 cc/hour, despite orders and care plan directions to keep the head of the bed elevated 30-45 degrees during feeding. Staff, including LPNs and the DON, confirmed the resident should have been positioned with the head of the bed raised during tube feeding.
A resident with repeated falls, muscle weakness, depression, and anxiety remained on Atorvastatin and Fenofibrate after the consultant pharmacist noted the combination should be avoided due to increased risk of myopathy and rhabdomyolysis and recommended stopping Fenofibrate. The chart had no physician response documented, progress notes did not show review of the recommendation, and staff interviews confirmed the pharmacist’s findings were not acted upon.
A facility failed to ensure safe medication storage when unsecured drugs and biologicals were found at the bedsides of three residents. Observations showed a resident had Milk [NAME], Nystatin powder, and Triamcinolone cream in the room without orders for those items, another resident had Fluticasone nasal spray and treatment medications in the room, and a third resident kept an Albuterol inhaler on the overbed table; staff, including the DON and LPNs, verified the items were unsecured and should have been locked.
The facility failed to maintain urinary catheters in a safe and sanitary manner for three residents. A resident's catheter drainage bag was observed on the floor, while another's was very full and visible without a privacy cover. Despite being informed, staff did not take corrective action. CNA Staff G explained proper catheter care procedures, which were not followed, compromising resident dignity and privacy.
A resident with a history of alcohol withdrawal and delirium, identified as an elopement risk, left the facility without staff knowledge. Despite having a wander alert device, the resident removed it and exited the facility, believing he was discharged. Staff interviews revealed the resident had been inquiring about discharge and the removal of the alert device. The administrator noted the resident was close to discharge and had the capacity to make his own decisions but did not sign out properly.
The facility experienced staffing shortages, resulting in delayed responses to resident call lights. A resident had to scream for help, another waited hours for repositioning, and a malfunctioning call light led to a fall. Despite staff presence, assistance was delayed, highlighting the need for improved staffing and response times.
Two residents in a facility were improperly transferred using mechanical lifts, contrary to their care plans. One resident, with a history of hemiplegia, was transferred using a sit-to-stand lift by a single CNA, resulting in severe knee pain and a hospital visit. Another resident, requiring a full-body lift, was also transferred incorrectly. These incidents highlight the facility's failure to ensure staff followed safety protocols and used the correct equipment.
A facility failed to ensure staff competency in using mechanical lifts, leading to unsafe transfers for two residents. One resident, with a history of hemiplegia, was improperly transferred using a Sit to Stand lift without assistance, resulting in knee pain. Another resident, unable to bear full weight, was transferred with the wrong lift despite care plan instructions. These incidents indicate a gap in staff training and adherence to care protocols.
The facility failed to ensure CNAs were competent in using mechanical lifts, leading to a resident's injury. A CNA used a Sit to Stand lift alone, against policy, causing a resident with mobility issues to slide out and fracture their femur. Other CNAs also demonstrated improper lift use, indicating widespread competency issues.
Failure to Provide Ordered ADL, Oral, and Incontinence Care
Penalty
Summary
The facility failed to provide assistance with showers, personal hygiene, and incontinent care as outlined in residents’ care plans and according to residents’ preferences for three dependent residents. The policy stated that residents unable to perform ADLs independently are to receive services necessary to maintain grooming, personal and oral hygiene, and that refusals and details of interventions refused are to be documented in the clinical record. For one resident with anoxic brain injury, severe cognitive impairment, contractures, and total dependence for personal hygiene and oral care, the care plan directed oral hygiene every shift and as needed, including morning and bedtime oral care. Observations found dry lips, white debris in the mouth, foul odor, and contracted hands with a chunk of black hair in one hand. CNA documentation for multiple months showed numerous shifts with no oral care documented, many shifts marked N/A, and some shifts documented the resident as independent or needing setup assistance. The resident’s care plan also addressed bladder and bowel incontinence, but CNA documentation for multiple months showed many shifts with no bladder incontinence care documented and additional shifts marked N/A. For another resident with muscle weakness, repeated falls, adult failure to thrive, anxiety, and bowel and bladder incontinence, the care plan required incontinence checks upon rising, before and after meals, and as needed, with washing, rinsing, and drying of the perineum and changing clothing after episodes. The resident stated she waited hours when wet, that it hurt, that she developed irritation from the wet brief rubbing, and that showers were not being provided. Documentation showed scheduled showers were sometimes replaced with bed baths, sometimes marked N/A, and sometimes had no care documented. Incontinence care documentation also showed multiple shifts with no care documented and many shifts marked N/A across all shifts reviewed. For a third resident with cerebral palsy, epilepsy, major depressive disorder, chronic kidney disease, chronic atrial fibrillation, and need for assistance with personal care, the care plan required partial assistance with bathing/showering twice weekly, toileting assistance, nail care, and sponge baths when a full bath or shower could not be tolerated. The resident was observed with foul urine odor, foul breath, long fingernails with black substance under them, dried skin flakes on clothing, and an unopened tube of toothpaste in the drawer. The resident stated staff took his nail clippers, he had been asking for nail trimming, no one came to set him up to brush his teeth, and staff did not come to help him use the toilet, leaving him wet. CNA documentation showed multiple shower days with no shower documented or N/A, and multiple shifts with no incontinent/toileting care documented across all shifts reviewed.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities to meet the interests of 2 residents reviewed for activities. Resident #43, who had diagnoses including Alzheimer's disease, major depressive disorder, and adjustment disorder, lived on the secured memory care unit and was assessed as having severe cognitive impairment. Her care plan documented that she loved snacks and going outside in the sun, and the community life progress review noted she was happy when outside in the sun. However, the resident stated she was legally blind, wanted to go outside for 15 minutes a day, and said no one ever let her outside. She also said she had not been outside for years. Facility records showed Resident #43 went to the patio only once in November 2025 and once in December 2025, with no other outside activities documented for those months. Electronic medical record responses from January 6, 2026 through February 3, 2026 showed no participation in outside activities, no one-on-one activities, and no selected directed outside activities. The February 2026 activities calendar did not include any scheduled outside activities. Staff interviews indicated the memory care residents did not go outside in the sun, that the patio was not used, and that this had been the practice for a long time. Resident #6 had diagnoses including anoxic brain injury, cardiac arrest, seizures, contractures of both hands and elbows, anxiety, and major depressive disorder. Her care plan stated she was dependent on staff for emotional, intellectual, physical, and social needs, spent most of her time in bed watching TV, and enjoyed music on her radio. On multiple observations, she was found awake in bed with her bedroom door closed, the TV and radio off, the lights off, and the room dark. She answered yes when asked if she enjoyed listening to music or watching television. Activity documentation showed limited one-to-one and group participation in December 2025 and January 2026, and the activity director stated the resident was her project and that staff were supposed to turn on the radio and TV for her.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the proper authorities within the required timeframe for one resident. The resident was on a dysphagia puree diet with honey thickened fluids when she was served the wrong textured meal tray on 6/8/25, and a piece of Italian sausage became caught in her throat. A nurse in the dining room assessed the resident, found no air exchange, and performed the Heimlich maneuver with one abdominal thrust, which dislodged the sausage. A chest x-ray later showed clear lung fields without evidence of infiltration, effusion, or pneumothorax, and the resident was seen by the RT, pulmonologist, and PCP with no significant findings. Facility records showed the ED was notified of the incorrect diet tray on 6/8/25 at 1:01 p.m., but the Federal Immediate report was not filed until 6/28/25, 20 days after the incident. The facility’s investigation later verified the allegation of neglect, stating the resident did receive the wrong meal tray and experienced a choking episode requiring the Heimlich maneuver. The facility’s policies required allegations of neglect to be reported per federal regulation and for the NHA to complete the Federal Immediate and Five-Day reports, but the report was not submitted within the required timeframe.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
Appropriate care was not provided for Resident #81, who was admitted with unspecified brain injury, fracture of the neck, and dysphagia and was dependent on staff for nutrition through a feeding tube. The admission MDS showed moderate cognitive impairment and documented that the resident had a feeding tube. The physician ordered the head of the bed to be elevated 30-45 degrees during enteral feeding or flushing, and the care plan stated the resident required tube feeding related to an abnormal swallow evaluation after a bike accident, with the head of the bed elevated 45 degrees during and 30 minutes after tube feeding. Despite these directions, Resident #81 was observed multiple times lying completely flat in bed while the tube feeding pump was on and infusing at 70 cc/hour. On 2/2/26 and 2/3/26, the resident was seen flat with the feeding running, and on 2/3/26 and 2/4/26 staff observed and confirmed the resident was flat during infusion. An LPN stated that lying flat while tube feeding was infusing created a risk for aspiration and that the head of the bed should be raised 45 degrees during feeding. Another LPN said the resident was at risk for nausea, vomiting, and aspiration if the head of the bed was not elevated, and the DON also stated the head of the bed should be raised 45 degrees when tube feeding was running to prevent aspiration.
Pharmacist Medication Review Recommendations Not Acted Upon
Penalty
Summary
The facility failed to ensure that irregularities identified during the consultant pharmacist’s monthly drug regimen review were acted upon for one resident. The resident had an admission date of 10/23/25 and diagnoses that included repeated falls, muscle weakness, depression, and anxiety. In the consultant pharmacist’s 10/31/25 medication review, the pharmacist documented that the use of Atorvastatin and Fenofibrate should be avoided because of an increased risk of myopathy and rhabdomyolysis without additional cardiovascular benefit, and recommended discontinuing Fenofibrate and ordering a fasting lipid panel in 4 weeks. There was no documentation of a physician response on the review form. Review of the resident’s physician orders for February 2026 showed that Atorvastatin Calcium 80 mg at bedtime and Fenofibrate 54 mg daily were still ordered. Progress notes contained no documentation that the physician reviewed the pharmacist’s recommendations. Staff interviews confirmed the process was to send pharmacist recommendations to the DON for physician review and signature, but the DON verified that the recommendations for this resident were not acted upon. An APRN also reviewed the record and confirmed the resident was still receiving both medications.
Unsecured Medications Found at Residents’ Bedsides
Penalty
Summary
The facility failed to ensure safe storage of medications for 3 residents observed with unsecured medications at the bedside. The facility policy stated that drugs and biologicals are to be stored in locked compartments and that only authorized staff have access to locked medications. During observation, Resident #37 had a bottle of Milk [NAME], a bottle of Nystatin antifungal powder, and a jar of Triamcinolone Acetonide cream on the bedside table and later remained unsecured in the room; RN staff verified these items were unsecured and stated the physician’s orders did not include them. Resident #70 had a bottle of Fluticasone Propionate Nasal spray stored at the bedside in a tray, and the DON stated this resident was not to have medications at bedside. During the initial tour, a tube of Santyl Ointment and a bottle of sodium hypochlorite solution 0.125% were observed on Resident #70’s nightstand, and an LPN stated treatment medications should not be in the resident’s room and should be kept in the treatment cart and locked. Resident #74 had an Albuterol Sulfate inhaler stored on the overbed table, and the resident said she kept and used the medication in her room as needed. An LPN verified the inhaler was unsecured and stated it should be locked in the medication cart.
Failure to Maintain Safe and Sanitary Urinary Catheter Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain urinary catheters in a safe and sanitary manner for three residents with indwelling urinary catheters. During an initial facility tour, it was observed that Resident #900's catheter drainage bag was on the floor, which was verified by RN Staff A. Additionally, Resident #899's catheter drainage bag was very full and visible to staff, other residents, and visitors, as it was located on the side of the bed facing the doorway without a privacy cover. This was confirmed by RN Staff A during an interview. Furthermore, Resident #800's catheter drainage bag was also noted to be on the floor and visible from the hallway. Despite being informed of this, RN Staff C did not take action to remove the urinary catheter bag from the floor. CNA Staff G explained that urinary catheter drainage bags should be attached to the bed frame on the side away from the door to ensure privacy and should not be on the floor. These observations and interviews highlight the facility's failure to maintain urinary catheters in a safe and sanitary manner, compromising the dignity and privacy of the residents involved.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who left the facility without staff knowledge. The resident, who had been re-admitted post-hospitalization with diagnoses including alcohol withdrawal and delirium, was identified as an elopement risk due to disorientation and impaired safety awareness. Despite having a wander alert device, the resident managed to leave the facility undetected. On the day of the incident, the resident was seen making phone calls and later walking in the hallways. Staff noted the resident was missing when they went to retrieve his lunch tray. The resident had not signed out, and a search was initiated, including notifying the police. It was later discovered that the resident had removed his wander alert bracelet and left the facility, believing he had been discharged. Interviews with staff revealed that the resident had expressed a desire to be discharged and had been inquiring about the removal of his wander alert bracelet. The receptionist on duty did not see the resident leave through the front door, suggesting he may have tailgated another person. The administrator confirmed that the resident was close to being discharged and had the capacity to make his own decisions, but failed to sign out properly.
Staffing Shortages Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely response to requests for assistance, affecting three residents. Observations and interviews revealed that the facility was often short-staffed, leading to delays in responding to call lights. A CNA reported frequent complaints from residents about unanswered call lights, and an RN expressed concerns that residents were not receiving the necessary care. Another RN acknowledged the staffing issues and noted that efforts to hire more staff were ongoing, but new hires often left after a short period. Specific incidents highlighted the deficiency, including a resident who had to scream for help when his call bell was not answered, sometimes waiting over an hour. Another resident and her husband reported long wait times for call light responses. A resident's daughter described how her father, who was receiving hospice care, was not repositioned for several hours, and her mother's call light was not functioning, leading to a fall. Despite the presence of staff in the hallway, assistance was delayed, and the Director of Nursing acknowledged excessive wait times and issues with the call light system.
Improper Use of Mechanical Lifts Leads to Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring the proper use of mechanical lifts and adherence to safety protocols during transfers. Specifically, two residents who required mechanical lifts for transfers were not handled according to the facility's policies. Resident #1, who had a history of cerebrovascular accident with left hemiplegia and was dependent on staff for transfers, was improperly transferred using a sit-to-stand lift by a single CNA without assistance. This resulted in the resident experiencing severe pain and swelling in the left knee, leading to a hospital visit where no fracture was found, but ongoing pain persisted. The incident with Resident #1 highlighted a failure to verify the correct transfer status and use the appropriate mechanical lift as indicated in the care plan and Kardex. The CNA involved did not follow the policy requiring two staff members for such transfers and left the resident unattended in the lift, leading to the resident sliding and experiencing pain. Despite the resident's complaints and the physical therapist's advice against using a sit-to-stand lift, the CNA proceeded with the transfer, resulting in the resident's distress and subsequent need for pain management. Similarly, Resident #2, who was dependent on staff for transfers and required a full-body mechanical lift, was observed being transferred with a sit-to-stand lift by a CNA. This was contrary to the care plan and Kardex instructions. The CNA admitted to not being aware of the correct lift requirement, despite having been counseled earlier. This oversight further exemplifies the facility's failure to ensure staff competency and adherence to established protocols, compromising resident safety and care.
Deficiencies in Mechanical Lift Use and Staff Competency
Penalty
Summary
The facility failed to ensure ongoing monitoring of staff competency in the use of mechanical lifts, leading to incidents involving two residents. For the first resident, a CNA used a Sit to Stand mechanical lift without assistance, contrary to the facility's policy requiring two staff members for such transfers. The resident, who had a history of hemiplegia and muscle weakness, was left alone in the lift and subsequently slid out, resulting in knee pain and swelling. Despite an X-ray showing no fracture, the resident experienced ongoing pain and required pain medication following the incident. In another incident, a CNA was observed using a Sit to Stand lift for a second resident who required a full body mechanical lift according to their care plan. The CNA had been counseled earlier about the correct lift to use but continued to use the incorrect equipment. The resident, who could not bear full weight on their legs, reported that staff had not been using the appropriate lift for transfers, which could compromise their safety. Both incidents highlight a failure in adhering to the facility's policies and procedures regarding mechanical lift use and staff competency. The facility's skills competency assessments indicated that the CNAs involved had been assessed and deemed competent in using the lifts, yet the incidents suggest a gap in practical application and adherence to care plans. These deficiencies in staff training and compliance with care protocols contributed to the unsafe transfer practices observed.
Deficiency in Mechanical Lift Competency Among CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were knowledgeable and competent in the safe use of mechanical lifts, leading to an incident involving a resident who suffered a serious injury. CNA Staff A transferred a resident using a Sit to Stand mechanical lift without assistance, contrary to the facility's policy requiring two staff members for such transfers. The resident, who had a history of cerebrovascular accident with left hemiplegia and other mobility issues, was left alone in the lift and subsequently slid out, resulting in a fracture of the left femur. This incident highlighted a failure to adhere to the care plan, which specified the use of a full-body mechanical lift by two staff members. Further observations revealed additional deficiencies in the use of mechanical lifts by other staff members. CNA Staff E was observed using a Sit to Stand Lift for a resident who required a full-body mechanical lift with two staff members, as per the care plan. Despite being counseled by the Assistant Director of Nursing (ADON) about the correct lift to use, Staff E continued to use the incorrect lift, demonstrating a lack of awareness and adherence to the resident's transfer requirements. Additionally, CNAs Staff F and G were observed improperly using a Stand Up mechanical lift during a demonstration. They failed to fully open the base of the lift, locked the rear casters, and experienced technical difficulties with the lift, which stopped mid-transfer. This improper use of the lift, including not following the manufacturer's instructions, further underscored the lack of competency among staff in handling mechanical lifts safely and effectively.
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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 Venice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advinia Care At Venice | 1.1 mi | ★★★★★ | 0 | 0 |
| Capri Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Village On The Isle | 1.6 mi | ★★★★★ | 0 | 0 |
| Venice Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Sunset Lake Healthcare And Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
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