Aviata at Bradenton

Inspectors wroteBased on record review and interviews, the facility failed to ensure documentation was complete and accurate related to physician orders for catheter care for one (Resident #1) out of five residents reviewed.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure kitchen sanitation requirements were met, due to kitchen walls had non-cleanable surfaces, and failed to ensure items in the kitchen pantry and walk-in refrigerator were dated, for one out of one walk-in refrigerators and one of one kitchen pantries. Findings Included:On 01/12/2026 at 10:15 AM, a kitchen tour was conducted with the District Manager of Dining, (DMD). The kitchen dishwasher was observed soiled with debris, build-up and corrosion on the motor and overhead hood of the dishwasher. The motor was observed with brown colored corrosion expanding from the base of the dishwasher motor. A white powdered material and white build-up was observed on the motor in various areas. The motor was observed with smudges. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was free from pest in one out of three pantries observed.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure resident equipment was maintained and sanitary to include resident room air conditioner unit filters in two of two nursing units.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASRR) Level I screening was completed prior to admission for four (#10, 21, 41, and 91) of the five residents reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective infection prevention program related to offering hand hygiene prior to eating for one of one dining room observed and proper storage for respiratory items for eight (#1, #16, #27, #50, #64, #72, #102, and #117) of eight residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to develop care plans with problem areas and interventions related to discharge planning for one (#8. of three sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure Activities of Daily Living (ADL) care was provided for three residents (#12, 16, 57) of four residents sampled.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's hearing aid was consistently available and utilized as needed to maintain communication, dignity, and quality of life for one (#72) of one resident reviewed.

Inspectors wroteThe facility failed to follow the clinical standard of practice to ensure adequate monitoring of behaviors and medication side effects for a resident prescribed psychotropic medication. This failure affected one (#41) of five residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Twenty-six medication administration opportunities were observed, and ten errors identified for two (#93 and #1) of five residents observed. These errors constituted a 38.46% medication error rate.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure medications were not accessible to unauthorized staff, residents, and visitors for one resident (#64) of 53 sampled residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to honor one (#64) of eight sampled residents with meals that were in the form of the resident's choice and dietary recommendation.

Inspectors wroteBased on interview and record review the facility failed to ensure documentation was complete and accurate for one (#57) of one resident reviewed timely medication administration documentation.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure timely and consistent incontinence services were provided for three residents (#3, #4, and #2) of four residents sampled for incontinence care.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a functioning grievance process for one resident (#2) of four residents reviewed for grievances.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a timely repair of a call bell light for one resident (#2) of five sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a grievance was investigated and tracked through to a conclusion for one resident (#1) out of five sampled residents.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to ensure the care plan interventions were implemented according to orders for two residents at risk for elopement (#3 and #4) related to use of a Roam Alert bracelets out of five sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a wandering device was placed on one resident (#3) out of 5 residents reviewed to be at risk for elopement.

Inspectors wroteBased on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for four (Resident #19, #1, #5, and #12) of four residents sampled for PASARR Level II.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to two (Residents#31 and #45) out of two residents sampled for Midline and Peripherally Inserted Central Catheter.

Inspectors wroteBased on record review and interview the facility failed to communicate with the dialysis center for one (Resident #51) out of one resident sampled for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and two errors were identified for two (Residents #136 and #45) out of five sampled residents. These errors constituted a 7.14 % medication error rate. Findings Included: On 06/14/2023 at 11:14 a.m., Staff F, Licensed Practical Nurse, Unit Coordinator entered Resident #136 bedroom and informed him it was time for his blood glucose level. Resident #136 was sitting up in his wheelchair and was receptive to the observation. Staff F performed a blood glucose level (BGL) that registered at 265 milligrams per deciliter (mg/dL). Staff F informed the resident she would return with his insulin. Staff F reviewed Resident #136 orders and stated, the sliding scale indicates 6 units of Aspart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice as it relates to maintaining complete and accurate medical records related to wound care services for one (Resident #45) out of 30 sampled residents.

Inspectors wroteBased on observations, staff interview and record review, the facility failed to maintain resident dignity during dining for four of four days observed (7/12/2021, 7/13/2021, 7/14/2021, and 7/15/2021). It was determined that seven staff members (A, B, C, D, E, H, and L) were not consistently knocking or announcing themselves prior to entering 12 occupied resident rooms (room [ROOM NUMBER], 104, 105, 108, 113, 119, 121, 130, 131, 132, 203, and 207), and two staff members (A and M) were observed standing up as they provided eating assistance for four residents (#7, #58, #63, and #38), who were seated, of a total sample of twenty-seven residents.

Inspectors wroteBased on resident observation and interview, medical record and policy reviews and interviews with nursing staff, the Director of Nursing (DON), and the Administrator, the facility failed to ensure that one resident (#60) out of twenty-seven sampled residents was properly assessed and monitored for self-administration of a nebulizer treatment.

Inspectors wroteBased on record review and interviews the facility failed to provide one resident (#28) of five sampled residents or their representative, with a completed written copy of the Nursing Home Transfer and Discharge Form when transferred emergently to an acute care facility.

Inspectors wroteBased on record review and interviews the facility failed to provide two residents (28 and 66) of five sampled, or their representative, with a written copy of the bed hold notice when they were transferred emergently to an acute care facility.

Inspectors wroteBased on observations, staff interview and medical record review, the facility failed to ensure one resident (#45) of twenty-seven sampled residents was provided with supervision and assistance with eating during three of four days observed (7/12/2021, 7/13/2021, and 7/14/2021).