Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record review and interviews, the facility failed to provide sufficient nursing staff to meet the
needs of eight (#3, #4, #5, #6, #7, #8 and #9) out of 12 sampled residents related to answering call lights
timely.
Findings included:
1. On 5/17/23 at 10:30 a.m., an interview was conducted with Resident #3 in his/her room as resident
reported the day shift (7 a.m. to 3 p.m.) is great, second shift (3 p.m. to 11 p.m.) it may take 15 minutes to
over 2 hours for them to answer the light. They are always short staffed, or staff don't care and don't
answer. I put my call light on because I need help, go to the bathroom or I'm in pain, they never come. I
have given up on telling people, doesn't do any good.
2. On 5/17/23 at 10:47 a.m., an interview was conducted with Resident #4 in his/her room as resident
reported, Call lights are awful on the second and third (11 p.m. to 7 a.m.) shift. I must go out and yell in the
hallway to get someone. Sometimes, I even have to go all the way to the nurses' station, where staff are
usually sitting at the desk. So frustrating, like we are doing this on purpose and get irritated for no reason.
We need assistance, what if I was having another heart attack or something, most people think they should
come quickly, within 5 minutes.
Review of Resident #4's medical record revealed that he was admitted to the facility on [DATE] with multiple
diagnoses to include end stage renal disease, dependence one renal dialysis, below the knee amputation,
convulsions, seizures, chronic kidney disease, epilepsy, and type 2 diabetes mellitus with complications to
name a few. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident
had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition was fully intact. Section G
for functional status indicated that the resident required limited assistance for transferring with a one person
assist and limited assistance for toilet use. Review of the care plan dated 11/26/22 and revised on 3/8/23 for
Resident #4 revealed an Activities of Daily Living (ADL) self-care deficit related to chronic disease process,
impaired mobility and right below the knee amputation. He may need more care following dialysis. Review
of the CNA (certified nursing assistant) [NAME] for Resident #4 shows to ensure call light is encouraged for
use and assist. Notify nurse asap if seizure occurs.
3. On 5/17/23 at 10:51 a.m., an interview was conducted with Resident #5 in his/her room as resident
reported, they never answer my call light in the evening - I'll be crying in pain, and no one comes.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
105373
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105373
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sand Key
1980 Sunset Point Rd
Clearwater, FL 33765
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #5's medical record revealed that he/she was admitted to the facility on [DATE] with
multiple diagnoses to include thrombocytopenia, chronic respiratory failure with hypoxia, severe protein
calorie malnutrition, chronic obstructive pulmonary disease, rheumatoid arthritis, idiopathic neuropathy,
major depressive disorder, epilepsy, history of falling, muscle weakness, and lack of coordination. Review of
the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for
Mental Status (BIMS) score of 13/15, indicating cognition was intact. Section G for functional status
indicated that the resident required limited assistance for transferring with a one person assist as well as for
toilet use. Section G also indicated that the resident was not steady. Review of the care plan dated 12/21/22
with revision on 1/8/23 revealed an Activities of Daily Living (ADL) self-care deficit related to chronic
disease process. Resident # 5 was care planned for toileting as limited assistance, one staff. Review of the
Certified Nursing Assistant (CNA) [NAME] indicates for the CNA to ensure call light is within use and
encourage use for assist with standing/transferring and ambulation, notify nurse as soon as possible (asap)
if seizure activity occurs.
4. On 5/17/23 at 10:55 a.m., an interview was conducted with Resident #9 in his/her room, resident
reported, They never come, well sometimes they do but mostly it takes an hour. Usually, by then you need
something different, as it has been so long.
Review of Resident #9's medical record revealed that she/he was admitted to the facility on [DATE] with
multiple diagnoses to include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting
right dominant side, major depressive disorder, need for assistance with personal care, difficulty in walking,
muscle weakness, acute kidney failure and compartment syndrome to name a few. Review of the Minimum
Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental
Status (BIMS) score of 15/15, indicating cognition was fully intact. Review of the care plan dated 11/4/22 for
Resident #9 revealed an Activities of Daily Living (ADL) self-care deficit related to recent hospitalization.
Resident #9 was care planned for bathing, grooming, toileting, and ADL needs met with assistance from
staff. Review of Resident #9 [NAME] shows to encourage resident to use soft touch call light for assist with
standing/transferring and ambulation dated 4/17/23.
5. On 5/17/23 at 11:00 a.m., an interview was conducted with Resident #6 in his/her room, resident
reported, they don't assist me; I call, and they don't come. Well, they sometimes come but not often.
Review of Resident #6's medical record revealed that she/he was admitted to the facility on [DATE] with
multiple diagnoses to include acute cystitis without hematuria, sepsis, sacrum fracture, bipolar disorder,
personality disorder, post-traumatic stress disorder, history of falling, Major Depressive disorder,
Rheumatoid Arthritis, anxiety disorder, sedative, hypnotic or anxiolytic dependence, cardiac murmur, and
suicidal ideations. The Minimum Data Set (MDS) assessment has not been completed, as resident just
admitted .
6. On 5/17/23 at 4:35 p.m., an interview was conducted with Resident #8 in his/her room as resident
reported, it can take no less than 45 minutes but usually at least an hour in the evening for the staff to
answer my call light. My urinal was not left in my reach, and I had to ball my sheet up and urinate into the
balled-up sheet. I still had to wait for them to clean me up and I was cold, wet no sheet. How demeaning. I
have told them; it doesn't seem to help. Resident needed to utilize the bathroom room during the interview,
resident pushed his call light at 4:38 p.m. C.N.A. entered the room at 4:52 p.m. to assist. When the surveyor
exited the room, several nurses were behind the nurses'
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105373
If continuation sheet
Page 2 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105373
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sand Key
1980 Sunset Point Rd
Clearwater, FL 33765
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
station.
Level of Harm - Minimal harm
or potential for actual harm
7. Upon exiting Resident # 8's room at 4:52 p.m. the call light to Resident #7's room was sounding.
Surveyor waited at the nurses' station to observe the call light response. Two nurses were at the nurses'
station, documenting, and 2 different C.N.A.s walked past the room on separate occasions, without
answering. A different C.N.A. entered the room at 5:05 p.m., the light was turned off.
Residents Affected - Few
Review of Resident #8's medical record revealed that he was admitted to the facility on [DATE] with multiple
diagnoses to include hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non
dominant side, spondylosis without myelopathy or radiculopathy of lumbar region, spinal stenosis, muscle
weakness, chronic kidney disease stage 3, difficulty in walking and lack of coordination to name a few.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief
Interview for Mental Status (BIMS) score of 15/15, indicating cognition was fully intact. Section G for
functional status indicated that the resident required extensive assistance for transferring with a two person
assist and extensive assistance for toilet use. Section G also indicated that the resident was not steady,
only able to stabilize with staff assistance moving on and off the toilet. Review of the care plan dated 5/2/23
for Resident #8 revealed an Activities of Daily Living (ADL) self-care deficit related to his CVA. Resident #8
was care planned for toileting as extensive assistance, one staff. Review of the CNA [NAME] shows
resident needs extensive assistance for all ADLs and to ensure call is encouraged to use with
standing/transferring and ambulation.
8. On 5/17/23 at 5:10 p.m. an interview with Resident #7, in his/her room as resident reported, I had to wet
myself, how embarrassing, it's awful I'm a grown man/women. I could transfer myself if they would add a
grab bar in front of toilet, there is only one next to the toilet on my left side. I had a stroke and cannot utilize
my left arm. I have told the social worker, although nothing happens. You stop telling after a while.
Review of Resident #7's medical record revealed that he was admitted to the facility on [DATE]. The
Minimum Data Set (MDS) assessment has not been completed as resident was just admitted . The record
did reveal the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition
was fully intact.
Review of the Resident Council Minutes from March 27, 2023 showed that CNAs do not come, 30 minutes
or not come at all. Surveyors were given a Signature page with Resident Council Meeting dated 4/11/23
with the Ombudsman's business card stapled to the paper. No minutes were provided.
Review of a staff listing with signatures dated 4/15/23, with Call Light Response Times handwritten on top
of the page, no other documents were received, as requested.
Review of the grievance log for February 2023 to May 17, 2023, showed one grievance on 5/9/23 to be
related to call lights. The grievance on 5/9/23 showed, resident stated that it takes a very long time to
answer call light and to be changed, has waited a few hours. Also feels some staff will talk to him/her
disrespectfully and the tone in which they speak to him/her. On 5/12/23 the grievance follow-up shows: All
staff meeting on 5/11/23 addressed residents' rights and customer service, tone in how staff speak to
residents and how it can be misinterpreted. Also addressed in servicing call lights timely and addressing
needs.
Review of a staffing list with signatures, showed a handwritten date in the upper right corner of 5/11/23,
documented at the top of the page, handwritten Town Hall Meeting. No other documents were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105373
If continuation sheet
Page 3 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105373
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sand Key
1980 Sunset Point Rd
Clearwater, FL 33765
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
received, as requested.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy on Call Lights: Accessibility and Timely Response, date reviewed/revised:
7/19/2022, shows: Policy: The purpose of this policy is to assure the facility is adequately equipped with a
call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call
lights will directly relay to a staff member or centralized location to ensure appropriate response. The next
section titled, Policy Explanation and Compliance Guidelines: number 10 shows: All staff members who see
or hear an activated call light are responsible for responding. If the staff member cannot provide what the
resident desires, the appropriate personnel should be notified.
Residents Affected - Few
Reviewed the call light audits forms that were provided showed:
-3/29/23 - Room-101A - time call light on: 24 minutes 22 sec; room [ROOM NUMBER]A time of response to
light, 20 minute 15 seconds. room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER]
response time 1 minute; room [ROOM NUMBER] response time 11 minutes; room [ROOM NUMBER]
response time 14 minutes.
-3/30/23 - room [ROOM NUMBER] response time 4 minutes, room [ROOM NUMBER] response time 4
minutes; room [ROOM NUMBER] response time 4 minutes.
-3/30/23 - room [ROOM NUMBER] response time 4 minutes 23 seconds.
-3/31/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 7
minutes; room [ROOM NUMBER] response time 3 minutes.
-4/1/23 - room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 7
minutes; room [ROOM NUMBER] response time 15 minutes; room [ROOM NUMBER] response time 6
minutes; room [ROOM NUMBER] response time 10 minutes; room [ROOM NUMBER] response time 17
minutes.
4/2/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 2
minutes; room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 10
minutes; room [ROOM NUMBER] response time 4 minutes; room [ROOM NUMBER] response time 5
minutes.
-4/3/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 8
minutes; room [ROOM NUMBER] response time 11 minutes; room [ROOM NUMBER] response time 6
minutes; room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 3
minutes.
-4/4/23 - room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 25
minutes.
-4/5/23 - room [ROOM NUMBER] response time 2 minutes.
-4/6/23 - room [ROOM NUMBER] response time 13 minutes; room [ROOM NUMBER] response time 9
minutes; room [ROOM NUMBER] response time 1 minute; room [ROOM NUMBER] response time 9
minutes; room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 3
minutes.
-4/7/23 - room [ROOM NUMBER] response time 6 minutes.
-4/11/23 - room [ROOM NUMBER] response time 10 minutes; room [ROOM NUMBER] response time 8
minutes;
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105373
If continuation sheet
Page 4 of 5
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105373
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sand Key
1980 Sunset Point Rd
Clearwater, FL 33765
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 16 minutes.
Level of Harm - Minimal harm
or potential for actual harm
-4/14/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 12
minutes.
Residents Affected - Few
-4/18/23 - room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 12
minutes; room [ROOM NUMBER] response time 13 minutes.
-4/20/23 - room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 5
minutes.
-4/22/23 - room [ROOM NUMBER] response time 7 minutes; room [ROOM NUMBER] response time 26
minutes; room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 3
minutes; room [ROOM NUMBER] response time 3 minutes; room [ROOM NUMBER] response time 3
minutes.
-4/23/23 - room [ROOM NUMBER] response time 5 minutes; room [ROOM NUMBER] response time 7
minutes; room [ROOM NUMBER] response time 2 minutes; room [ROOM NUMBER] response time 5
minutes; room [ROOM NUMBER] response time 8 minutes; room [ROOM NUMBER] response time 6
minutes.
-4/25/23 - room [ROOM NUMBER] response time 6 minutes; room [ROOM NUMBER] response time 11
minutes.
-4/26/23 - room [ROOM NUMBER] response time unreadable; room [ROOM NUMBER] response time 13
minutes; room [ROOM NUMBER] response time 15 minutes; room [ROOM NUMBER] response time 6
minutes.
-4/27/23 - room [ROOM NUMBER] response time 12 minutes; room [ROOM NUMBER] response time 10
minutes.
-5/3/23 - room [ROOM NUMBER] response time 20 minutes; room [ROOM NUMBER] response time 20
minutes.
-5/4/23 - room [ROOM NUMBER] response time 8 minutes; Room not listed response time 20 minutes.
On 5/17/23 at 6:09 p.m., an interview with the Director of Nursing (DON) who stated that he was made
aware of some call light issues earlier this year. He decided to initiate call light audits and educate the staff
on response time face to face. The DON stated he let the staff know his expectations are to answer call
lights within 10 to 15 minutes and the bathroom (emergency) light in 3 to 5 minutes. The DON stated he did
not really review the audits and the audits did stop on 5/4/23. The audits were also only completed on the
day shift. The DON stated this did not go through the Quality Assurance and Performance Improvement
committee for follow up on the call light trend.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105373
If continuation sheet
Page 5 of 5
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
FAQ · About this visit
Common questions about this visit
What happened during the May 18, 2023 survey of Aviata at Sand Key?
This was a inspection survey of Aviata at Sand Key on May 18, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Aviata at Sand Key on May 18, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.