F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, review of facility policy, and clinical record review, the facility failed to immediately inform the
resident representative when there was a significant change in the resident's physical status and decision
to transfer the resident to the hospital for 1 (Resident #1) of 3 residents sampled.The findings
included:Review of facility policy and procedure N-105 effective [DATE], revised [DATE], Notification of
Change in Condition revealed Policy: The center to promptly notify the Patient/Resident, the attending
physician, and the Resident Representative when there is a change in the status or condition. Procedure:
The nurse to notify the attending physician and Resident Representative when there is a(n): Accident,
Significant change in the patient/resident's physical, mental, or psychosocial status, Need to alter treatment
significantly due to but not limited: Adverse consequences, Acute condition, Exacerbation of chronic
condition, A transfer or discharge of the Patient/Resident from the Center. In the event of an emergency
situation, 911 to be called and the attending physician and the Resident Representative to be notified as
soon as possible . Document the notification in the medical record.A review of the clinical record revealed
Resident #1 was admitted to the facility on [DATE] with diagnoses of surgical aftercare following surgery on
the digestive system, disruption or dehiscence of closure of internal operation (surgical) wound (a surgical
incision unexpectedly breaks open during the healing process), presence of cardiac and vascular implant
and graft (a history of heart and blood vessel surgery), and presence of aortocoronary bypass graft (a
history of heart blood vessel surgery).Review of the Quarterly Minimum Data Set (MDS) (standardized
assessment tool that measures health status in nursing home residents) dated [DATE] revealed Resident
#1 had normal cognitive functioning. He required supervision or touching assistance for transfers,
sit-to-stand, and walking up to 50 feet.Review of the clinical record for Resident #1 revealed a Progress
Note [DATE] at 9:30 p.m. documented Resident #1 complained of not feeling well, patient stated that he
hasn't felt well in a couple of days now and keeps having bowel movements. He said he didn't even feel well
enough to go out to smoke his cigarettes today. The progress note documented Staff B Licensed Practical
Nurse (LPN) went to her medication cart to check his orders for anything for GI (Gastointestinal) upset and
moments after a Certified Nursing Assistant (CNA) alerted her to go to him quickly. Upon entering the
patient's room he was seen sitting on the toilet hunched over and was being held up by the other CNA.
Staff B LPN called a Code Blue (emergency situation), called 911 and Resident #1 was transferred to the
hospital.Review of the clinical record for Resident #1 revealed a Change in Condition assessment dated
[DATE] at 12:22 a.m. The Change in Condition documented in the evaluation was Unresponsiveness. The
Change in Condition Assessment did not document the family representative was notified. This section was
left blank.Review of the clinical record for Resident #1 revealed a Transfer Assessment was initiated on
[DATE], but it was blank.Review of the clinical record revealed there was no documentation that Resident
#1's representative was
(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 3
Event ID:
106032
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
106032
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sarasota
1507 S Tuttle Ave
Sarasota, FL 34239
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
notified of his change in condition or transfer.On [DATE] at 3:07 p.m. in an interview, the DON (Director of
Nursing) said she called the hospital on [DATE] around 5:30 or 6:00 a.m. for an update on Resident #1. She
said she heard the resident had multiple cardiac events overnight and was alive. She said after she
received that update, early in the morning on [DATE] the nephew of Resident #1 (the resident's
representative) called to ask what had happened at the facility. She said the resident's representative told
her the hospital had called him in the middle of the night to inform him that the resident was in the
Emergency Room. She said she told Resident #1's representative that an aide had answered the resident's
call light and he was not looking good. She said she told him the aide got the nurse and EMS was called.
She said she told him it seemed like a vaso-vagal event (fainting due to nerve stimulation).The DON said
the Change in Condition Assessment in Resident #1's clinical record does not indicate that the Emergency
Contact was notified. She said best practice is that the facility notify the family or Emergency Contact of a
change in condition. She said she thought that maybe the Staff A LPN Unit Manager's signature on the
Agency for Healthcare Administration (AHCA) form indicated that she had informed the resident's
representative of the change in condition and transfer.On [DATE] at 3:54 p.m. in an interview, Staff A LPN
Unit Manager said she came to work at the facility in the morning on [DATE]. She said at approximately
9:00 a.m. she spoke to Resident #1's representative and let him know the resident was coded (had
cardiopulmonary resuscitation, also known as CPR) and sent to the hospital. She said she did not
document after speaking to the resident representative on [DATE].
Event ID:
Facility ID:
106032
If continuation sheet
Page 2 of 3
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
106032
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/14/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Sarasota
1507 S Tuttle Ave
Sarasota, FL 34239
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, record review, and review of facility policies, the facility failed to report an allegation of neglect
that resulted in death within the specified required timeframe for one resident (Resident #1) reviewed.The
findings included:Review of facility policy N-1265 effective 11/30/2014, revised 11/16/2022 Abuse, Neglect,
Exploitation & Misappropriation revealed Once an allegation of abuse is reported, the Executive Director, as
the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to
appropriate officials in accordance with Federal and State regulations.Review of facility investigation
revealed on 12/26/25 at approximately 8:03 p.m. in a phone conversation with the Director of Nursing
(DON) and the Administrator Resident #1's representative stated he felt Resident #1 should have been
transferred to the hospital sooner. The investigation documented that the Administrator became aware of
the situation on 12/26/25 at 8:03 p.m. The report of this allegation of neglect was submitted to the Agency
on 12/27/25 at 3:29 p.m.On 1/14/26 at 3:07p.m. in an interview, the DON said that Resident #1 was
transferred to the hospital on [DATE]. She said she spoke to the resident's representative the morning of
12/26/25 and he informed her that the resident had passed away. She said later in the day the
representative was asking more questions about what happened at the facility before Resident #1 was sent
to the hospital. She included the Administrator on a 3-way phone call with the representative on 12/26/25
and the representative said he thought they should have sent the resident to the hospital sooner. The DON
said she felt it was an allegation of neglect. She acknowledged that the allegation was not reported to the
Agency until 12/27/25 at 3:29 p.m. She said the delay may have been because she and the Administrator
were trying to gather more information. She said they were trying to see if there was anything they'd have to
add to the report before they submitted it.
Event ID:
Facility ID:
106032
If continuation sheet
Page 3 of 3