Aviata at North Florida: Pain Medication Withheld - FL
The inspection was triggered by a complaint and conducted on August 29, 2025.
The man with the amputations, identified in inspection records only as Resident 2, told an inspector on August 25 that he was supposed to get a scheduled medication every four hours and wasn't receiving it because staff wouldn't wake him. Four days later, at 7:20 in the morning, he said it again: he hadn't gotten his oxycodone the night before at midnight. He said it was always the same nurse.
He was right. The medication administration record for August showed the 5 mg oxycodone tablet was skipped at midnight on August 13, 15, 20, 22, 24, and 29, and at 4 a.m. on August 17. Seven missed doses in a single month. His physician's order, written August 10, was explicit: give one tablet by mouth every four hours for pain, hold only if lethargic.
He was sleeping. Not lethargic. Sleeping.
The second resident, identified as Resident 9, had paraplegia, a colostomy, chronic pain, and major depressive disorder. His physician ordered oxycodone with acetaminophen every four hours for pain rated seven to ten. His records showed missed midnight doses on August 22, 24, and 29. On the morning of August 29, he told an inspector he hadn't gotten his medication the night before. He said he had complained to other nurses about the missed doses. Nothing was done.
Both residents pointed to the same overnight period. Both care plans, reviewed by inspectors, listed the same intervention: administer analgesic medication as ordered by the physician.
The Assistant Director of Nursing told inspectors that afternoon that the nurse, identified only as Staff B, a licensed practical nurse, said both residents were sleeping and so she did not wake them. The ADON was direct about what that meant: Staff B did not follow the physician's orders.
Staff B confirmed it herself. In an interview at 3:24 p.m. on August 29, she told inspectors both residents were asleep and she did not administer the pain medication.
There is no indication in the inspection record that the facility had identified the pattern before the complaint was filed. Resident 2 had been flagging the problem for at least four days before the inspection concluded. His care plan, in place since March and revised in April, documented his acute and chronic pain, neuropathy, and restless leg syndrome. The plan called for medication to be given as ordered. The orders were not being followed.
Resident 9 told inspectors he had raised the issue with multiple nurses. The inspection record does not indicate any of those conversations prompted a review of his medication administration records or a conversation with Staff B.
For Resident 2, the missed doses stretch back to August 13, more than two weeks before the inspection. In that window, a man who lost both legs above the knee, who wakes with nerve pain from diabetes and the involuntary movements of Parkinson's disease, went without his prescribed opioid at least seven times because the nurse on duty decided not to wake him.
He woke up anyway. He just woke up in pain.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At North Florida from 2025-08-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVIATA AT NORTH FLORIDA in GAINESVILLE, FL was cited for violations during a health inspection on August 29, 2025.
The inspection was triggered by a complaint and conducted on August 29, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.