Aviata at Bryan Dairy: CPR Failure Triggers Immediate Jeopardy - FL
The inspection report does not describe the resident by name, age, or diagnosis. It does not say what happened to them.
What the report does say is this: the facility's own written policy required CPR to be performed on every resident in cardiac arrest unless that resident had a fully executed Florida Do Not Resuscitate Order on file, a specific state form, DH1896, stored in the advanced directive section of the medical record. Two licensed nurses were supposed to verify the resident's identity and check for that form before any decision was made. In the absence of a valid DNR, CPR was to begin immediately and continue until emergency medical technicians arrived and took over.
That did not happen.
The nurse was suspended pending the facility's investigation. No further details about the nurse, the suspension, or the outcome of the investigation appear in the inspection record.
Aviata at Bryan Dairy sits on Bryan Dairy Road in Largo, a city in Pinellas County on Florida's Gulf Coast. The facility's CMS provider number is 106116. The complaint inspection was completed October 24, 2025.
The immediate jeopardy designation placed this violation at the top of CMS's harm scale, meaning inspectors concluded that the facility's failure had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. CMS uses that threshold sparingly. When it applies, it requires the facility to act fast and prove it has.
Aviata moved quickly, at least on paper. Within days of the citation, the facility's leadership, including the medical director, executive director, director of nursing, and assistant administrator, convened an emergency quality improvement committee to reconstruct what went wrong. Their conclusion: the facility had not consistently trained nurses on CPR procedures when they were hired, and had not been running regular mock drills to keep those skills current.
It is a remarkable admission. CPR is not an advanced clinical skill. It is the most basic emergency response a licensed nurse is expected to provide. The idea that a facility housing more than 100 residents had allowed that training to lapse, that no one had noticed, that it took a resident going into cardiac arrest to surface the gap, is what the record shows.
The facility's remediation was extensive, at least in volume. Code blue drills were run across multiple shifts over several weeks. By the time inspectors returned to verify the corrective plan, thirteen drills had been completed involving 115 staff members. The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives, including how to identify a valid DNR and who has authority to initiate one. Licensed nurses and certified nursing assistants received instruction on the CPR policy, on what to do during a code blue, and on the specific roles each person was expected to fill. Eleven licensed nurses completed a training on identifying changes in a resident's condition. All staff currently working completed education on abuse, neglect, exploitation, and misappropriation policy.
That last item, the abuse and neglect training, appears in the corrective plan without explanation. The inspection narrative does not describe any allegation of abuse or neglect separate from the CPR failure. Its inclusion suggests the facility used the moment to push through a broader retraining sweep, or that investigators flagged concerns the public record does not fully disclose.
Inspectors interviewed 25 of the facility's 117 licensed nursing staff across all shifts during their verification visit. Those staff members told inspectors they had been trained and understood the new procedures. Documentation confirmed that 100 percent of staff currently working had completed the required education. The facility was still working toward full completion on the change-in-condition competency.
Based on that verification, inspectors determined the immediate jeopardy had been removed. The violation was reduced to a scope and severity of D, meaning it affected a limited number of residents and did not rise to the level of actual serious harm once the corrective plan was in place. The non-compliance itself, however, remained on the record.
The facility's written CPR policy, quoted at length in the inspection report, describes a system with multiple checkpoints. The paging system is used to announce a code blue to the room number or location three times. Two nurses verify resident identification. Two nurses check for the DNR form. If no valid DNR exists, CPR begins. The policy is detailed, specific, and apparently insufficient, because the nurse who was suspended either did not know it, did not follow it, or made a different judgment in the moment. The report does not say which.
What the root cause analysis found was a training problem, not a judgment problem. That distinction matters. A training failure is correctable with drills and documentation. A judgment failure, a nurse who knew the policy and chose not to follow it, is a different kind of problem, one that drills cannot fully address. The inspection record does not resolve which of those this was.
The resident at the center of this citation is absent from the narrative in the way inspection reports often make people absent, reduced to a code status, a room number, a policy that was or wasn't followed. The report does not say whether the resident survived. It does not say whether emergency medical technicians reached them in time, or whether the delay in CPR changed the outcome, or whether the resident had family who were told what happened and when.
The facility knows. The family, if there is one, knows. The inspection record does not say.
What it says is that a nurse was suspended, that drills were run on two shifts and then three shifts and then three shifts again, that 115 staff members cycled through simulations of the emergency that had already happened to someone on one of their floors, and that by the time inspectors left, the paperwork was complete and the immediate jeopardy designation had been lifted.
The resident in cardiac arrest is not named anywhere in the 18 pages of this inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Bryan Dairy from 2025-10-24 including all violations, facility responses, and corrective action plans.
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 6, 2026 · Our methodology
AVIATA AT BRYAN DAIRY in LARGO, FL was cited for immediate jeopardy violations during a health inspection on October 24, 2025.
The inspection report does not describe the resident by name, age, or diagnosis.
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.