Aviata at Beneva: Wound Care Falsified Records - FL
The resident, identified in inspection records only as Resident 99, rated her pain a 9 out of 10 during wound care. She cannot turn in bed without two people helping her.
Federal inspectors visited the facility on August 13, 2025, following a complaint. What they documented across the preceding days was a picture of wounds worsening under the care of a facility where the person responsible for checking skin had been marking evaluations complete without doing them.
On the morning of August 12, inspectors watched a unit manager and a CNA director position Resident 99 for wound care. The left hip wound was yellow, filled with slough, dead tissue, and draining a moderate amount of tan fluid. The resident was already on the antibiotic Bactrim for the infection there. The sacral wound, on her lower back, was approximately the size of a deck of cards. It was black. There was an open area at the six o'clock position of the wound.
Both wounds were being treated with Dakins solution, a broad-spectrum antiseptic, soaked into gauze and covered with a dry dressing.
The wound care physician, reached by phone that same morning, said the resident refuses to cooperate with treatment. She declined a low air loss mattress, which he had recommended to reduce pressure on her wounds. She does not always allow him to examine her when he visits, which he does once a week. She does not comply with turning and repositioning schedules. "She is very stubborn," he said. He described the prognosis for the sacral wound as having a low chance of healing. He noted she spends most of her day sitting outside smoking.
The unit manager said the same, that the resident often refuses to let the wound care physician look at her wounds and declines treatments.
A resident who is alert and oriented has the right to refuse care. That part of the record is not in dispute.
What is in dispute is something else entirely.
On February 2 and February 16, a licensed practical nurse identified as LPN Staff A signed the Treatment Administration Record confirming she had completed weekly skin evaluations. She had not done them. When inspectors interviewed her on August 12, she said she could not remember why she skipped the February 2 evaluation. For February 16, she offered this: she must have been busy.
Signing off on care that was never delivered is not a memory lapse. It is a falsified record. Skin evaluations exist precisely to catch what happens when wounds are allowed to develop undetected, when pressure builds, when tissue dies. Whether the missed evaluations in February contributed to the condition of Resident 99's wounds by August is not something the inspection report establishes. What it establishes is that the documentation meant to protect her was fiction.
The registered nurse who spoke with inspectors on August 11 noted she was not the regular wound care nurse. She said that when there is an extra person on the assignment, someone does the wound care. Resident 99's three wounds, she confirmed, require daily treatment.
Inspectors classified the falsified records as causing actual harm, specifically severe pain, affecting a small number of residents.
Resident 99 told inspectors she had asked for a pain pill during wound care. The pain she rated a 9 out of 10 was the pain of having her wounds cleaned and dressed. She requires two people to move her in bed. She spends her days outside.
The wound care physician said it is "on and off" with her. The sacral wound, black and open, has a low chance of healing.
The nurse who was supposed to be checking her skin in February said she must have been busy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Beneva from 2025-08-13 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 22, 2026 · Our methodology
AVIATA AT BENEVA in SARASOTA, FL was cited for violations during a health inspection on August 13, 2025.
The resident, identified in inspection records only as Resident 99, rated her pain a 9 out of 10 during wound care.
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.