Aviata At North Florida
AVIATA AT NORTH FLORIDA in GAINESVILLE, FL — inspection on June 5, 2026.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #56's physician order dated 4/2/2026 read, Citalopram Hydrobromide Oral Tablet 20 MG [milligram] give 1 tablet by mouth one time a day related to depression.
During an interview on 6/4/2026 at 9:12 AM, Staff I, Registered Nurse MDS Coordinator, stated, [Resident #56's Name] did have medication for depression starting on 4/2/2026.
The diagnosis should have been checked off.
The assessment will need to be corrected.
During an observation on 06/02/2026 at 9:35 AM, Resident #19 was observed in the Physical Therapy Gym receiving services.
Weights applied to wrists and ankles with Velcro.
Resident was able to make full effort at minimally moving all 4 extremities at the same time in a circular motion successfully with maximum effort while sitting in his electric wheelchair.
During interview on 06/03/2026 1:10 PM, Staff F, MDS Coordinator, stated I don't see any corrections being done for [Resident #13's Name] MDS in Section GG for No impairment in range of motion upper and lower extremity. I know about the diagnosis of Quadriplegia, and I have also seen him wiggle around in his wheelchair by himself.
During interview on 06/04/2026 at 4:35 PM with Staff G, PT(Physical Therapist) stated, [Resident #19's Name] is a quadriplegic with spinal cord injury that happened about 5 years ago. He does have limitations in his range of motion in his upper and lower extremities.
Review of Resident #19's MDS Section GG Functional Abilities dated 04/15/2026 read, Functional Limitation in Range of Motion Code 0 (No impairment) A.
Upper Extremity Code 0 B.
Lower extremity Code 0 Review of Resident 19s Care Plan dated 04/17/2026 read, FOCUS Alteration in usual Functional Performance in Mobility/Transfer status related to chronic pain, Quadriplegia, OA(osteoarthritis), and muscle weakness.
Review of the facility policy and procedure titled Comprehensive Assessments with a last review date of 3/11/2026 read, Policy Interpretation and Implementation. 1.
Comprehensive assessments are conducted in accordance with criteria and timeframes established in Resident Assessment Instrument (RAI) User Manual.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
actions that can be measured.
comprehensive care plan for oxygen and resident behaviors for 1 (Resident #113) of 8 residents
Resident #113 was lying in bed.
Oxygen was being administered at 3 liters via nasal cannula.During an observation on 6/02/2026 at 10:48 AM Resident #113 was lying in bed with eyes closed resting calmly.
Oxygen was being administered at 3 liters via nasal cannula.Review of Resident #113's physician order dated 5/4/2026 read, Respiratory: Oxygen-3L [liters] Continuous.Review of Resident #113's physician order dated 5/5/2026 read, Respiratory: Oxygen- 3L Continuous, nasal cannula.Review of Resident #113's physician order dated 5/22/2026 read, Respiratory: Oxygen- 4L Continuous.Review of Resident #113's Baseline Care Plan and Summary dated 5/4/2026 read, Other Services/Orders: O2 [oxygen].Review of Resident #113's care plan reviewed on 6/03/2026 did not document a focus for respiratory services or behaviors regarding oxygen.
During an interview on 6/3/2026 at 11:30 AM, Staff J, Licensed Practical Nurse (LPN), stated, [Resident #113's name] has orders for oxygen and it should be 4 liters.
During an interview on 6/3/2026 at 11:31 AM, Staff J, LPN, confirmed Resident #113's oxygen was being administered at 3 liters per minute.
During an interview on 6/3/2026 at 11:31 AM, Staff J, LPN, stated, [Resident #113's name] has behaviors and tends to take off his oxygen and touch the oxygen concentrator and move the flow rate.
During an interview on 6/4/2026 at 8:59 AM, Staff I, Registered Nurse Minimum Data Set Coordinator, stated, I was informed yesterday that he (Resident #113) just got oxygen now and that he has behaviors concerning the oxygen. I was not aware he was on oxygen.
The oxygen focus is not on is care plan and it should have been included.
Review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered with a last review date 3/11/2026 read, Policy Statement. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation. 2.
The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS Assessment (Admission, Annual, or Significant Change in Status), and no more that 21 days after admission.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
for a facial skin growth.
Findings Include:During an observation on 6/1/2026 at 10:41 AM Resident
side of chin midline between ear and mouth. A part of the growth is hanging from the chin and was tangled with the resident's long hair. (photographic evidence)
During an interview on 6/1/2026 at 10:43 AM, Resident #97 states, I have this growth on the left side of my chin, and the nurse practitioner wants it taken off. It is benign.
During an interview on 6/4/2026 at 1:00 PM, Consultant stated, [Name of Health Plan](I SNP - type of Medicare advantage) was selected by the patient. It is a program that helps to reduce costs, and they make appointments for Residents.
During an interview on 6/4/2026 at 3:12 PM, Resident #97 stated, It is growing and I need to see a dermatologist. (photographic evidence)
During an interview on 6/4/2026 at 3:50 PM, the DON stated, [Name of Health Care Plan] should have scheduled an appointment for the dermatology consult.
Consults need to be scheduled in a timely manner.
There is no policy for scheduling appointments.
Record review of Resident #97's provider order dated 2/16/2026 reads Needs follow up with in house dermatology lesion to left jaw, previously biopsied
Record review of Resident #97's provider order dated 3/6/2026 reads refer to dermatology for facial lesion, [Name of Health Care Plan] to schedule.
Record review of mobile dermatology provider note dated 12/9/2025 reads, Chief Complaint: Being seen to discuss biopsy results, shave biopsy performed on 11/25/25 visit for evaluation of the lesion located on the left angle of jaw.
Recommend lesion be re-biopsied with deeper and wider shave after lesion has been adequately cleaned and debrided in preparation.
Record review of Resident #97's APRN #2's provider note dated 2/4/2026 reads, There is a lesion on left side of the patient's face.
Waiting on dermatology.
Patient states he has seen dermatology and is waiting on a new appointment.
Record review of Resident #97's APRN #3's provider noted dated 2/6/2026 reads, He reports concern regarding a facial lesion on his left jaw area, stating he previously had this area biopsied, but does not recall receiving follow up results.
Record review of Resident #97's nurse's note dated 3/10/2026 at 2:09 PM, authored by Staff S LPN Unit Manager reads, Communicate (sic) with [Name of Nurse Practitioner from Health Care Plan] regarding pending referrals to urology and dermatology.
She stated that they are currently in the process of scheduling both appointments and will provide an update once the appointment have been confirmed.
Record review of Resident #97's nursing note dated 3/12/2026, authored by Staff S Unit Manager, reads, Conferred with [Name of Health Care Plan Representative] regarding the pending dermatology appointment for the area of concern noted on the resident's face.
She was informed that the mass appears to have increased in size over the past month and that is important for the resident to be evaluated by a specialist as soon as possible for proper assessment and treatment. [Name of Health Care Plan Representative] stated that she will begin the process of scheduling the dermatology appointment today.
Resident notified.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
Operation. a.
Ensures two caregivers are present.
review date of 3/11/2026 read, Purpose: The purpose of this procedure is to establish the general
training or instructions.
General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
maintenance of acceptable parameters of nutritional status.
Findings include:
During an interview via
Name] came in from the hospital with tube feeding and a diet. He doesn't eat much; we tried cutting back on his tube feedings, but he lost weight. I provide a list of residents I want weekly weights done on. I am there once a week and meet with the IDT(interdisciplinary team), Administrator and the DON (director of nursing); we work as a team. I will then reassess and check it monthly to see how he is doing and talk to the staff. He has been eating a lot of snacks brought in by the family. I think that is why he has gained weight.Review of Resident #13's Physician Order dated 03/19/2026, reads, Weigh Weekly d/t (due to) significant weight change.Review of Resident #13's weights: 05/29/2026 - No weight recorded, 05/22/2026- No weight recorded, 05/15/2026 -176.6 pounds, 05/08/2026-No weight recorded, 05/01/2026- 172.8 pounds, 04/27/2026-171.2 pounds, 04/20/2026-171.0 pounds, 04/13/2026- no weight recorded, 04/06/2026-177.4 pounds, 03/30/2026-No weight recorded, 03/23/2026-176.2 pounds 03/18/2026-176.8 pounds, 03/09/2026 -178.0 pounds, and 03/05/2026-177.4 pounds.Review of Resident #13's Dietary Progress Note Dated 05/07/2026 read, Significant weight change note: Diet: NAS(no salt added) diet, regular texture, thin liquids.
Supplement/interventions for weight loss: health shake 4oz(ounces) BID(twice a day) (440 kcal(kilocalorie) and 14g(grams) of protein) w/ 50-100% intakes, TF (tube feeding)order: bolus 474ml(milliliters) of Jevity 1.5 BID(twice per day) PO(per os) intake: average 0-100%. CBW(current body weight): 172.8 pounds on 05/01/26.
Weight history: 1mon: 04/06/2026 177.4 pounds (-4.6 pounds, -2.6%). 3mon: 02/11/2026 175.6 pounds (-2.8 pounds, -1.6%). 6mon: 11/26/2025, 198.4 pounds, -12.9% , -25.6 pounds - significant weight loss, unplanned, undesirable.Review of Resident #13's Plan of Care Dated 04/17/2026 contains focuses including risk for malnutrition, r/t(related to) significant weight loss, and dysphagia(difficulty in swallowing) with interventions including weights per facility protocol and as ordered.Review of Facility Policy Titled Weight Assessment and Intervention Last review date 03/11/2026 read, Policy Statement - Resident weights are monitored for undesirable or unintended weight loss or gain. 1.
Residents are weighted upon admission and at intervals established by the interdisciplinary team.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
used, maintained, and discarded in accordance with manufacturer recommendations, infection
placement into service.
The label must contain the date and time the bottle was opened and the
opening or sooner if empty, contaminated, leaking, damaged, or visibly cloudy. 6.
Nursing staff shall monitor residents receiving humidified oxygen for proper equipment function, adequate humidification, and signs of respiratory distress or infection.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
of Resident #82's dialysis communication record dated 05/18/2026 showed the section to be
review date 03/11/2026 read, Policy Statement Residents with end-stage renal disease (ESRD) will
and the contracted ESRD facility include all aspects of how the residents' care will be managed, including: a. how the care plan will be developed and implemented; b. how information will be exchanged between facilities; and c. responsibility for waste handling, sterilization and disinfection of equipment.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
minimal harm was posted on a daily basis.Finding includes:During an observation on 6/1/2026 at 9:05 AM, nursing staffing information dated 6/1/2026 was posted to the right side of the main entrance next to the
nursing staffing information dated 6/1/2026 was posted to the right side of the main entrance next to the receptionist desk.
Census was documented 103. [photographic evidence obtained]
Review of the facility Resident Listing Report dated 6/1/2026 documented census was 102.During an observation on 6/1/2026 at 3:40 PM, nursing staffing information dated 6/2/2026 was posted to the right side of the main entrance.During an observation on 6/2/2026 at 5:02 PM, nursing staffing information dated 6/3/2026 was posted to the right side of the main entrance. [photographic evidence obtained]During an observation on 6/3/2026 at approximately 5:09 PM, nursing staffing information dated 6/4/2026 was posted at the 100 Hall nursing station near the off hours facility entrance.
The Director of Nursing was standing at the nursing station.
During an interview on 6/3/2026 at approximately 5:10 PM with the Director of Nursing confirm nursing staffing information posted was dated 6/4/2026.
The Director of Nursing stated, The scheduler will prepare the staffing information sheet before leaving and any corrections will be made tomorrow.
The staffing sheet should not be posted in the front of the posting it should be place behind the current day and tomorrow when the new shift starts it should be changed.
During an interview on 6/4/2026 at 11:28 AM with the Administration stated, The staff coordinator should not post the staffing information the day before.
She can make one before she leaves and leave it behind the current one.
The following day corrections should be made if needed and post the current staffing information for the day.
During an interview on 6/4/2026 at 12:23 PM with the Staffing Coordinator stated, I spoke to the Director of Nursing yesterday evening. I was putting it [staffing information] out before I leave at end of day for the following day. I don't even think I even notice that (census was documented incorrectly) it was incorrect.
Everything happened real fast.
Review of the facility policy and procedure titled Posting Direct Care Daily Staffing Numbers with a last review date of 3/11/2026 read, Policy: Our Facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.
Policy Interpretation and Implementation. 1.
Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNS) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) and in a clear and readable format. 3.
Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift.
The information recorded on the form shall include the following: c.
The resident census at the beginning of the shift for which the information is posted. e.
The shift for which the information is posted.
in accordance with accepted professional standards.
for 1 (Resident #112) of 3 residents reviewed for skin conditions.Findings include:Review of Resident
antibiotic ointment to great toe.Review of Resident #112's Medication Administrator record for the month of April 2026 did not documented Soaks in Epsom salt or triple antibiotic ointment to the great toe.Review of Resident #112's Treatment Administrator record for the month of April 2026 did not documented Soaks in Epsom salt or triple antibiotic ointment to the great toe.
During an interview on 6/3/2026 at 1:57 PM, the Director of Nursing stated, I know there was an order for [Resident #112's name], but it was not documented. I looked at the treatment records and was not able to find it. I did speak to staff and they say they did provide care.
During an interview on 6/3/2026 at 2:00 PM, Staff L ,Licensed Practical Nurse, stated, I saw nursing providing the treatment.
The Epsom salt is still in the medication cart.
The staff wrote the order and forgot to check off the box so it would show on the MAR [Medication Administration Record].
During an interview on 6/3/2026 at 2:09 PM, with Staff M Wound Care Nurse stated, I was doing the treatments daily for [Resident #112's name].During an interview on 6/3/2026 at 2:20 PM with Resident #112 confirmed staff did provide the Epsom salt soaks and triple antibiotic ointment to her great toe.
During an interview on 6/4/2026 at 3:46 PM with the Director of Nursing stated, A physician order should be on the MAR and staff should document they have completed the treatment and administration.
Review of the facility policy and procedure titled Documentation of Medication Administration with a last review date of 3/11/2026 read, Policy Statement. A medication administration record is used to document all medications administered.
Policy Interpretation and Implementation. 1. A nurse or certified medication aide (where applicable) documents all medications administer to each resident on the resident's medication administration record (MAR). 2.
Administration of medication is documented immediately after it is given.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
Review of the Pest Control Inspection report dated 6/01/2026, from [local pest control company] read, Other open recommendations: Cracks or damage to wall allowing pest access.
Please repair to prevent pest entry.
The baseboard within the building haves {sp} cracks and voids that could allow entry to pest.: Interior - Detail – Debris collecting interior.
Please remove debris to prevent unsanitary condition and attraction by pests.
Detail – Pipes extending through wall allowing pest access.
Please fill in gaps between pipes and wall to prevent pest entry.
Review of Work Order #7235 with a creation date of 3/18/2026 read, Room/Area – Dietary – kitchen; Notes – Need Pest Control ASAP and need holes closed up ASAP (as soon as possible).
Priority – Critical.
The status of the work order was Set to be completed, on 4/20/2026.
The status of the work order was never completed.
During an interview on 06/01/2026 at 12:27 PM, Resident #11 stated, I have seen a lot of roaches in my room and around the floor. It has been quite a few months since they have come in and sprayed.
During an interview on 06/01/2026 at 10:08 AM, Resident #71 stated, I see roaches all over my room at night. I notified the administrator a few months ago about the roaches, and no one has ever come in to spray.
During an interview on 06/01/2026 at 10:37 AM, Resident #104 stated, There are roaches in my room.
During an interview on 6/04/2026 at 1:05 PM the Administrator confirmed the presence of live pests in the facility.
During an interview on 6/04/2026 at 1:10 PM, the Director of Plant Operations stated that they were not aware of or working on the repair recommendations made to the facility from the pest control company on 5/22/2026, 5/29/2026, and 6/01/2026.
Review of the policy and procedure titled Pest Control, with the last review date of 3/11/2026, read, Policy Statement: Our facility shall maintain an effective pest control program.
Policy Interpretation and Implementation: 1.
This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
105460 06/05/2026
Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.