Aviata At Bryan Dairy
AVIATA AT BRYAN DAIRY in LARGO, FL — inspection on October 24, 2025.
Found 4 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
abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
The facility was
jeopardy to resident health or competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate safety jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.
106116 10/24/2025
Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777
hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR
jeopardy to resident health or competency, abuse/neglect/exploitation/misappropriation, and participation in code blue safety drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all
the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.
106116 10/24/2025
Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777
provided to all residents who are identified to be in cardiac arrest unless such resident has a fully
jeopardy to resident health or call for assistance. a.
Two licensed nurses are to verify: Resident identification. b.
Fully executed safety Florida Do Not Resuscitate Order (DH1896), located in the advanced directive section of the medical record. e to 2.
Use the paging system to call Code Blue to Room Number or location of the event three
will immediately begin CPR 4.
Will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: a.
The resident responds. b.
Notify the physician and the resident representative/ legal representative.c.
Document in the medical record.
The facility's immediate actions to remove the Immediate Jeopardy included:- An audit of each resident's code status was initiated on [DATE] and completed on [DATE]. - On [DATE] the licensed nurse was suspended, pending the facility's investigation.- An ADHOC Quality Improvement Performance Committee (QAPI) was conducted on [DATE] to review the incident, discuss corrective actions and provide recommendations.
The team members in attendance were the medical director, executive director/NHA, director of nursing, and the assistant administrator/ANHA .- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
The root cause analysis identified lack of consistent staff training upon hire in orientation and ongoing monthly mock drills.
The QAPI committee approved the recommendations on [DATE].- Code blue drills were initiated on [DATE] on two shifts, three shifts on [DATE], three shifts on [DATE], three shifts on [DATE], and two shifts on [DATE].
Licensed nurses work 12-hour shifts.
Thirteen code blue drills had been completed with 115 staff members.
Ongoing drills will continue until all staff have completed and will continue weekly for four weeks and then ongoing monthly with the results reported to the QAPI committee.- From [DATE] to [DATE], the regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.- From [DATE] to [DATE], licensed nurses and CNA's received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.- From [DATE] to [DATE], 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.- On [DATE], licensed nurses received education on the identification of a change in condition including competency.
Eleven licensed nurses completed the training. - Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.Verification of the facility's removal plan was conducted by the survey team on [DATE].- Interviews were conducted with twenty-five out of 117 licensed nursing staff who worked across all shifts.
The staff members were able to state they had been trained and were knowledgeable about the new policies and procedures initiated by the facility.- A review of in-service documentation revealed 100% of staff currently working had completed education and training related to CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
The facility was conducting on-going training to reach 100% completion for the identification of change condition with competency.Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.
106116 10/24/2025
Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777
Jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the
jeopardy to resident health or safety
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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.