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
jeopardy to resident health or safety
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Bryan Dairy
9035 Bryan Dairy Rd Largo, FL 33777
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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 recommendations made from the root cause analysis.
The team members in attendance were the medical director, executive director, director of nursing, and the assistant administrator.- 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 are 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Bryan Dairy
9035 Bryan Dairy Rd Largo, FL 33777
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviata at Bryan Dairy
9035 Bryan Dairy Rd Largo, FL 33777
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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. - The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR and the completed road map from orientation will be signed acknowledging the education received.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.
Facility ID: