Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At Oakfield during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including a stage 3 pressure injury requiring daily wound care, was discharged home without a documented discharge plan, without confirmation of home health services, and without needed supplies. Progress notes and the care plan lacked evidence of discharge planning discussions with the resident or representative, and there was no nursing documentation of discharge education or supplies provided. Social services documented that home health was expected, but later learned after discharge that the initial home health agency had not agreed to accept the resident, and the resident’s family reported that no home health visit occurred and no supplies were sent home, contrary to facility discharge planning policy.
A resident with sepsis, muscle weakness, and gait abnormalities, who required extensive assistance with ADLs and used a walker or wheelchair, was found on the floor beside the bed after an unwitnessed fall. The nurse documented a red mark on the forehead and a skin tear on the left elbow and used a mechanical lift with a CNA to return the resident to bed, but the medical record contained no neurological checks or other required post-fall assessments. During interviews, the ADON and DON acknowledged that the fall was unwitnessed, that the cause of the forehead mark was not clarified, and that no neuro checks were completed, despite the facility’s Fall Management policy requiring neuro checks, comprehensive post-fall evaluation, documentation, and care plan updates after a fall.
A resident admitted with a colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes had these devices clearly documented on the Medicaid certification form, MDS, care plan, and NP/physician progress notes, which called for daily assessment and meticulous stoma and nephrostomy care. However, the facility’s admission data collection only recorded a colostomy and omitted the urostomy and nephrostomy tubes, and the physician orders contained detailed instructions only for colostomy appliance changes and peristomal skin care, with no orders for urostomy or nephrostomy care. The DON stated that admission orders should have addressed these devices and that nurses are expected to reconcile hospital discharge orders and enter all orders into the EMR, while staff reported they follow physician orders and document ostomy care on the TAR. This disconnect between documented clinical needs and the absence of corresponding urostomy/nephrostomy orders and TAR entries resulted in a failure to provide ostomy-related care consistent with professional standards of practice.
A resident with a history of dementia and other health issues developed a stage 3 pressure ulcer, but the facility failed to provide necessary treatment and documentation. Despite having orders for wound care, treatment was documented only once over several days. The facility's policies required regular skin evaluations and documentation, which were not consistently followed, leading to the deficiency.
Failure to Plan and Document Safe Discharge With Confirmed Home Health and Supplies
Penalty
Summary
The deficiency involves the facility’s failure to document and plan the discharge process for one resident, resulting in a discharge that did not ensure needed services and supplies were in place. The resident was admitted with multiple serious diagnoses, including sepsis, osteomyelitis of the femur, COPD, muscle weakness, malignant neoplasm of the rectum, a colostomy, chronic kidney disease, and a female genital tract fistula, and had physician orders for daily wound care to a stage three pressure injury on the coccyx. Record review showed the resident’s care plan did not include a discharge plan, and progress notes lacked documentation of discharge planning discussions with the resident or the resident’s representative. A nursing progress note documented that the resident went home via stretcher, and a social service discharge note stated the resident was to receive home health, but there was no documentation of nursing discharge responsibilities, including education or supplies provided at discharge. Interviews and documentation further showed that the home health provider had not been confirmed prior to discharge, and no supplies were provided to the resident at the time of discharge. The resident’s representative reported the resident was discharged home without supplies and that the home health company did not show up. Social services later learned, through a post-discharge contact with the family, that the initial home health company had not agreed to care for the resident, and the resident had to obtain a different home health provider. Staff confirmed there was no documentation of the nurse’s role in the discharge and acknowledged that documentation should have included education and supplies given. Review of the facility’s Discharge Planning policy showed requirements for early discharge planning, completion of a discharge planning record, provision of discharge summaries and instructions, and post-discharge follow-up, which were not reflected in the resident’s record.
Failure to Implement Required Post-Fall Evaluations After Unwitnessed Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not implementing required post-fall evaluations for one resident. The resident was admitted with diagnoses including sepsis, muscle weakness, and gait and mobility abnormalities, and required substantial to maximal assistance with multiple ADLs, including transfers and positioning. A fall risk assessment indicated the resident was a low fall risk, cognitively intact, and used a walker or wheelchair. A progress note documented that during room checks on 12/18/2025 at 1:05 PM, a nurse found the resident on the floor beside the bed after the resident reported slipping while trying to push herself back into bed. The nurse documented a head-to-toe assessment noting a red mark on the forehead and a skin tear on the left elbow, and that a mechanical lift was used with a CNA to return the resident to bed. Record review showed no neurological checks or other fall-related assessments following this unwitnessed fall, despite the presence of a red mark on the resident’s forehead and a skin tear. During interviews, the ADON, DON, and NHA acknowledged the fall was unwitnessed and that the facility did not ask the resident if the red mark on the forehead was due to a head injury, instead accepting the resident’s explanation. The ADON stated they did not know the cause of the red mark and confirmed that no neuro checks were found in the record. The DON stated that unwitnessed falls require monitoring, neuro checks, complete skin assessments, treatment for possible skin care, frequent monitoring, and range of motion assessments, and acknowledged these required post-fall steps were not completed. Review of the facility’s Fall Management policy showed that post-fall strategies must include resident evaluation, initiation of neurological checks, physician and representative notification, post-fall evaluation, care plan updates, 72-hour post-fall documentation, IDT review with root cause analysis, and weekly review, which were not implemented for this resident after the fall.
Failure to Establish and Implement Urostomy/Nephrostomy Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide urostomy and nephrostomy tube care consistent with professional standards of practice for one resident who required such services. The resident was admitted with multiple significant diagnoses, including sepsis, acute osteomyelitis, COPD, chronic kidney disease, artificial openings of the urinary tract, female genital tract fistula, history of malignant neoplasm of the large intestine, colostomy status, and DVT. Admission documentation (the Medicaid 3008 form) identified the presence of a urostomy, bilateral nephrostomy tubes, and a colostomy. However, the facility’s admission/readmission data collection only documented a colostomy under gastrointestinal status and did not document the presence of a urostomy or nephrostomy tubes under genitourinary status. The resident’s MDS admission assessment did identify nephrostomy tubes and ostomies (including urostomy and colostomy), and subsequent NP and physician progress notes documented that the resident had a permanent colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes, with all appliances intact on exam. These notes directed staff to continue daily assessment for leakage, obstruction, decreased output, skin breakdown, hematuria, foul odor, catheter-related pain, and signs of infection, and to maintain meticulous stoma and nephrostomy care. The resident’s care plan also referenced skin excoriation on the sacrum and coccyx related to an ileal conduit, ostomy, and nephrostomy tubes. Despite this, the physician orders in the record only contained a detailed order for colostomy appliance changes and associated skin care, with no corresponding orders for urostomy or nephrostomy tube care. During interviews, the DON stated that at admission, batch or standing orders are generated based on hospital discharge orders and that nurses are expected to reconcile hospital discharge orders with the physician, with all orders entered into the electronic medical record. The DON acknowledged that at the time of this resident’s admission, the orders should have addressed urostomy and nephrostomy tube care but could not explain the missing orders. Staff reported that ostomy care is to be provided every shift and as needed, with care orders reflected on the TAR and documented there, and that nurses follow physician orders when caring for residents with ostomies. Facility policies required individualized care plans, monitoring of treatment effectiveness, and incorporation of identified needs (such as ostomies and nephrostomy tubes) into the care plan and CNA Kardex. The lack of specific physician orders and corresponding TAR entries for urostomy and nephrostomy care, despite clear documentation of these devices in assessments and progress notes, led to the cited deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment to promote healing and prevent infection for a resident with a stage 3 pressure ulcer. The resident, who had a history of a left femur fracture, muscle weakness, muscle wasting, and dementia, developed a stage 3 pressure ulcer on the sacrum on November 19, 2024. Despite having orders for wound care, including the use of a low air loss mattress and specific dressing changes, the treatment was documented as completed only once between November 19 and November 23, 2024. The resident's medical records indicated that the pressure ulcer was identified on November 6, 2024, but there were no documented pressure wound care orders at that time. The Director of Nursing confirmed that there should have been orders documented when the wounds were identified. Additionally, the facility's policies required weekly skin evaluations and documentation of any skin impairments, but the records showed inconsistencies in the documentation and follow-up of the resident's skin condition. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that there was a lack of adherence to the facility's policies regarding pressure ulcer care and documentation. The facility's policies outlined the need for timely documentation of physician orders and regular skin evaluations, which were not consistently followed in this case. This failure to provide appropriate care and documentation contributed to the deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawthorne Center For Rehabilitation And Healing Of | 0.8 mi | — | 0 | 0 |
| Aviata At Central Park | 0.9 mi | — | 3 | 0 |
| Victoria Crossing Rehabilitation Center | 1.1 mi | — | 11 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 8.9 mi | — | 1 | 0 |
| Whispering Oaks | 9.1 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.