Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

AVIATA AT THE SEA - PASADENA

SOUTH PASADENA, FL · 58 certified beds · Last Life Safety survey February 2, 2023

CMS Certification Number 105012 · first certified March 1979

Ownership

Operated by AVIATA HEALTH GROUP · For profit - Limited Liability company

  • Ownership changed September 1, 2023 (change of ownership)to ASPIRE AT THE SEA - PASADENA from 1820 SHORE DRIVE OPERATIONS LLC
26
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
7
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file

Position within FL

26 citations — more than 99% of the 694 certified nursing homes in FL. Compared within FL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 8 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (May 2024 to December 2024), and past the point by which nine in ten FL facilities have been surveyed. This facility’s last Life Safety survey was February 2023. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

8 of the 26 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index

  • F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.

This facility26FL median7National median11
Citations on file over three years, compared
MeasureCitations
This facility26
Median facility in FL7
Median facility nationally11

Survey history

Citations at each Life Safety survey
112019-0972021-0682023-02
Citations at each Life Safety survey
Survey dateCitations
September 27, 201911
June 23, 20217
February 2, 20238

Most-cited tags

Most-cited tags at this facility
K-03243K-03533K-02912K-07612E-00042K-09182E-00152E-00131
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0324Provide properly protected cooking facilities.32023-02-02
K-0353Inspect, test, and maintain automatic sprinkler systems.32023-02-02
K-0291Install emergency lighting that can last at least 1 1/2 hours.22021-06-23
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.22023-02-02
E-0004Develop and maintain an Emergency Preparedness Program (EP).22021-06-23
K-0918Have generator or other power source capable of supplying service within 10 seconds.22023-02-02
E-0015Address subsistence needs for staff and patients.22023-02-02
E-0013Develop Emergency Preparedness policies and procedures.12019-09-27

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 8
  • Smoke Deficiencies 8
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Egress Deficiencies 3
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies8
Smoke Deficiencies8
Gas, Vacuum, and Electrical Systems Deficiencies5
Egress Deficiencies3
Miscellaneous Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 2, 2023 — 8 citations

Citations issued on February 2, 2023
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (March 6, 2023)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (March 6, 2023)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (March 6, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (March 6, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 6, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (March 6, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (March 6, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 6, 2023)

June 23, 2021 — 7 citations

Citations issued on June 23, 2021
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (July 23, 2021)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (July 23, 2021)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (July 23, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (July 23, 2021)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (July 23, 2021)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (July 23, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (July 23, 2021)

September 27, 2019 — 11 citations

Citations issued on September 27, 2019
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (October 11, 2019)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (October 11, 2019)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (October 11, 2019)
E-0029Develop a communication plan.Deficient, Provider has date of correction (October 11, 2019)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (October 11, 2019)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 11, 2019)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 11, 2019)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 11, 2019)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 11, 2019)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (October 11, 2019)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 11, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.