The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Aviata At Fletcher are:
F-0600 · August 21, 2024 · Grade J — Immediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date August 30, 2024
F-0678 · August 21, 2024 · Grade J — Immediate jeopardy
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date August 30, 2024
F-0842 · January 7, 2026 · Grade E — Potential for more than minimal harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date February 5, 2026
F-0760 · September 30, 2025 · Grade E — Potential for more than minimal harm
Ensure that residents are free from significant medication errors.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date October 30, 2025
F-0565 · October 24, 2024 · Grade E — Potential for more than minimal harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date January 6, 2025
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Aviata At Fletcher, 15 subject areas appear across health and fire-safety inspections.
Quality of life and daily care
9 citations between February 26, 2021 and September 30, 2025. The most serious was graded J — immediate jeopardy, affecting one or a very small number of residents. Surveyors found a situation that caused — or was likely to cause — serious injury, harm, impairment, or death, and that needed immediate correction. 3 of these citations came out of complaint investigations. Correction record: 9 citations show a recorded correction date.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0678 · August 21, 2024 · Grade J — Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
F-0691 · April 21, 2022 · Grade E — Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
F-0684 · September 30, 2025 · Grade D — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Freedom from abuse, neglect, and exploitation
4 citations between October 30, 2023 and December 9, 2024. The most serious was graded J (immediate jeopardy). 3 of these citations came out of complaint investigations. Correction record: 4 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0600 · August 21, 2024 · Grade J — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0607 · December 9, 2024 · Grade D — Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F-0609 · July 11, 2024 · Grade D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Assessments and care planning
7 citations between February 26, 2021 and January 7, 2026. The most serious was graded E (potential for more than minimal harm). 2 of these citations came out of complaint investigations. Correction record: 7 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0842 · January 7, 2026 · Grade E — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F-0842 · December 9, 2024 · Grade D — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F-0641 · July 11, 2024 · Grade D — Ensure each resident receives an accurate assessment.
Resident rights
6 citations between February 26, 2021 and September 30, 2025. The most serious was graded E (potential for more than minimal harm). 4 of these citations came out of complaint investigations. Correction record: 6 citations show a recorded correction date.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0565 · October 24, 2024 · Grade E — Honor the resident's right to organize and participate in resident/family groups in the facility.
F-0561 · July 11, 2024 · Grade E — Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F-0558 · April 21, 2022 · Grade E — Reasonably accommodate the needs and preferences of each resident.
Medication and pharmacy services
2 citations between April 21, 2022 and September 30, 2025. The most serious was graded E (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0760 · September 30, 2025 · Grade E — Ensure that residents are free from significant medication errors.
F-0758 · April 21, 2022 · Grade D — Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Food, nutrition, and hydration
2 citations between April 21, 2022 and July 11, 2024. The most serious was graded E (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0812 · July 11, 2024 · Grade E — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-0812 · April 21, 2022 · Grade E — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration and leadership
1 citation between October 24, 2024 and October 24, 2024. The most serious was graded E (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 1 citation shows a recorded correction date.
Administrative citations suggest the problem sits with management systems, not one staff member. Ask who is responsible for quality oversight and what the home's own quality committee changed afterward.
F-0867 · October 24, 2024 · Grade E — Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Physical environment and safety
1 citation between July 11, 2024 and July 11, 2024. The most serious was graded E (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0926 · July 11, 2024 · Grade E — Have policies on smoking.
Infection prevention and control
2 citations between July 11, 2024 and October 24, 2024. The most serious was graded D (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · October 24, 2024 · Grade D — Provide and implement an infection prevention and control program.
F-0880 · July 11, 2024 · Grade D — Provide and implement an infection prevention and control program.
Miscellaneous
2 citations between February 26, 2021 and July 11, 2024. The most serious was graded D (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0761 · February 26, 2021 · Grade D — To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K-0761 · July 11, 2024 · Grade C — To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Construction
1 citation between February 26, 2021 and February 26, 2021. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0100 · February 26, 2021 · Grade D — Meet other general requirements.
Egress
1 citation between February 26, 2021 and February 26, 2021. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0291 · February 26, 2021 · Grade D — Install emergency lighting that can last at least 1 1/2 hours.
Fire, smoke, and emergency safety
1 citation between February 26, 2021 and February 26, 2021. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0353 · February 26, 2021 · Grade D — Inspect, test, and maintain automatic sprinkler systems.
Services
1 citation between February 26, 2021 and February 26, 2021. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · February 26, 2021 · Grade D — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems
1 citation between February 26, 2021 and February 26, 2021. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0918 · February 26, 2021 · Grade D — Have generator or other power source capable of supplying service within 10 seconds.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Aviata At Fletcher appears in CMS data on 11 survey dates between February 26, 2021 and January 7, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
January 7, 2026
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
September 30, 2025
Complaint health survey — 3 citations, worst grade E (potential for more than minimal harm)
December 9, 2024
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
October 24, 2024
Complaint health survey — 4 citations, worst grade E (potential for more than minimal harm)
August 21, 2024
Complaint health survey — 2 citations, worst grade J (immediate jeopardy)
July 11, 2024
Health survey including complaint investigations — 9 citations, worst grade E (potential for more than minimal harm)
July 11, 2024
Fire-safety survey — 1 citation, worst grade C (minimal or no harm potential)
October 30, 2023
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 21, 2022
Standard health survey — 8 citations, worst grade E (potential for more than minimal harm)
February 26, 2021
Standard health survey — 3 citations, worst grade E (potential for more than minimal harm)
February 26, 2021
Fire-safety survey — 6 citations, worst grade D (potential for more than minimal harm)
Penalties imposed
October 24, 2024 — Fine of $32,200
July 11, 2024 — Fine of $25,762
How Aviata At Fletcher compares with peer homes
Raw citation counts mean more in context. The table below compares Aviata At Fletcher with the median reviewed facility in Hillsborough County (9 homes in this research set) and across Florida (156 homes), using the same CMS data. On health citations alone, Aviata At Fletcher sits above 50% of its reviewed county peers — in the worse half of the county.
Measure
Aviata At Fletcher
Hillsborough Co. median
Florida median
Health citations on record
34
34
30
Citations from complaint investigations
15
9
7
Citations at actual-harm level or worse
2
3
3
Immediate-jeopardy citations
2
2
2
Total fines in CMS penalty records
$57,962
$85,965
$59,961
Penalty records (fines + payment denials)
2
2
2
What families should ask Aviata At Fletcher
- Ask for the plan of correction and follow-up monitoring for the quality of life and daily care citations — most recently F-0678 on August 21, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the freedom from abuse, neglect, and exploitation citations — most recently F-0600 on August 21, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the assessments and care planning citations — most recently F-0842 on January 7, 2026 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the resident rights citations — most recently F-0584 on February 26, 2021 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 2 totalling $57,962, the most recent dated October 24, 2024 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Aviata At Fletcher first document the change?
- Were recent complaint-related citations at Aviata At Fletcher connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
105644
Legal business name
WEST FLETCHER AVE OPCO LLC
Ownership type
For profit - Individual
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
March 1, 1989
Chain name
AVIATA HEALTH GROUP
Certified beds
120
Average residents per day
115.3
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
3 star
Reported nurse staffing hours per resident day
3.35556
Total nursing staff turnover
44.9%
Public records are a starting point, not a conclusion
This profile of Aviata At Fletcher uses official CMS provider data as a research starting point. It does not state that Aviata At Fletcher abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Legal help resource
Suspect nursing home abuse or neglect?
Public records are only part of the picture. If your family believes a Florida nursing home harmed your loved one, you can speak with a Florida nursing home abuse lawyer about what happened and what options your family may have. Senior Justice Help is not a law firm and is not affiliated with any law firm; this link is provided as a resource only.
Injury and neglect guides
When a Florida care injury may involve negligence
Inspection records show what regulators found; they do not by themselves prove a legal claim. If your family is looking back at a serious injury or death in a Florida nursing home or care facility, these guides explain the deadlines, procedures, records, and questions that apply in Florida:
- Stroke misdiagnosis lawyer information in Florida
- Falls and fractures in Florida care facilities: legal information
- Pressure injuries and bedsores: Florida legal information
- Sepsis from infection in Florida care facilities: legal information
- Medication errors in Florida care facilities: legal information
- Wrongful death in a Florida care facility: legal information
Sources for Aviata At Fletcher
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.