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Aviata At Santa Barbara

216 Santa Barbara Blvd, Cape Coral, FL 33991 · For profit - Limited Liability company · 120 certified beds · (239) 772-4600 Medicare & Medicaid certified

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Special Focus candidate (CMS is watching this home)Abuse/neglect citation on record (F0600) — cited Jan 2026Resident-funds citation (F0565)6 immediate-jeopardy citations$111,543 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
Worth asking about
  • CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 6 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $111,543 in federal fines (most recent 2025-08-06)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
706 SW Pine Island Rd., Unit 102 · (239) 451-5954 · Call to confirm hours
Pharmacy
4 NE Pine Island Rd · (239) 242-2231 · Call to confirm hours
Grocery
Publix0.2 mi
100 Hancock Bridge Pkwy W · (239) 458-8900 · Call to confirm hours
Park
400 Santa Barbara Blvd S · (239) 573-3128 · Typically dawn to dusk
Place of worship
211 Hancock Creek South Blvd · (239) 848-2653

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.5%8.7%15.4%better
Long-stay residents who lose too much weight3.3%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.3%4.6%6.5%better
Long-stay residents who were physically restrained0.3%0.0%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.6%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers0.9%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control4.0%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table5.3%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.5%94.7%79.4%better
Short-stay residents rehospitalized after admission28.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit8.2%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.352.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.381.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.4%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
62.2%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 62.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 127 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.4%CMS range 35.6–56.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.7–17.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge62.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge56.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.6%CMS range 4.2–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.56
RN hours/ resident / day
0.76
LPN hours/ resident / day
2.06
Aide hours/ resident / day
3.38
Total nurse hours/ resident / day
0.42
RN hoursweekends
34.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 115.6 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.09 hrs/resident/day on weekends vs 3.50 on weekdays — 12% thinner on weekends. RN hours go from 0.62 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2025-08-29)
3
at the previous standard inspection (2023-09-14)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 16 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2026-04-16 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policy and procedure and staff interviews, the facility failed to provide immediate and appropriate basic life support to 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest).On [DATE] at approximately 2:07 a.m., the clinical staff consisting of one Registered Nurse (RN) and one Licensed Practical Nurse (LPN) administered Cardiopulmonary resuscitation (CPR) to Resident #1 when he was found without a pulse or respirations. The Licensed Nurses did not activate Emergency Medical Services (EMS) and discontinued CPR after approximately 20 minutes. The RN pronounced the resident's death without the required credentials. Clinical staff re-started CPR 4 hours later at the direction of the Director of Nursing and called EMS. Resident #1 was pronounced deceased by EMS.The facility failure to immediately activate EMS and administer CPR to Resident #1 until the arrival of EMS placed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2026-04-16 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policies and procedures, and staff interviews, the facility failed to ensure clinical staff had the competencies to respond appropriately to emergencies and ensure 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) received timely life saving measures when found without pulse or respirations.Resident #1 had a full code status. On [DATE], Resident #1 was found in cardiac and respiratory arrest. Clinical staff administered cardiopulmonary resuscitation (CPR) for 20 minutes then pronounced the resident's death without authority to do so and without activating Emergency Medical Services (EMS). Clinical Staff re-started CPR and activated EMS 4 hours after CPR was stopped and the resident had no pulse and respirations.The facility failure to ensure nursing staff were trained and competent to respond appropriately to cardiac and respiratory arrests placed other residents with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Lcited before2025-08-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, review of facility's policies and procedures, residents and staff interviews the facility failed to have processes in place to prevent avoidable accidents for 6 (Residents #3, #103, #59, #74, #5, #95) of 6 residents by failure to accurately assess smoking risks, failure to identify unsafe storage and use of ignition devices where oxygen is in use and failure to adequately supervise residents who smoke tobacco products and electronic cigarettes. Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen. On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and a lighter approximately 4 feet from Resident #103 who was receiving oxygen. On 8/27/25 a CNA was observed leaving cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the designated smoking area. Residents #59 and #74 were roommates and smokers. Resident #59 received supplemental oxygen via nasal cannula. On 8/27/25 Residents #74 and #59 were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Lcited before2025-08-29 · tag F0726 — failed to have competent, trained nursing staff — widespread
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to ensure licensed nurses had the appropriate training and competencies to complete accurate smoking risk evaluations and identify unsafe smoking practices. The smoking risk evaluations for 7 (Residents #59, #105, #3, #74, #64, #5, #95) of 7 residents reviewed contained conflicting, inaccurate information and did not accurately reflect the residents' abilities to smoke independently. Each smoking evaluation noted the resident was a safe smoker and needs constant supervision.4 (Residents #3, #5, #59, and #74) of 4 residents observed with oxygen in use in their rooms were allowed to store ignition devices in their rooms while oxygen was in use.On 8/27/25 a Certified Nursing Assistant (CNA) was observed leaving cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the designated smoking area.Staff assigned to monitor residents who require constant supervision during smoking had not received appropriate training…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · L2025-08-29 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, residents and staff interviews, the facility administration failed to utilize its resources effectively to provide effective oversight and enforcement of safe smoking practices. The smoking evaluations for 5 (Residents #59, #3, #74, #64 and #5) of 6 residents reviewed contained conflicting and inaccurate smoking risks. The evaluations noted the residents were safe smokers and required constant supervision for smoking. The licensed nurses who completed the smoking evaluations had no documentation of training or competencies to ensure the smoking evaluations were complete and accurately reflected each resident's smoking risks.Residents #3, and #59 were smokers and used supplemental oxygen in their rooms. Resident #5 used oxygen and vaped electronic cigarettes in her room. The residents retained and stored ignition devices (lighters or electronic cigarettes) in their rooms while oxygen was in use. The management staff responsible to enforce safe smoking practices had not received training and did not consistently complete the observation of assigned…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · L2025-08-29 · tag F0926 — failed to keep the home smoke-free / fire-safe — widespread
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's supervised smoking policy to ensure accurate residents' smoking evaluations and prohibiting the use and storage of ignition devices around oxygen use in residents' rooms for 6 (Residents #3, #103, #59, #74, #5, and #95) of 6 residents reviewed for safe smoking.Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen via nasal cannula.On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and lighter approximately 4 feet from Resident #103 who was in bed receiving supplemental oxygen.Residents #59 and #74 were roommates and smokers. Resident #59 received supplemental oxygen. Both residents required constant supervision while smoking. On 8/27/25 Resident #59 was receiving oxygen. A lighter was stored within 2 feet of the oxygen source and on the windowsill of the shared bedroom.Resident #5 received…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policies and procedures, resident representative and staff interviews, the facility failed to allow the return to the facility post hospitalization for 1 (Resident #2) of 7 residents reviewed for discharge planning process.Resident #2 was discharged to a different nursing home approximately 73 miles from his family.The findings included:Review of the facility's policy and procedure titled, Transfer/Discharge Notification & Right to Appeal with a revision date of 04/28/25 revealed, Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. The center must permit each resident to remain in the center, and not transfer or discharge the resident unless:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the center;The transfer or discharge is appropriate because the resident's health has improved sufficiently so the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, resident representative and staff interview the facility failed to have documentation of incontinent care to meet the needs of 1 (Resident #999) of 4 residents reviewed for toileting needs.The findings included:On 3/3/36 at 9:39 a.m., in a telephone interview, Resident #999's family representative said on 2/4/26 she came to visit the resident and found her in bed with the bedding soaked with urine and no incontinent brief or pad was in place. The representative said the resident had a very strong odor of urine.Review of the clinical record revealed Resident #999 had an admission date of 7/27/20 with most readmission on [DATE]. Diagnoses included chronic obstructive pulmonary disease, traumatic brain injury, anxiety and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of1/16/26 documented Resident #999 was always incontinent of bowel and bladder. The MDS noted the resident's cognitive skills for daily decision making…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to prevent verbal abuse from staff for 2 of 3 residents reviewed. (Patient #1 and Patient #2)The findings included: Review of the facility Abuse, Neglect, Exploitation & Misappropriation policy (last revised on 11/16/2022) says that residents should be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The policy further noted no employee may at any time commit an act of physical, psychological, or emotional abuse. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. The policy defines mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The policy defines verbal abuse as the use of oral,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, resident and staff interviews, the facility failed to ensure staff provided incontinence care in accordance with accepted standards of care to meet the needs of 1 (Resident #800) of 3 residents reviewed.The findings included:On 10/15/25 at 9:24 a.m., Resident #800 was observed in bed in her room. In an interview Resident #800 said staff put two incontinent briefs and a towel on her because she was a heavy wetter. With the resident's permission, the incontinent briefs were observed. Resident #800 was wearing two incontinent briefs. A folded towel was placed inside the briefs. Resident #800 said it took 2 to 3 staff to provide incontinent care and change her briefs. She said the other day Certified Nursing Assistant (CNA) Staff A came in to change her. She tried to explain to the CNA how they did her care and that it took 2 to 3 staff to change her. The resident said that CNA Staff A did not explain what she was going to do and did not listen to her. She reported the incident.Review of the clinical record revealed Resident #800 had an admission…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-29 · tag F0843 — widespread
    Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to have a written transfer agreement in effect with one or more hospitals approved for participation in Medicare/Medicaid programs. The findings included:On 8/29/25 a request was made to the facility to review the facility's transfer agreement with one or more hospitals approved for participation in the Medicare/Medicaid programs. On 8/29/25 at 12:15 p.m., in an interview the Regional [NAME] President of Operations said the facility did not have a transfer agreement with any hospital.On 8/29/25 at 1:30 p.m., in an interview the Administrator verified the facility did not have a transfer agreement with one or more hospitals approved for participation in the Medicare/Medicaid program.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-29 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility's policy and procedure, residents and staff interviews, the facility failed to act promptly upon the grievance expressed by the resident council group during their monthly meetings. The findings included:Review of the facility's Complaint/Grievance policy and procedure N-1042 dated 11/30/14 and revised 10/24/22 revealed that the center would support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center would make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. An employee receiving a complaint/grievance from a resident, family and/or visitor would initiate a Complaint/Grievance Form. The original grievance form was then submitted to the Grievance Office/designee for further action. The Grievance Officer/designee would act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame; this should not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-29 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews the facility failed to provide appropriate care and services to prevent complications of enteral feeding tubes for 3 (Residents #52, #15 and #94) of 4 residents reviewed.The findings included: Review of the clinical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnosis included but not limited to aphasia following cerebral infarction, neuropathy, and gastrostomy.Care Plan initiated 8/12/25, revision date 8/20/25 revealed Resident #52 is at risk for complications, infections, fluid balance, aspiration (accidental inhalation of food, liquid into the airways or lungs) related to Resident #52 requires tube feeding to meet hydration/nutrition needs secondary to cerebrovascular accident (stroke). Interventions include observe for signs and symptoms of infection, report promptly; provide local care to g-tube site as ordered and monitor for signs and symptoms of infection.Review of physician orders reveals Resident #52 does not have an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-29 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure timely acquiring and administering of medications to meet the needs of 3 (Residents #48, #51, and #18) of 3 residents selected for medication administration observation.The findings included:1. On [DATE] at 8:16 a.m., during a medication administration observation for Resident #48, Licensed Practical Nurse (LPN) Staff M said Resident #48's Tenofovir Discoproxil Fumarate (hepatitis medication) was not available. She said the medication was ordered on [DATE] and had not arrived from the pharmacy yet. Review of Resident #48's Medication Administration Record for [DATE] revealed several days medications had not been documented as given including: [DATE]th and 25th which had blank boxes for Levothyroxine (thyroid medication), Naloxogol Oxalate (medication for constipation), Torsemide (diuretic medication). [DATE]th also had a blank box for Insulin Glargine (diabetic medication). No documentation was found explaining what the blank boxes meant or that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-29 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the facility's policy and procedure, and staff interview, the facility failed to ensure 2 (Residents #65, and #51) of 5 residents reviewed for immunization received education regarding the benefits and potential side effects and were offered pneumococcal immunization.The facility failed to ensure 1 (Resident #65) of 5 residents residing at the facility between October 1, 2024, and March 31, 2025, received education and was offered the influenza immunization.The findings included:Review of the Pneumococcal Vaccine Policy dated 2001, revised October 2019 revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. (1) Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated prior to admission. (2) Assessments of pneumococcal vaccination status will be conducted within five working days of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-29 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #15 and #57) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability. The findings included:Review of the Facility policy titled Advanced Beneficiary Notice - ABN with a revision date of 11/10/2015 revealed, An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form . The form will be reviewed with the resident or authorized representative .Procedure 1. d. The resident or authorized representative is to choose one of the three options, date and sign the form. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . On 8/27/25 the Social Services Director (SSD) provided the Advance Beneficiary Notices of non-coverage that had been issued to current…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-08-29 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility's policy and procedure and staff interview the facility failed to refer 1 (Resident #11) of 2 residents with signs of serious mental illness, intellectual disability or a related condition for a Level II Pre admission Screening and Resident Review as required. The findings included: Review of the facility's policy for Preadmission Screening and Resident Review (PASSR) with a revision date of 11/8/2021 indicated: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medial record. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records. Review of the clinical record for Resident #11 revealed an admission date of 7/20/15. Diagnoses included…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an ongoing program of activities to meet the needs of 1 (Resident #113) of 3 reviewed for activities program.The findings included:Review of Individual Activities Policy and Procedure dated 11/1/21 revealed residents who are unwilling and/or unable to attend scheduled group activities are provided one-to-one individualized recreational and Community Life based on their needs, interests, and functional ability. (1) Review the preferred activities and activity times of the resident found on the following form: Activity Plan of Care, MDS (3) Include resident and family in development of recreational and Community Life interventions that meet their needs, interests, and functional ability. (4) Determine and schedule activities and times that support preferences. (5) Obtain the appropriate supplies for the 1:1 visits.Review of clinical record revealed Resident #113 was admitted to the facility on [DATE]. Diagnosis included but were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-29 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the facility's policies and procedures and staff interviews, the facility failed to have documentation of COVID-19 vaccination status, screening, education, and offering of the vaccine for 1 (Resident #65) of 5 residents reviewed for immunization status. The findings included:Review of Covid-19 Vaccine for Residents Policy and Procedure with an effective date of 8/03/21, and a revision date 11/17/2021 revealed documentation that residents or their representatives will be educated about and offered the Covid-19 vaccine.(1) Covid-19 vaccinations will be offered to residents (or their representative if they cannot make health care decision) per Centers for Disease Control (CDC) and/or Federal Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine.(2) Residents/representatives will be educated on the Covid-19 vaccine they are offered, in a manner they understand, including information on the benefits and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-06 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure 3 (Residents #1, #2 and #3) of 3 residents reviewed received care and services in accordance with professional standards of practice by failing to ensure laboratory testing were done as ordered for Residents #1, #2, and #3. The facility failed to document family reported concerns and failed to notify the practitioner of several episodes of loose stools for Resident #1.The findings included:Resident #1:Review of the facility's policy and procedure titled, Laboratory, Diagnostic and X-Ray with a revision date of 02/02/2024 revealed, Procedure: Obtain a physician's order for laboratory work, diagnostic testing, and x-ray. Complete the required requisition form(s). Schedule laboratory work, diagnostic test and or x-ray as indicated.Review of the clinical record for Resident #1 revealed an admission date of 6/12/25.Review of the progress notes revealed on 7/5/25 the Advanced Practice Registered Nurse (APRN) documented Resident #1 was evaluated for persistent bilateral leg edema (swelling) and shortness of breath. Lungs…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-06 · tag F0770 — failed to provide lab services — pattern
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility staff failed to follow processes to ensure laboratory testing were done as ordered to meet the needs of 3 (Residents #1, #2 and #3) of 3 residents reviewed.The findings included:Review of the facility's policy and procedure titled, Laboratory, Diagnostic and X-Ray with a revision date of 02/02/2024 revealed, Procedure: Obtain a physician's order for laboratory work, diagnostic testing, and x-ray. Complete the required requisition form(s). Schedule laboratory work, diagnostic test and or x-ray as indicated.Review of the clinical record for Resident #1 revealed an admission date of 6/12/25.Review of the progress notes revealed on 7/5/25 the Advanced Practice Registered Nurse (APRN) documented Resident #1 was evaluated for persistent bilateral leg edema (swelling) and shortness of breath. The practitioner documented a CMP (Complete metabolic panel) and Pro-BNP (measures a specific protein) were ordered to monitor electrolytes and volume status. The plan of care was discussed with the nurse. The progress note documented next labs…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed provide appropriate interventions to prevent falls for 2 (Residents #1, and #2) of 3 residents surveyed with a history of falls with major injury. Failure to provide appropriate fall interventions creates a potential for falls and fall related injuries to the residents. The findings included: The facility policy on Fall Management Document N-1259 effective 11/30/14 and last revised 7/29/19 reads, Residents are evaluated for fall risk. Patient Centered interventions are initiated, based on resident risk . Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of future falls and minimize the potential for resulting injury. Clinical record review revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Metabolic Encephalopathy, Osteoarthritis, Bradycardia (heart rate below 60 beats per minute) and Idiopathic Hypotension. Review of the care plan initiated on 4/1/24…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policy and procedure review, and staff interviews, the facility failed to report an injury of unknown source and serious bodily injury was reported to the State Survey Agency within the prescribed timeframe for 1 (Resident #1) of 1 resident reviewed. The findings included: Review of the facility's policy and procedure for Abuse, Neglect, Exploitation and Misappropriation with a revision date of 11/16/22 noted, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source . to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-14 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy and procedure, clinical record review and staff interviews, the facility failed to provide appropriate services and interventions to maintain function and prevent the decline in range of motion for 2(Resident #19 and #24) of 3 residents sampled with a limitation in range of motion (ROM). The findings included: The facility policy N-904, Contractures, Prevention (revised 8/22/17) documented To prevent contracture of extremities for those residents who no longer have full use of their extremities . Each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Residents with inactive extremities should have ROM exercises done to those extremities as part of their daily care . Hand rolls may be placed in any hand that the resident cannot move. These can be commercial rolls or wash cloths rolled up and should be removed daily during care . Some residents may have braces or splints to prevent or help release contractures, so be sure to follow physician's order regarding schedule of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin pens were properly labeled and dated when opened in 2 (Cart #4 and #5) of 3 medication carts reviewed. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: The facility policy 5.3 Storage and Expiration Dating of Medications, Biologicals, documented, Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 1. On 9/11/23 at 10:06 a.m., observation of medication cart #4 with Registered Nurse (RN) Staff H revealed: One opened Glargine insulin 100-unit Pen for Resident #19 with no date of when it was opened. The Pharmacy label specified to discard unused medication after 28 days. Photographic evidence obtained. One…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy and staff interviews, the facility failed to provide the Skilled Nursing Advance Beneficiary Notice of Non-coverage to 1 (Resident #31) of 3 residents who was discharged from Medicare Part A services but remained at the facility. The findings included: The facility Policy and Procedure for Advance Beneficiary Notice - ABN with effective date of 11/30/2014 and revised 11/10/2015 stated, An ABN will be utilized to notify residents of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form. The facility will place their name, address, and telephone number at the top of the notice header; and may elect to include their logo. The form cannot otherwise be modified other than the additional information that is required. The form will be reviewed with the resident or authorized representative. A review of the SNF Beneficiary Protection Notification Review form completed by the Business office Director for Resident #31 noted Medicare Part A Skilled Services Episode start date of 5/29/23 and a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of facility policy, and staff interviews, the facility failed to ensure proper storage of medications in 1 (Medication cart #4) of 3 medication carts reviewed for proper storage and labeling of medications. The findings included: The facility policy N-853 Medication-Oral Administration (revised 8/15/19) instructed to, . Prepare medication for one resident at a time . On 10/13/21 at 10:12 a.m., during an observation of medication cart number 4, revealed three medication cups with unidentified pills and two medication cups with a brown powder. *Photographic Evidence Obtained* On 10/13/21 at 10:04 a.m., in an interview, Registered Nurse (RN) Staff B confirmed the findings in the medication cart. RN Staff B said the residents were not in their rooms, so he wrote the room number on the medication cups to administer the medications later. On 10/13/21 at 10:06 a.m., in an interview Unit Manager Registered Nurse Staff A confirmed the findings of the unidentified medications and said RN Staff B should not have pre-poured the medications.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$111,543 in federal fines across 6 penalties.

  • $88,166 — penalty dated 2025-08-06
  • $4,336 — penalty dated 2025-02-27
  • $4,336 — penalty dated 2025-02-27
  • $4,336 — penalty dated 2025-02-27
  • $4,337 — penalty dated 2025-02-27
  • $6,032 — penalty dated 2024-07-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AVIATA HEALTH GROUP — 50 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 1 of 52.0-1.0 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 49 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Aspire At EvansFort Myers, FL 1 of 5Aviata At BenevaSarasota, FL 1 of 5Aviata At Big BendPerry, FL 1 of 5Aviata At Bryan DairyLargo, FL 1 of 5Aviata At FletcherTampa, FL 1 of 5Aviata At Palma Sola BayBradenton, FL 1 of 5Aviata At Saint LucieFort Pierce, FL 1 of 5Aviata At SarasotaSarasota, FL 1 of 5Aviata At SeminoleSeminole, FL 1 of 5Aviata At The BayTampa, FL 1 of 5Aviata At The PalmsPalm Harbor, FL 1 of 5Aviata At VeniceVenice, FL 2 of 5Aviata At Arbor SpringsOcala, FL 2 of 5Aviata At BradentonBradenton, FL 2 of 5Aviata At BrentwoodLecanto, FL 2 of 5Aviata At Colonial LakesWinter Garden, FL 2 of 5Aviata At EnglewoodEnglewood, FL 2 of 5Aviata At Grand OaksPalm Coast, FL 2 of 5Aviata At Green Cove SpringsGreen Cove Springs, FL 2 of 5Aviata At GreenacresGreen Acres, FL 2 of 5Aviata At Lakeside OaksDunedin, FL 2 of 5Aviata At OakfieldBrandon, FL 2 of 5Aviata At South DaytonaSouth Daytona, FL 2 of 5Aviata At TallahasseeTallahassee, FL 2 of 5Aviata At The HarborSafety Harbor, FL 2 of 5Aviata At The Sea - PasadenaSouth Pasadena, FL 2 of 5Aviata At The Sea - Pompano BeachPompano Beach, FL 2 of 5Aviata At West Palm BeachWest Palm Beach, FL 2 of 5Aviata at Sand KeyClearwater, FL 3 of 5Aspire At Ridge HavenNew Port Richey, FL 3 of 5Aviata At BrooksvilleBrooksville, FL 3 of 5Aviata At Central ParkBrandon, FL 3 of 5Aviata At Coral BayWest Palm Beach, FL 3 of 5Aviata At CountrysidePalm Harbor, FL 3 of 5Aviata At JacksonvilleJacksonville, FL 3 of 5Aviata At North Fort MyersN Ft Myers, FL 3 of 5Aviata At RosewoodOrlando, FL 3 of 5Aviata At San JoseJacksonville, FL 3 of 5Aviata At St CloudSaint Cloud, FL 3 of 5Aviata At The Sea - Harbor BeachFort Lauderdale, FL

Showing 40 of 49; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
SANTA BARBARA PARENT LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/02/2023
CORALEE HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/02/2023
FREUND, NOCHUMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/02/2023
NASSIF, RODERICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/10/2023
PAPINEAU, BERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
DAGAN, AMITAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
GOLDBERGER, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
GOLDBERGER, FAIGYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
HERSKOWITZ, ELIEZERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
HERSKOWITZ, YAAKOVIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
TRAVITSKY, AARONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/16/2025
ASPIRE MGT LLCOrganizationADP OF THE SNFsince 11/02/2023

CMS files one row per role, so the 15 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$2.2M
Net patient revenuemost recent cost report
-92.1%
Operating marginrevenue minus expenses
$121K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 4%Other / private 19%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $121K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$491per resident / day
operating cost
$14,931per month
≈ monthly operating cost
$256per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105588. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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