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Aviata At Jacksonville

4101 Southpoint Drive East, Jacksonville, FL 32216 · For profit - Corporation · 116 certified beds · (904) 296-6800 Medicare & Medicaid certified

Call the home — (904) 296-6800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 2025$4,778 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • 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
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $4,778 in federal fines (most recent 2023-10-10)
  • nursing-staff turnover (58%) runs well above the national median (45%)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4100 Southpoint Dr E · (904) 644-8472 · Call to confirm hours
Pharmacy
6820 Southpoint Pkwy · (904) 379-9896 · Call to confirm hours
Grocery
4168 Southpoint Pkwy S Ste 305 · (904) 296-3331 · Call to confirm hours
Park
6621 Barnes Rd S · (904) 733-3831 · Typically dawn to dusk
Place of worship
6857 Southpoint Pkwy · (904) 396-1663

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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 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 held steady at 3 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 rating3★
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 increased3.5%8.7%15.4%better
Long-stay residents who lose too much weight4.2%5.5%5.4%better
Long-stay residents with a catheter left in their bladder1.1%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms10.5%4.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.4%2.5%3.3%better
Long-stay residents whose ability to walk worsened5.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.5%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.4%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control7.0%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 table11.1%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.8%94.7%79.4%better
Short-stay residents rehospitalized after admission23.9%26.1%22.6%typical
Short-stay residents with an outpatient ER visit10.2%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.982.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.671.151.80better

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.

10.3%U.S. median 10.7%
Went back to hospital
31.8%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 31.8% 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 66 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.6–16.810.7%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 discharge31.8%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 discharge27.3%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 discharge19.7%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 identified100.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened3.9%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 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

0.53
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.46
RN hoursweekends
57.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 109.7 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.26 hrs/resident/day on weekends vs 3.56 on weekdays — 8% thinner on weekends. RN hours go from 0.56 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%.

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

6
deficiencies at the latest standard inspection (2025-12-11)
6
at the previous standard inspection (2023-12-13)

Deficiencies are unchanged from the previous inspection. 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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Fcited before2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to clean one of two microwaves located in a unit nourishment room. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: Observations of the nourishment rooms were conducted during the follow-up tour on 12/10/2025 at 10:55 am. During the tour, the unit microwave in one of two nourishment rooms located on the 100-300 unit was observed to have black substances of unknown origin resembling fungal growth on the inside ceiling. Another observation was made on 12/11/2025 at 11:42 am of the same black substances on the inside ceiling of the microwave. (Photographic…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-11 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to document and respond appropriately to resident grievances regarding missing clothing items for 1 out of 5 residents reviewed. (Resident #46)The findings include:During an interview on 12/9/2025 at 2:45pm, Resident #46 reported missing two pairs of pants. She said, I told [Environmental Services Account Manager] about it, but nothing ever got done.Review of the grievance log for the previous 12 months did not reveal a grievance filed by the resident.During an interview on 12/11/2025 at 10:30am, the Environmental Services Account Manager stated, I remember she [Resident #46] said something to me about a pair of pants a few months ago, but like I tell them, I check the inventory and if it's listed on the inventory, then I look for it. The ES Account Manager was asked if he initiated a grievance for all reported missing items. He stated, Not until I see if I can find it, then I let Social Services know either I found it, or I didn't. When asked how he kept track of residents' verbal reports of missing items, he replied, It's…

    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 · D2025-12-11 · 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

    Based on record reviews and interviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately to the administrator and to other officials in one of one identified occurrence. (Resident #118)The findings include:Review of the grievances for dining complaints revealed a grievance filed by Resident #118 on August 25, 2025. The grievance stated, Kitchen staff told me he could make my life harder. I don't understand what I actually did. I was talking to the nurse . The documentation section of the grievance form revealed that the Certified Dietary Manager (CDM) documented, Spoke with [identified employee name] about abuse towards residents. [Identified employee name] has been issued an ECA [Employee Corrective Action]. It is documented that the complaint is resolved and that the complainant is satisfied with the resolution.During an interview on 12/11/2025 at 10:00 am, Resident #118 stated, The deal was he [identified employee name] wasn't supposed to leave the kitchen anymore. That's what I was told. Well, he's leaving the kitchen. He just…

    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 · D2025-12-11 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and policy and procedure review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: Observations of the tray line on 12/10/2025 at 10:55 am revealed the Dietary Aide (Caller) calls the diet, the cook prepares and plates the food, and the Manager in Training checks tickets to ensure items match, then load the meal trays on the cart. Observations revealed meal tickets not matching the meal plated/inaccurate protein portions or meal tray placed in the cart for distribution with missed food item/apple/cranberry order/preference not provided per meal ticket; nectar shake not provided per meal ticket; bread not followed by…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and policy and procedure review, the facility failed to ensure food served was prepared by methods that conserve nutritive value and appearance by failing to provide appetizing and appealing food in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting on their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a tour of the kitchen on 12/10/2025 at 10:55 am, carrots served on the tray line were observed to be discolored with black spots making them unsuitable for consumption, leading to five bowls being pulled and discarded to ensure food safety and quality. During the facility survey, additional complaints received included: Resident #11 reported her grilled cheese sandwich was too hard to consume; Resident #64 reported receiving black broccoli, It was rotten, they took it out of the bag like that and steamed it and served it. They overcook everything. The grilled cheese was hard as a rock.; Resident #73…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to appropriately document side effects and behaviors for psychotropic medications, in accordance with the corresponding key on the Medication Administration Record for two of five residents reviewed for psychotropic medications. (Residents #15 & #72)The findings include:1. Review of Resident #15's medical record revealed a physician's order for behavior monitoring every shift for antipsychotics agents with a start date of January 24, 2022. Data entry for corresponding codes included; 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress note. Review of Resident #15's medication administration records for November 2025 revealed that NA [Not Applicable] was documented on the following dates: 11/1/2025, 11/2/2025, 11/3/2025, 11/5/2025, 11/10/2025, 11/16/2025, 11/17/2025, 11/19/2025, 11/26/2025, 11/27/2025, 11/29/2025, and 11/30/2025. Review of Resident…

    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 · Dcited before2023-12-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and clean interior for two (Residents #208 and #3) of 30 residents in the sample. The findings include: 1. On 12/10/23 at 1:10 p.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid were observed on the outside of the unit, on the floor, and inside each drawer. (Photographic evidence obtained) The floor in front of the unit was sticky under one's shoes. The resident was asked if this was her bedside nightstand. She stated, I guess so. It looks like a medication cart or something. Two bags were observed on top of the unit, one containing clothing and one containing personal items. The resident was asked if those items belonged to her. She replied yes. On 12/11/23 at 8:40 a.m., Resident #208's bedside unit was observed to be a treatment cart type of unit. Red splashes of a sticky liquid…

    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 · D2023-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, record review, and facility policy review, the facility failed to provide two (Resident #90 and Resident #84) residents who were unable to carry out activities of daily living, from a total sample of 30 residents, the necessary services to maintain personal hygiene (fingernail care). The findings include: 1. On 12/10/23 at 12:30 p.m., Resident #90 was observed in his room with elongated/jagged fingernails with brown debris under each nail on both hands. Right hand fingernails were in contact with the palm of his hand due to a hand contraction. The resident was asked if he was satisfied with the state of his fingernails. He shook his head no. He was asked if staff cleaned and trimmed his fingernails. He clicked his tongue and shook his head no. He was asked if he had asked staff to clean and trim his fingernails. He nodded yes. (Photographic evidence obtained) On 12/11/23 at 1:45 p.m., Resident #90 was observed self-propelling in a wheelchair in the hallway, headed toward his…

    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 · D2023-12-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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, interviews, record review, and facility policy review, the facility failed to implement interventions, including monitoring placement and function of wander-alarm devices, consistent with a resident's needs, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident for one (Resident #93) of 30 residents sampled. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. The findings include: On 12/10/23 at 12:45 p.m., in an interview with Resident #93's spouse, he stated, They put that bracelet thing on her ankle and the door locks when I take her outside. He stated his wife did not wander or walk around, that she used a wheelchair. He further stated staff did not tell him why she had the device on her ankle. Resident #93 presented as pleasantly confused when interviewed. She was unable to answer simple questions accurately. A Wanderguard device was observed on her right ankle. On 12/11/23 at 8:30 a.m., Resident…

    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 · Dcited before2023-12-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, received that care as ordered and consistent with professional standards of practice, for one (Resident #35) of a total sample of 30 residents. The findings include: On 12/10/23 at 2:21 p.m., Resident #35 was observed lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator, located at bedside, was set at a flow rate of 3L/min. (3 liters of oxygen per minute) (Photographic evidence obtained) On 12/11/23 at 9:33 a.m., a second observation was made of Resident #35 lying in bed receiving oxygen via a nasal cannula. Her oxygen concentrator was set with a flow rate of 3L/min. (Photographic evidence obtained) On 12/13/23 at 9:47 a.m., a third observation was made of Resident #35 lying in bed wearing a nasal cannula with her oxygen concentrator flow rate set at 3L/min. (Photographic evidence obtained) A review of the medical record revealed no active physician's orders for oxygen therapy. Further review 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
Show the remaining 12 citations
  • Potential for harm · D2023-12-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medication error rates were not 5% or greater. Two errors were identified out of 32 opportunities for error, resulting in a medication error rate of 6.25% and affecting two (Residents #64 and #33) of five residents observed during medication administration, from a total of 30 residents in the sample. The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. The resident was observed eating lunch and had already consumed more than 50% of the meal at the time of the blood glucose testing. LPN I then proceeded to administer Aspart Sliding Scale insulin to Resident #64 according to his blood glucose level. At this time the resident had consumed all of his lunch meal. An interview was conducted with Licensed Practical Nurse (LPN) I on 12/11/23 at 11:48 a.m. She was asked to review the orders for blood glucose monitoring and Aspart insulin administration. She pulled the order up on her medication cart…

    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 · D2023-12-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections, by inappropriately storing and disposing of used sharps. The findings include: On 12/11/23 at 11:36 a.m., Licensed Practical Nurse (LPN) I was observed checking Resident #64's blood glucose level. When she was finished, she placed the used lancet in her jacket pocket and not in the sharps container. After administering Aspart sliding scale insulin to Resident #64, she disposed of the lancet and the KwikPen insulin needle, wrapped in her used gloves, into the trash can in the resident's room. An interview was conducted with LPN I on 12/11/23 at 11:48 a.m. She was asked to explain the procedure for disposal of sharps. She stated, Sharps material is disposed of in the sharps container, but this (referring to a new KwikPen insulin needle that she retrieved from the medication cart) is not a sharps. LPN I confirmed that 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 · D2023-10-10 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and 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 interviews, record reviews, and facility policy review, the facility failed to ensure it provided an effective discharge planning process that evaluated and identified changes requiring modifications and updates as needed for 1 (Resident #1) of 4 residents reviewed for discharge. Failure to effectively communicate discharge concerns and assess individual needs can potential put residents at risk for an unsafe discharge. The findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] from an acute hospital and was discharged home alone on 10/5/23. Resident #1's primary diagnosis was metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood, such as from an illness). Additional diagnoses included hypertension, hyperlipidemia, depression, altered mental status, cognitive communication deficit, and non-Alzheimer's dementia. Resident #1 participated in the MDS assessment, and no discharge planning was occurring. Review…

    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 · Ecited before2022-02-17 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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, record review and facility policy and procedure review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary in five resident rooms (102, 500, 501, 512 and 511) affecting six (Residents #4, #59, #19, # 49, #151, and #92) out of a total of 41 residents in the sample. Specifically, there were concerns with sticky floors in bathrooms, dead roaches, debris on floors and under resident's beds, enteral feeding product splattered on feeding pumps, IV poles, walls, mattresses, bed frames and floors, and Air Conditioning (AC)/Heating units filters were not clean. A clean-living environment is necessary to reduce the spread of infection and promotes the highest well-being of residents. The findings include: On 02/14/2022 at 10:32 AM, Resident #4's and #59's room (#102) was observed. Enteral food product was splattered on the feeding pump, IV pole, walls, mattress, bed frame and floor. A brown biological…

    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 · Ecited before2022-02-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 reviews, the facility failed to ensure physician's orders for oxygen were in place prior to administering oxygen for two (Residents #301 and #453) of eight residents receiving treatment for respiratory care, out of a total of 41 residents sampled. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #301's clinical record revealed she was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease. Secondary diagnoses included, but not limited to malignant neoplasm of unspecified of bronchus or lung, chronic obstructive pulmonary organism (COPD), malignant neoplasm of the lung, and pneumonia. On 02/14/22 at 11:03 AM, Resident #301 was observed in her room receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 Liters per minute (L/Min). The oxygen tubing was not properly connected to the concentrator and the resident was not receiving oxygen.…

    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 before2022-02-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review and facility policy and procedure review, the facility failed to ensure nutritional supplements kept in 2 of 2 nourishment refrigerators were stored in accordance with professional standards for food service saftey and failed to ensure equipment in the nourishment rooms were clean and free of debris. The findings include: During an observation of the two-nourishment rooms in the facility on 02/16/22 at 12:21 PM revealed the following: Each refrigerator had a container of Med Pass which were expired (expiration dates of 01/13/22 and 01/27/22). A review of the Medpass shake instructions revealed, use within 4 days of opening. (Photographic evidence obtained) The freezer in the nourishment room on hall 200 contained a dried brownish stain in it. (Photographic evidence obtained) Microwaves in the nourishment rooms were not clean. One microwave had dried reddish stain in it and the other had a dried whitish stain in it. (Photographic evidence obtained) On 02/17/22 at 10:14 AM, a second observation of nourishment room on hall 200 revealed…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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, clinical record review and interviews, the facility failed to provide reasonable accommodation of individual needs by ensuring one (Resident #92) of 41 residents in the sample, from a total of 102 residents had access to his call light at all times. The findings include: A review of Resident #92's clinical record revealed he was admitted to the facility on [DATE] with diagnoses including a stroke affecting right non-dominant side, contracture right hand and right lower leg, cognitive communication deficit, type 2 diabetes, and aphasia. A review of the resident's Minimum Data Set (MDS) assessment completed on 01/24/2022, documented his Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. He required extensive 2 person assist with bed mobility and transfer. The resident had impairment of his right side and was wheelchair bound. On 02/14/2022 at 12:45 PM, Resident #92 was observed in bed watching television. The call button was not within…

    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 · D2022-02-17 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 interviews and record reviews, the facility failed to ensure the resident's right to make choices about aspects of his or her life by failing to make appointments for health care services for one (Resident #51) of three residents reviewed for medical appointments, out of a total of 41 residents in the sample. The findings include A clinical record review for Resident #51 revealed he was admitted to the facility on [DATE]. On 02/14/2022 at 2:11 PM, an interview was conducted with Resident #51. He reported, he had been waiting to see an orthopedic surgeon and a dermatologist. A review of the resident's Quarterly Minimum Data Set (MDS) assessment completed on 01/04/2022, documented his Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. Further record review for Resident #51 revealed a physician referral made on 12/15/2021 to see an orthopedic doctor. A dermatology consult referral was made and signed on 12/15/2021. A second referral form for a dermatology consult…

    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 before2022-02-17 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 interviews, record review and facility policy and procedure review, the facility failed to adequately investigate grievances to ensure satisfaction with the resolution for two (Residents #59 and #47) of two residents reviewed for grievances, related to staff behavior and missing items, out of a total of 41 residents in the sample. The findings include: 1. During an interview on 02/15/2022 at 7:15 AM, Resident #59 stated that the Employee F, Certified Nursing Assistant (CNA) is rude. Resident #59 stated the CNA had worked with her 2-3 times and she is always hateful to her. Employee F was assigned to Resident #59 on the overnight shift last night 7 PM to 7 AM. She had put her call light on and when the CNA entered the room, she asked her why she had her light on. Resident #59 stated that she asked her Why are you so hateful to me? The CNA replied, Excuse me? So, she asked her Why are you mad at me? The CNA told her, I don't want to be an enabler. You ask for help for things you know you can do. Resident…

    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 · D2022-02-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, interviews and facility policy and procedure for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure that three (Residents #9, #59 and #73) out of a total of 41 residents in the sample, were screened for a Level II. The findings include: 1. A review of the medical record for Resident #9 revealed a PASRR dated 10/16/20 was completed and required a Level II be initiated. Resident #9 was admitted on [DATE] with a diagnosis of paranoid personality disorder, anxiety, bipolar disorder, schizoaffective disorder, and major depressive disorder. The PASSAR noted depressive disorder and schizophrenia and has a hospital discharge exemption which noted a Level II was needed no later than 40th day of admission. On 02/16/22 at 10:06 AM, an interview was conducted with the Social Service Director (SSD). She brought the level 1 for resident and reported, she could not find a Level II was conducted. The form was reviewed which indicated a 30-day exemption from 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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, medical record review and interviews, the facility failed to provide appropriate services and communication devices for one (Resident #4) out of two residents sampled for communication, out of a total of 41 residents in the sample. The resident's communication board was stapled to the bulletin board in her room under an activities department calendar. Failure to provide a communication device for a resident whose ability to communicate is impaired could potentially affect the resident's ability to communicate in an emergency and negatively affect his/her health outcome. The findings include: A review of the clinical record for Resident #4 revealed she was admitted to the facility on [DATE]. Her diagnoses included: Aphasia following unspecified cerebrovascular disease, unspecified dementia without behavioral disturbances, acquired absence of unspecified leg above knee, contracture unspecified hand, unspecified lack of coordination, anxiety disorder, other depressive episodes, cognitive…

    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 · D2022-02-17 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 reviews, interviews, and facility policy and procedure review, the facility failed to ensure that two (Residents #300 and #452) of six residents receiving antibiotics, out of a total of 41 residents in the sample, remained free of significant medication errors by failing to administer antibiotic medication as ordered. The findings include: 1. A review of clinical records for Resident #300 revealed she was admitted to the facility on [DATE] with primary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery. Other secondary diagnoses included Type II diabetes mellitus, pressure ulcer of right heel, encounter for change or removal surgical wound. A review of Resident #300's physician's orders revealed an order for vancomycin trough one time every Monday for osteomyelitis with start date of 02/14/22 and vancomycin HCL (antibiotic administered for bacterial infection) in dextrose solution 1-5 Gram /200 ML - use 200 ml intravenously at…

    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

“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

$4,778 in federal fines across 1 penalty.

  • $4,778 — penalty dated 2023-10-10

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 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 3 of 54.1-1.1 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 Santa BarbaraCape Coral, 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 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
SOUHTPOINT PARENT LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
JACKSONVILLE HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2023
FREUND, NOCHUMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
JONES, DEANNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023
YAZJI, GEORGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/19/2023
DAGAN, AMITAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
GOLDBERGER, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
GOLDBERGER, FAIGYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
HERSKOWITZ, ELIEZERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
HERSKOWITZ, YAAKOVIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
TRAVITSKY, AARONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/09/2025
ASPIRE MGT LLCOrganizationADP OF THE SNFsince 09/01/2023
BRAND SONNENSCHINE LLPOrganizationADP OF THE SNFsince 09/01/2023
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 09/01/2023

CMS files one row per role, so the 17 rows in the source record cover these 14 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.

5 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.

$6.7M
Net patient revenuemost recent cost report
-24.7%
Operating marginrevenue minus expenses
$69K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 3%Other / private 16%

About 82% 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 $69K 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

$325per resident / day
operating cost
$9,869per month
≈ monthly operating cost
$260per 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 105917. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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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