Aviata At Kissimmee Gardens
1120 W Donegan Ave, Kissimmee, FL 34741 · For profit - Corporation · 120 certified beds · (407) 847-2854 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 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 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.5% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.8% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.7% | 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 table | 10.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 36.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.2% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.60 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.18 | 1.15 | 1.80 | better |
‡ 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.
32.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.9% 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 59 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 32.9%CMS range 20.2–48.3 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.7–15.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 50.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 45.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 28.8% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.5–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.21 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 120 beds and averages 115.9 residents a day — about 97% 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.20 hrs/resident/day on weekends vs 3.47 on weekdays — 8% thinner on weekends. RN hours go from 0.96 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below 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
Deficiencies are fewer than at the previous inspection — improving. 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.
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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · D2026-01-15 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 observation, interview, and record review, the facility failed to honor a resident's preference and did not respond timely to resident's request for a Coronavirus Disease 2019 (COVID-19) booster vaccine for 1 of 4 residents reviewed for choices, of a total sample of 40 residents, (#113).Findings: Review of the medical record revealed resident #113, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her diagnoses included cerebra ischemia (stroke), type 2 diabetes, insomnia, and anxiety disorder. Review of resident #113's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 10/13/25 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. The MDS assessment noted no behavioral symptoms and no rejection of care or treatment during the look-back period. On 1/12/26 at 9:51 AM, resident #113 stated she requested a COVID-19 booster vaccine in October 2025 and was…
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.
- Potential for harm · D2026-01-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate documentation for application and removal of Thromboembolic Deterrent (TED) hose for 1 out of 1 residents sampled for application of TED hose, of a total sample of 40 residents, (#45).Findings: TED hose are stockings that help prevent blood clots and swelling in your legs, (retrieved from www.drugs.com on 1/16/26).Resident #45 was admitted to the facility on [DATE] with diagnoses that included partial weakness and paralysis after a stroke affecting the right dominant side, heart disease, altered mental status and major depressive disorder. A review of the Annual Minimum Data Set (MDS) assessment with reference date 10/19/25 revealed resident #45 had a Brief Interview for Mental Status Score of 13 out of 15, which indicated normal cognition.A review of the medical record revealed on 12/10/25 change in condition documentation of pitting edema in the right lower leg for resident #45 and physician's orders initiated on…
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.
- Potential for harm · Dcited before2026-01-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene during medication administration and failed to sanitize equipment between residents per infection control standards to prevent cross-contamination and the spread of infection, for 1 of 4 nurses reviewed for medication administration.Findings: On 1/13/26 at 9:00 AM, Licensed Practical Nurse (LPN) A was observed for a medication pass on resident #128. She took resident #128's blood pressure, set the used cuff on top of her cart, but did not clean or sanitize it. The nurse made two trips to the medication room, touched the medication machine, handled the medications, but did not perform any hand hygiene. She entered the resident's room three different instances passing the hand sanitizer dispenser located to the right of the doorway each time. There was also a full bottle of alcohol-based hand sanitizing solution on her cart, which she did not use. On 1/13/26 at 9:18 AM, LPN A confirmed she was aware she should sanitize her hands with alcohol-based hand sanitizing solution each…
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.
- Potential for harm · E2024-04-18 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available on 2 of 3 units to meet residents' needs related to timely administration of scheduled medications, (Cliffstone and Pebblestone). Findings: Observations on 4/15/24 at 10:53 AM, and at 12:43 PM, showed Registered Nurse (RN) O at her medication cart still administering 9:00 AM medications. On 4/15/24 at 6:02 PM, RN O stated she completed the scheduled 9:00 AM medications at approximately 12:00 PM to 12:30 PM. She stated medications were supposed to be given either one hour before or one hour after the scheduled medication times. On 4/16/24 at 10:07 AM, and at 10:47 AM, RN M was observed in the process of medication administration on Cliffstone unit. On 4/16/24 at 10:50 AM, RN M stated he had three additional residents who had not received their 9:00 AM medications. He explained he was delayed because he had to explain each medication to another resident. On 4/16/24 at 11:12 AM, RN M was again observed at his medication cart. He stated he had one more resident to…
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.
- Potential for harm · E2024-04-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 observation and interview, the facility failed to ensure beverages and dishware were stored and served in a safe and sanitary manner to prevent foodborne illness. Findings: 1. On 4/15/24 at 9:58 AM, during the initial observation of kitchen with the Certified Dietary Manager (CDM), it was noted plate bases were placed on the drying rack stacked together without room to allow air flow for drying. Wet trays were stacked on top of each other in a pile, not allowing air flow for drying. Additionally, wet drinking glasses were placed on a tray upside down with no room between lip of glass and tray for air flow for drying. The CDM stated a tray liner was supposed to get placed between the lip of the glasses and the tray for air flow when drying. On 4/18/24 at 1:51 PM, during a follow-up kitchen observation with the CDM, plate bases were again seen placed on drying rack stacked together without room for air flow for drying and wet drinking glasses were placed on a tray upside down with no room between lip of glass and tray for air flow for drying. Tray liners the CDM had cut…
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.
- Potential for harm · D2024-04-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 promote dignity in dining for 3 of 3 residents reviewed for dignity, of a total sample of 46 residents, (#77, #86, and #265). Findings: 1. Review of resident #77's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, mild protein-calorie malnutrition, and dysphagia. Review of resident #77's Minimum Data Set (MDS) annual assessment with Assessment Reference Date (ARD) of 3/18/24 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because she was rarely/never understood. The MDS assessment noted resident #77 was totally dependent on staff for all activities of daily living (ADLs), including eating. Review of resident #77's care plan, initiated on 7/12/22, revealed she had an ADL self-care performance deficit related to Alzheimer's disease, generalized weakness, gait/balance problems, and incontinence. On 4/15/24 at 12:32 PM, Certified Nursing Assistant (CNA)…
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.
- Potential for harm · Dcited before2024-04-18 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 ensure an evaluation for self-administration of medication was conducted and failed to obtain a physician's order for self-administration of medication for 1 of 10 residents reviewed for choices, of a total sample of 46 residents, (#30). Findings: Resident #30 was admitted to the facility on [DATE], with diagnoses which included poly-osteoarthritis, hypertension, adjustment disorder with mixed anxiety and depressive mood, bilateral artificial knee joint, and hyperlipidemia. Review of the resident's quarterly Minimum Data Set assessment with Assessment Reference Date of 2/05/24, revealed the resident's cognition was intact, with a Brief Interview For Mental Status score of 13 out of 15. Observations on 4/15/24 at approximately 12:04 PM, and on 4/16/24 at 5:14 PM, showed a container of Biofreeze gel on resident #30's tray table. The resident stated she used the medication on her shoulders and neck for pain approximately three to four times…
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.
- Potential for harm · D2024-04-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise care plans to reflect accurate, appropriate, and individualized interventions related to showers/bathing and eating needs for 3 of 8 residents reviewed for activities of daily living (ADLs), of a total sample of 46 residents, (#31, #77 and #86). Findings: 1. Review of resident #31's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes and mood disorder. Review of resident #31's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 2/09/24 revealed he was totally dependent on staff for showers/bathing, lower body dressing and putting on/taking off footwear. Review of resident #31's care plan, revised on 8/30/22, revealed a focus on ADL self-care performance deficit related to hemiplegia, limited mobility, difficulty walking and poor communication. The interventions incorrectly noted…
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.
- Potential for harm · D2024-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, and obtain physician orders for treatment of non-pressure related skin conditions for 2 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 46 residents, (#42, & #56). Findings: 1. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease, dementia, peripheral vascular disease, edema, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/11/24, revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status (BIMS) score of 00 of 15. The assessment indicated the resident was dependent on staff for toileting hygiene, chair/bed-to-chair transfers, and required substantial/maximum assistance to roll left/right, and for personal hygiene. On 4/18/24 at 10:00 AM, resident #42 was lying in bed on 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.
- Potential for harm · D2024-04-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Occupational Therapy (OT) recommendation for Restorative Nurse Program (RNP) for Range of Motion (ROM) was initiated and maintained for 1 of 1 resident reviewed for limited ROM, of a total sample of 46 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, fibromyalgia, contracture of the left hand, left elbow, and left shoulder, pseudobulbar affect, schizoaffective disorder-Bipolar type, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/15/24 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status BIMS score of 12 out of 15. The assessment indicated the resident had impairment in functional limitation in ROM to one side of her upper…
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.
Show the remaining 9 citations
- Potential for harm · D2024-04-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, interview, and record review, the facility failed to ensure oxygen therapy was administered per physician orders for 2 of 2 residents reviewed for oxygen therapy, of a total sample of 46 residents, (#14 and #58). Findings: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), and cerebral infarction (stroke). The Minimum Data Set (MDS) modification of the quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status, (BIMS) of 15 which indicated the resident was cognitively intact. The assessment also reflected resident #14 received oxygen. Observations on 4/15/24 at 3:17 PM, and 4/16/24 at 10:28 AM, revealed resident #14 wearing a nasal cannula attached to an oxygen concentrator set at 6 liters per minute (LPM) of oxygen. Review of the Order Summary Report dated 3/15/23 revealed a physician's order for oxygen at 10 LPM by nasal cannula, every shift. On 4/16/24, the order was changed to oxygen at 6 LPM…
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.
- Potential for harm · D2024-04-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observation, interview, and record review the facility failed to ensure medications were administered within the designated guidelines, and per professional standard and practices, for 2 of 7 residents observed during medication administration, of a total sample of 46 residents, (#30, & #90). Findings: 1. Resident #30 was admitted to the facility on [DATE], with diagnoses which included poly-osteoarthritis, hypertension, adjustment disorder with mixed anxiety and depressive mood, bilateral artificial knee joint, and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24, revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 13 out of 15. On 4/17/24 at 5:10 PM, resident #30 said she received her scheduled 9:00 AM medications sometime around 10:30 AM depending on what the nurse was doing. Review of the resident's Medication Administration Audit Report for the period 4/15/24 to…
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.
- Potential for harm · D2024-04-18 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained for self administration of medications. Findings: Review of the facility's QAPI Plan revealed the QAPI team would identify, collect and analyze data from different departments reflecting performance and establish benchmarks for each area. The form indicated the team would analyze the problem area by conducting a root cause analysis, identify solutions and develop a Performance Improvement Plan (PIP) to address the identified area. The PIP would include goals, actions responsible party, target dates and status/outcome with results reported monthly to the QAPI committee. Completed PIPs would be filed and monitored periodically to assure achievements were being sustained. Concerns with self-administration of medication was identified and cited at F554 on the previous recertification survey conducted 10/23/23 through…
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.
- Potential for harm · Dcited before2024-04-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 a safe and sanitary environment while handling linens to prevent cross-contamination and spread of infection and failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards. Findings: 1. On 4/17/24 at 3:06 PM, Laundry Attendant K was stocking a linen cart with clean bed sheets, blankets, and pads on the [NAME] unit. One sheet fell on the floor, and she picked it up, flapped it, folded it and placed it back in the cart on top of clean linens. On 4/17/24 at 3:07 PM, Laundry Attendant K acknowledged she picked up the bed sheet from the floor and placed it back with the clean linens. She stated she was not supposed to pick up items from the floor and put them with clean supplies because the floor was considered dirty. On 4/17/24 at 5:30 PM, the Housekeeping/Laundry Manager stated Laundry Attendant K told her she made a mistake and placed a dirty sheet she had picked up…
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.
- Potential for harm · D2024-04-18 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 ensure a resident's bathroom was adequately equipped to allow residents to call for staff assistance through a communication system in 1 of 6 resident rooms reviewed for environmental status, (room [ROOM NUMBER]). Findings: On 4/15/24 at 12:12 PM and 4/16/24 at 5:16 PM, no call light system was noted in the bathroom shared by rooms #125 and #127. On 4/16/24 at 5:28 PM, resident #19 stated she used the bathroom by herself. She indicated she had been in the same room a few months and had not needed staff assistance while in the bathroom. She stated a resident in the other room who could not talk also used the same bathroom. Review of the Maintenance Work Orders binder in the [NAME] Hall Unit revealed there were 2 work orders for room [ROOM NUMBER] in March 2024. One of the work orders for room [ROOM NUMBER] was dated 3/26/24 for a broken toilet which was repaired on 4/01/24. On 4/16/24 at 5:49 PM, the Director of Maintenance explained 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.
- Potential for harm · Dcited before2023-10-26 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was conducted for 1 of 1 resident of a total sample of 44 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), generalized weakness, major depressive disorder, Myasthenia Gravis without acute exacerbation, nonrheumatic mitral (valve) prolapse, heart failure, and convulsions. Review of the Admission/readmission Data Collection form with effective date of 8/16/23, revealed the resident was alert, and oriented. Review of the resident's Medication Administration Record (MAR) for the period 8/17/23 to 8/21/23, revealed code entries of 2 indicating drug refused for the resident's medications including, Prednisone 20 milligram (mg) for COPD on 8/18/23, Rosuvastatin 40 mg for elevated lipids on 8/17/23, and 8/18/23, Spironolactone 12.5 mg for heart failure on 8/18/23, and 8/19/23, Trazadone 50 mg 2…
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.
- Potential for harm · D2023-10-26 · tag F0679 — failed to provide activities — isolatedProvide 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 ensure an individualized activity program based on preferences and plan of care was provided for 1 of 2 dependent residents reviewed for Activities, of a total sample of 44 residents, (#73). Findings: Resident #73 was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included Alzheimer's disease, generalized muscle weakness, symptoms and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/18/23, revealed the resident was rarely/never understood. The assessment noted daily and activity preferences indicated the resident liked listening to music, doing things with groups of people, and participating in favorite activities. Review of the Psychosocial Evaluation conducted on 4/01/22, revealed the resident preferred one on one, and small group activities. Her current interest included animals/pet, music, and television on Spanish…
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.
- Potential for harm · D2023-10-26 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 observation, interview, and record review, the facility failed to ensure a Midline intravenous dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed of a total sample of 44 residents, (#152). Findings: Resident #152, an 84- year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included aphasia, occlusion and stenosis of unspecified cerebral artery, [NAME] fever, chronic obstructive pulmonary disease, heart failure, gastrostomy, and atrial fibrillation. Review of the Medical Certification for Medicaid Long-Term Care Services And Patient Transfer Form (3008) dated 10/16/23 revealed the resident's primary diagnosis was sepsis, and acute kidney injury. Documentation indicated the resident was alert, disoriented, could not follow simple instructions, and had a Midline that was inserted on 10/12/23. A midline . is a long, thin, flexible tube that is inserted into a large vein in the upper arm.…
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.
- No harm found · C2023-10-26 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 interview, and record review, the facility failed to ensure binding arbitration agreements explicitly granted the resident or their representative the right to rescind the contract within 30 calendar days of signing for 2 of 3 residents reviewed for arbitration agreements, (#202, #250). Findings: 1. Resident #202 was admitted to the facility on [DATE] and signed the Optional Arbitration Agreement (form revised 4/17) on 10/18/23. The agreement read, It is understood by Resident that he or she is not required to use this Facility .It is further understood that the Agreement to Arbitrate is a separate and stand-alone contract from the admission Agreement The agreement did not include option to rescind the agreement within 30 calendar days of signing. 2. Resident #250 was admitted to the facility on [DATE] and signed the Optional Arbitration Agreement (form revised 4/17) on 10/17/23 which did not include option to rescind the agreement. On 10/26/23 at 1:18 PM, the Admissions Director said she was…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.4 | +2.6 vs chain |
| Health inspection | 4 of 5 | 2.0 | +2.0 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 49 homes this chain runs (chain average 2.4★, per CMS)
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 / manager | Type | Role | Since |
|---|---|---|---|
| WEST DONEGAN SNF PARENT LLC | Organization | DIRECT OWNERSHIP INTEREST | since 09/01/2023 |
| KEYSTONE SNF HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/01/2023 |
| FREUND, NOCHUM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2023 |
| MISHRA, ABHISHEK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/26/2020 |
| STEPTOE, CHANEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2023 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/04/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/10/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 11/04/2025 |
| HERSKOWITZ, ELIEZER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/10/2025 |
| HERSKOWITZ, YAAKOV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/10/2025 |
| TRAVITSKY, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/10/2025 |
| ASPIRE MGT LLC | Organization | ADP OF THE SNF | since 09/01/2023 |
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.
This home reported $71K 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
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
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.
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 106074. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.