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Aviata At North Fort Myers

991 Pondella Rd, N Ft Myers, FL 33903 · For profit - Limited Liability company · 120 certified beds · (239) 995-8809 Medicare & Medicaid certified

Call the home — (239) 995-8809 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20241 actual-harm citation$14,120 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
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
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,120 in federal fines (most recent 2024-11-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

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

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Diplomat Parkway
Pharmacy
2020 NE Pine Island Rd · (239) 800-6067 · Call to confirm hours
Grocery
2020 NE Pine Island Rd · (239) 800-6068 · Call to confirm hours
Park
5170 Orange Grove Blvd · (239) 652-4520 · Typically dawn to dusk
Place of worship
940 Pondella Rd · (239) 677-7680

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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 increased9.7%8.7%15.4%better
Long-stay residents who lose too much weight7.5%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.0%4.6%6.5%better
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 injury4.0%2.5%3.3%worse
Long-stay residents whose ability to walk worsened9.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.1%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine98.9%99.2%95.3%typical
Long-stay residents with pressure ulcers1.0%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control8.4%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 table1.5%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine86.1%94.7%79.4%typical
Short-stay residents rehospitalized after admission28.5%26.1%22.6%worse
Short-stay residents with an outpatient ER visit3.1%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.652.131.67typical
Long-stay outpatient ER visits per 1,000 resident days1.281.151.80better

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.

41.2% 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 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.2%U.S. median 51.5%
Got home and stayed home
11.0%U.S. median 10.7%
Went back to hospital
64.5%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 64.5% 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 110 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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 SNF41.2%CMS range 32.5–49.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 7.8–14.310.7%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 discharge64.5%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 discharge61.8%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 discharge51.8%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 identified98.2%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 discharge87.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 3.8–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

0.45
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.17
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.30
RN hoursweekends
41.6%
Total nursing turnover
73.7%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.5 residents a day — about 93% occupied, or roughly 8 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 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.18 hrs/resident/day on weekends vs 3.58 on weekdays — 11% thinner on weekends. RN hours go from 0.51 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%. 1 administrator has left in the past year.

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 (2026-04-09)
9
at the previous standard inspection (2024-03-13)

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.

ABCDEFGHIJKL

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

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

  • Actual harm · Gcited before2022-05-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure care according to industry standards by not following physician's orders for quarterly lab draws for 1 (Resident #31) of 1 resident reviewed for seizures. Not following physician's orders for quarterly lab values puts a resident with seizure disorder at risk of seizures and hospitalization by not ensuring therapeutic levels of the seizure medication are within the bloodstream. The findings included: On 5/1/22 at 10:06 a.m., Resident #31 was observed lying in bed in her room. The resident did not respond to verbal stimulation, stared straight ahead, making unintelligible noises, like whimpering. Review of the Minimum Data Set, dated [DATE] indicated Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The active diagnosis for Resident #31 included unspecified convulsions, seizure disorder, and anoxic brain injury. Resident #31 was originally admitted to the facility 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-04-09 · 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

    Based on observation and interview with the Dietary Manager, the facility failed to store food in an appropriate manner in accordance with guidelines of the FDA (Food and Drugs Administration) Food Code to ensure food was stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The findings included:The facility policy and procedure titled, Food Storage: Cold Foods, revised 4/2018, policy #019's Policy Statement stated, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Procedures . All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . References : https://www.fda.gov/downloads/food/guidanceregualtions/retailfoodprotection/foodcode/ucm374510.pdf. The undated dietary department policy titled, Labeling and Dating Inservice noted, . Importance of Labeling and Dating. Proper labeling and dating ensures that all…

    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 · E2026-04-09 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to ensure the clinical record of 1 (Resident #11) of 2 residents reviewed for accurate documentation was completely and accurately documented. The findings included: Review of the clinical record for Resident #11 revealed an admission date of 10/31/22.Diagnoses included: Acute gastric ulcer with hemorrhage; Traumatic subdural hemorrhage with loss of consciousness (head injury); Mild protein-calorie malnutrition; Dysphagia (difficulty swallowing); Epilepsy; Cerebrovascular disease (disease of the blood vessels in the brain).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11scored 14 on the Brief Interview for Mental Status, indicating intact cognition. The MDS noted that Resident #11 required setup or clean-up assistance for eating.Review of the care plan completed on 2/19/26 revealed that Resident #11was at risk for malnutrition related to prior medical history of anxiety disorder, major depressive…

    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 before2026-04-09 · 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 observation, record review and staff interviews, the facility failed to ensure fall prevention interventions were implemented for 1 (Resident #53) of 3 residents reviewed who sustained multiple falls at the facility.The findings included:Review of the clinical record of Resident #53 revealed an admission date of 1/26/26. Diagnoses included Chronic Obstructive Pulmonary Disease, Systemic Lupus, unspecified displaced fracture of surgical neck of left humerus, syncope (fainting) and collapse.Review of the 5-Day Minimum Data Set (MDS) Assessment with an assessment reference date of 2/5/26 revealed that Resident #53's cognition was severely impaired. The resident required substantial/maximal assist with toileting, bathing and transfers; partial/moderate assistance with dressing, sit to stand, and bed mobility.A Change in Condition progress note dated 1/27/26 revealed Resident #53 resident had a fall. Nursing staff assisted the resident in getting back to bed. Education provided on fall prevention measures. Resident to call for assistance before getting out of bed/chair when…

    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 before2026-04-09 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and record review, the facility failed to ensure ongoing communication with the dialysis center related to the ongoing assessment of a dialysis resident before and after each dialysis treatment for 1 (Resident #128) of 1 resident receiving dialysis.The findings included:The facility's policy Coordination of Hemodialysis Services #N1359 with a revision date of 07/02/2019 stated residents which have required an outside ESRD (End Stage Renal Disease) facility will have services coordinated by the facility. There would be communication between the facility and the ESRD facility regarding the residents. A dialysis communication form would be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing would collect and complete the information regarding the resident to send to the ESRD center . Upon the resident's return to the facility, nursing will review the dialysis communication form and information completed by the dialysis center or the information sent by the dialysis center. Nursing will complete the post dialysis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to have documentation of a performance review and in-service education based on the outcome of the review for 1 (Staff E) of 4 Certified Nursing Assistants (CNAs) reviewed.The findings included:On 4/8/26, review of CNA Staff E's employee file revealed a date of hire of 9/11/24. The employee file lacked documentation of an annual performance evaluation for the year 2025.On 4/8/26 at 2:18 p.m., the Human Resources Director reviewed CNA Staff E's employee file and confirmed in an interview that no annual performance evaluation had been completed since CNA Staff E's original hire date.On 4/9/26 at 8:03 a.m., in an interview, the Nursing Home Administrator verified that CNA Staff E had been employed at the facility since 9/11/24. She said they were unable to find an annual performance evaluation for CNA Staff E.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to have documentation of dementia management training for 2 (Staff E and Staff D) of 4 Certified Nursing Assistants (CNAs) reviewed.The findings included:Review of the CNA Staff E's employee file revealed the Dementia Care: Effective Communication training assigned to the CNA on 9/11/24 had a status of not started.No other annual dementia training was in the employee records.Review of CNA Staff D's employee file revealed the Dementia Care: Effective Communication training was assigned to the CNA on 9/1/23 and had a status of not started. No other annual dementia training was in the employee records.On 4/8/26 at 1:04 p.m., in an interview, the Human Resources Director said that the education transcripts of CNAs Staff D and Staff E did not include dementia training. She verified that CNAs Staff D and Staff E never completed the Dementia Care: Effective Communication training that were assigned to them respectively on 9/1/23 and 9/11/24.On 4/8/26 at 2:20 p.m., in an interview, the Nursing Home Administrator confirmed that…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-10-22 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, residents, staff and contractor's interview, the facility failed to have an effective pest control program to ensure a pest free environment in residents' rooms and in the kitchen of the food serving establishment.The findings included:On 10/20/25 at 9:05 a.m., during a tour of the [NAME] Unit, a live brown insect was observed crawling on the bathroom floor of room [ROOM NUMBER].On 10/20/25 at 9:49 a.m., in an interview Resident #6 said she's had ants crawling in her bed.On 10/21/25 at 3:50 a.m., in an interview Registered Nurse (RN) Staff BB said ants were an issue at the facility. During the interview, multiple ants were observed crawling on the wall at the nurse's station next to the [NAME] Unit.On 10/21/25 at 4:00 a.m., during a tour of the [NAME] Unit the following observations were made:Live crawling insects in the hallway and in room [ROOM NUMBER].Numerous ants were crawling on the clean linen in the linen cart.During confidential interviews, direct care staff who…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-10-22 · 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 observation, record review, residents and staff interviews, the facility failed to provide housekeeping, and maintenance services to maintain a clean, comfortable and pest free environment in all 3 ([NAME], [NAME] and [NAME]) of 4 units observed. The facility failed to maintain the walk-in refrigerator and freezer in a clean and sanitary mannerThe findings included:1. On 10/20/25 at 9:05 a.m., a tour of the [NAME] unit revealed the following: room [ROOM NUMBER]: Unlabeled, uncovered wash basins were stacked and stored on the toilet tank of the shared bathroom. Photographic evidence obtained. A live brown insect was observed crawling on the bathroom floor. Photographic evidence obtained. The raised toilet seat was rusty. Photographic evidence obtained. The bed remote of room [ROOM NUMBER] B was coated with a sticky brown substance. The bed control was not functioning properly. The head of the bed could not be raised. room [ROOM NUMBER]: An extension cord was observed plugged to the wall next to the bed…

    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 before2024-11-14 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to ensure 1 (Resident #2) of 1 resident reviewed for dialysis received care and services to meet her needs. The findings included: The facility's policy and procedure Coordination of Hemodialysis Services with a revision date of 07/02/2019 noted, Residents requiring an outside ESRD (End Stage Renal Disease) facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident . Procedure: The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. The ESRD facility is to review the Dialysis Communication form and either : a. Complete the communication form and return with the resident or b. Provide treatment information to the facility. Upon the resident's return to the facility, nursing will review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-14 · 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 review, review of facility's policies and procedures, and staff interviews, the facility failed to report a resident's injury of unknown origin to the Agency for Health Care Administration within the required time for 1 (Resident #3) of 3 residents' incidents reviewed. The findings included: The facility's Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/2022 noted under reporting/response, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect . including injuries of unknown source . to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator and to other officials in accordance with State law . Once the allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in…

    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
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-07-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to obtain necessary medical follow-up appointment for 1 (Resident #2) of 3 residents reviewed. The findings included: Review of the facility policy and procedure titled, Medical Consultations with a revision date of 8/24/2017 showed, The medical staff requesting a consultation will order the consultation and a Request for Consultation will be initiated by nursing to the consulting physician . The consultation will include the examination of the resident and the medical record . The attending will need to note in his re-certification notes that consultation occurred and the outcome of this. On 7/1/24 at 10:55 a.m., in an interview Resident #2 said she had a mammogram done on 5/1/24. She said she already had a biopsy before coming to the facility but needed another one. Resident #2 stated, I'm scared and started crying. She said, I don't know why they are not making an appointment for me. Resident #2 said she has told staff that her breast…

    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 before2024-04-25 · 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 resident and staff interviews and record reviews the facility failed to follow Physician orders to ensure the health and safety of one resident, Resident #1, of 4 residents reviewed for significant medication errors. The findings included: Administering Medications Policy dated 2001 and Revised April 2019 states, Medications are administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration record space provided for that drug and dose. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medications was administered; the dosage; the route of administration; the injection site; Any complaints or symptoms for which the drug was administered; Any results achieved and when those results were observed; and the signature and title of the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-13 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility policy review, and staff interview the facility failed to provide the advance beneficiary notice to 2 (Residents #24, and #27) of 3 sampled residents reviewed. The findings included: Review of facility policy titled Advanced Beneficiary Notice (ABN), revised 11/10/2015, which states, Policy: An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described in the form .The form will be reviewed with the resident or authorized representative . Procedure: 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice . 2. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . If the resident refuses to sign the notice, the notice is still valid as long as the facility documents that the notice was given but the resident refused to sign. 3. In the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-13 · 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 observation, resident and staff interviews and record review the facility failed to provide a safe, sanitary, and homelike environment in 3 (Canterbury, Buckinham and [NAME]) of 4 halls, as evidenced by dry wall damage in resident's rooms, damaged resident furnishings and rusted resident equipment. Failure to identify and complete needed repairs could cause safety and sanitary hazards to vulnerable residents. The findings included: On 3/10/24 during the initial tour of the rooms on the 100 hallway; observation revealed there was damage to the dry walls next to the bathroom and behind the resident's beds in rooms [ROOM NUMBER]; a large hole was noted in the dry wall next to the air conditioner unit in room [ROOM NUMBER]; and also noted were the over the bed tables in room [ROOM NUMBER] and 115 and the over the toilet commode chair in room [ROOM NUMBER] had multiple rusted areas. Review of the Maintenance Plan policy and procedure #ALF-1015, dated 11/30/14, stated the facility would ensure the continued…

    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 before2024-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policies and procedures, clinical record review and staff and resident interviews, the facility failed to follow procedures to thoroughly evaluate and analyze the fall incidents, for 1(Resident #19) of 2 residents. The facility also failed to ensure smoking material including lighters were securely stored for 1 (Resident #71) of 25 residents identified by the facility as currently smoking. The findings included: 1. The facility policy N-1259 Fall Management effective 11/30/14 (Revised 7/29/19) documented Residents are evaluated for fell risk. Patient centered interventions are initiated based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of future falls and minimize the potential for a resulting injury. Fall Mitigation: Fall risk is based off results of the Fall Risk Evaluation. Fall Mitigation Strategies: Develop resident centered interventions based on resident risk factors. Update 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-03-13 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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, record review, and facility policy review the facility failed to maintain ongoing, effective communication with dialysis centers and failed to ensure 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis received appropriate care and services before and after dialysis treatments. The facility failed to have documentation of an agreement with the dialysis centers providing treatment to Residents #176 and #63. The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Residents requiring an outside ESRD [end stage renal dialysis] facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring Dialysis Services. The agreement shall include how the residents care is to be managed. Procedure: 1. The Dialysis…

    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 · E2024-03-13 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility policy the facility failed to ensure nursing staff were competent to provide care and services to 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis. The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Procedure: 1. The Dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center . 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center . 5. Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the Resident's Clinical record. 1. Review of the clinical record revealed Resident #176 was admitted to the facility on [DATE] with a diagnosis of end…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure the accuracy of a Pre-admission Screening and Resident Review (PASRR) and make the necessary corrections for 1(Resident #37) of 1 resident with admitting diagnoses of mental illness. The findings included: The facility policy titled Preadmission Screening and Resident Review (PASSR) with a revision date of 11/8/2021 stated, The center will assure that all Serious Mentally Ill (SMI) and intellectually disabled (ID) residents received appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. Review of the admission Record for Resident #37 revealed an admission…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy and procedure review, and interviews, the facility failed to develop and implement a comprehensive individualized care plan for 4 (Residents #37, #104, #18, and #102) of 26 residents reviewed. The findings included: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, specified, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The development of a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial…

    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 · D2024-03-13 · 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 observation, review of facility policy and procedure, review of the clinical record and staff interview, the facility failed to follow their policy and procedure and physician orders for the use of oxygen for 1 (Resident #273) of 1 resident reviewed for oxygen use. The facility failed to have a system in place to ensure the oxygen concentrator filters were removed and cleaned per the manufacturers recommendation. The facility had 19 residents with oxygen concentrators. The findings included: The facility policy N-1440 Oxygen effective 11/30/14 (revised 8/23/17) documented, Obtain Physician's order. Set flow at level ordered by the physician. Review of the manufacturers recommendation for the oxygen concentrator Cleaning the Cabinet Filter, specified Risk of danger. To avoid damage to the internal components of the unit, do not operate the concentrator without the filter installed or with a dirty filter . Remove the filter and clean as needed. On 3/10/24 at 9:55 a.m., Resident #273 was observed in bed, there was an oxygen concentrator in her room that was turned on and set…

    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 before2024-03-13 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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, review of facility policies and procedures, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests for 3 (Residents #23, #51 and #49) of 26 sampled residents. The findings included: The facility policy HL-200 Pest Control, effective 11/30/14 documented The facility will maintain a pest control program which includes inspection, reporting and prevention. Any unusual occurrence or sighting of insects should be reported to the Supervisor. Proper action will be taken. On 3/10/24 at 9:28 a.m., during an observation of Resident #49's bathroom one live small brown crawling insect was noted in the bathroom sink. There was a wash basin on the floor under the sink with two larger brown insects on their back with legs in the air, not moving. There was a live brown insect making a web from the sink to the wash basin. There were several small dead brown insects in the wash basin. 3/10/24 at 9:29 a.m., Central Supply…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-05-04 · 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 observation, record review and interview the facility failed to maintain the kitchen and nourishment room equipment in a safe and clean manner. The facility failed to ensure kitchen staff contain hair to prevent contamination of food. The findings included: Healthcare Services Group (HCSG) policy 027 revised May 2014 Staff Attire read, It is the center policy that all employees wear approved attire for the performance of their duties. Action Steps 1. The food service Director insures all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 5/1/22 at 9:30 a.m., during a tour of the kitchen the following was observed: Walk-in cooler with boxes of food supplies stored on the floor of the cooler. Hand washing sink with grime, and black bio growth. Juice machine dispenser nozzle was on counter with the nozzle touching the counter where it could be contaminated. Tray of cornbread sitting on plastic container uncovered underneath kitchen…

    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 · Ecited before2022-05-04 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, Resident, staff, and Practitioners interviews, the facility failed to ensure 1 (Resident #92) of 6 resident reviewed for unnecessary medications was free of significant medication errors. The findings included: On 5/1/22 at 10:34 a.m., Resident #92 said her Sinemet for Parkinson's disease is scheduled for 5:00 p.m., and staff did not administer it to her until 7:30 p.m. She said she gets the Sinemet so late it causes her to have tremors. Resident #92 said she complained about receiving her Sinemet late to the Director of Nursing (DON) and the Advanced Practice Registered Nurse, but nothing is being done. On 5/1/22 at 1:32 p.m., record review for Resident #92 showed the following physician's orders: Sinemet CR Tablet Extended Release 25-100 MG (milligrams) (Carbidopa-Levodopa ER) give 1 tablet by mouth at bedtime at 9:00 p.m. for Parkinson and give 1 tablet by mouth two times a day for Parkinson at 9:00 a.m., and 5:00 p.m. The physician's orders also included to administer Carbidopa-Levodopa 25/100 1 tablet by mouth four times a day at 7:00 a.m., 11:00 a.m.,…

    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 · E2022-05-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, and staff interview, the facility failed to maintain medications secured in locked treatment carts to limit access to unauthorized personnel in 3 (Canterbury, [NAME], and [NAME]) of 4 units of the facility. The findings included: The Policies and Procedures for Medication and Medication Supply Storage and Disposal with effective date of 11/30/2014 states Medications will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications. On 5/1/22 at 10:00 a.m., observed unlocked, unattended, and unsecured treatment cart at the Canterbury nurse's station. The drawers were unlocked and easily accessible. There was no staff located at the nurse's station. The cart was stocked with prescription and over the counter medications and dressing supplies. On 5/2/22 at 10:05 a.m., observed treatment cart at [NAME] nurses' station that was unlocked, unattended, and unsecured. There was no staff around.…

    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 · D2022-05-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate services and interventions for the management of contractures for 1 Resident (Resident #92) of 5 residents reviewed with limited range of motion. The findings included: Record review for Resident #92 showed an occupational therapy Discharge summary dated [DATE] noting Resident #92 was discharged to nursing for long term care. The discharge recommendations included bilateral hand splints. The therapy communication to restorative program form dated 4/21/22 included to don a left-hand splint on Tuesdays, Thursdays and Saturdays and a right-hand splint on Mondays, Wednesdays an Fridays. The form specified Day time, pt [patient] may remove. The instructions for the splints noted the expected outcome was to preserve range of motion and finger extension; correct finger contracture; palmar integrity; inhibit fingernail access. On 5/2/22 at 9:19 a.m. and 2:12 p.m., Resident #92 was observed without hand splints. On 5/2/22 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-04 · 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 observation, record review, resident and staff interview the facility failed to document and follow up on grievances and ensure staff provided care and services to prevent skin injuries to 1 (Resident #94) of 1 resident observed with multiple skin tears to the hands. The findings included: Review of Personal Appearance, Dress code and Name badge (HR-305) policy and procedure with an effective date of 11/30/2014 noted, .Fingernails should be clean and well groomed. Employees who provide direct patient care and dietary employees should not wear fingernails beyond the end of the finger for safety and infection control. The facility's policy and procedure for skin tears-abrasions and minor breaks, care of, revised September 2013 read, . When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/Accident.Reporting. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if abrasion is uncomplicated or not associated with significant trauma. On 5/1/22 at 10:14 a.m., Resident #94 was observed with 4 band aids to both…

    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

“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

$14,120 in federal fines across 3 penalties.

  • $6,152 — penalty dated 2024-11-14
  • $4,823 — penalty dated 2024-03-13
  • $3,145 — penalty dated 2023-12-11

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

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 49 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Aspire At EvansFort Myers, FL 1 of 5Aviata At BenevaSarasota, FL 1 of 5Aviata At Big BendPerry, FL 1 of 5Aviata At Bryan DairyLargo, FL 1 of 5Aviata At FletcherTampa, FL 1 of 5Aviata At Palma Sola BayBradenton, FL 1 of 5Aviata At Saint LucieFort Pierce, FL 1 of 5Aviata At SarasotaSarasota, FL 1 of 5Aviata At SeminoleSeminole, FL 1 of 5Aviata At The BayTampa, FL 1 of 5Aviata At The PalmsPalm Harbor, FL 1 of 5Aviata At VeniceVenice, FL 2 of 5Aviata At Arbor SpringsOcala, FL 2 of 5Aviata At BradentonBradenton, FL 2 of 5Aviata At BrentwoodLecanto, FL 2 of 5Aviata At Colonial LakesWinter Garden, FL 2 of 5Aviata At EnglewoodEnglewood, FL 2 of 5Aviata At Grand OaksPalm Coast, FL 2 of 5Aviata At Green Cove SpringsGreen Cove Springs, FL 2 of 5Aviata At GreenacresGreen Acres, FL 2 of 5Aviata At Lakeside OaksDunedin, FL 2 of 5Aviata At OakfieldBrandon, FL 2 of 5Aviata At 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 JacksonvilleJacksonville, 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
PONDELLA PARENT LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
FORT MYERS HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2023
FREUND, NOCHUMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
NASSIF, RODERICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023
SHARRER, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/16/2024
DAGAN, AMITAIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
GOLDBERGER, ABRAHAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
GOLDBERGER, FAIGYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
HERSKOWITZ, ELIEZERIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
HERSKOWITZ, YAAKOVIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
TRAVITSKY, AARONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 07/15/2025
ASPIRE MGT LLCOrganizationADP OF THE SNFsince 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.

$7.3M
Net patient revenuemost recent cost report
-9.5%
Operating marginrevenue minus expenses
$81K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 8%Other / private 25%

This home reported $81K 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

$296per resident / day
operating cost
$9,001per month
≈ monthly operating cost
$270per 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 105507. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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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