Lecanto, FL

Aviata At Brentwood

1-star overall rating with 2-star inspections with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2333 N Brentwood Cir, Lecanto, FL

(352) 746-6600

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

106

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aviata Health Group

Operator or chain grouping

Approved since

1984-04-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.37

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

1.92

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.21

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.29

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.01

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

3.45

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

6,227

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.58

Composite VBP score used to determine payment impact.

Payment multiplier

0.9878

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.66

Baseline 18.33% · Performance 19.27% · Measure score 4.66 · Achievement 4.66 · Improvement 0

Healthcare-associated infections

6.79

Baseline 7.08% · Performance 5.80% · Measure score 6.79 · Achievement 6.79 · Improvement 5.62

Total nurse turnover

Baseline 55.17% · Performance 62.69% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.98

Baseline 3.92 hours · Performance 3.64 hours · Measure score 1.98 · Achievement 1.98 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.43%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 143 · Observed rate 7.69% · Lower 95% interval 6.97%
Discharge to community	39.79%	50.57% 10.8 pts worse	Worse than the National Rate · Eligible stays 112 · Observed rate 34.82% · Lower 95% interval 31.59%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	74.03%	95.27% 21.2 pts worse	Numerator 134 · Denominator 181
Falls with major injury	1.1%	0.77% 0.3 pts worse	Numerator 2 · Denominator 181
Discharge self-care score	35.07%	53.69% 18.6 pts worse	Numerator 47 · Denominator 134
Discharge mobility score	36.57%	50.94% 14.4 pts worse	Numerator 49 · Denominator 134
Pressure ulcers or injuries, new or worsened	1.1%	2.29% 1.2 pts better	Numerator 2 · Denominator 181 · Adjusted rate 1.25%
Healthcare-associated infections requiring hospitalization	5.81%	7.12% 1.3 pts better	No Different than the National Rate · Eligible stays 71 · Observed rate 2.82% · Lower 95% interval 3.24%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 149
Staff flu vaccination coverage	23.81%	42% 18.2 pts worse	Numerator 40 · Denominator 168
Discharge function score	33.58%	56.45% 22.9 pts worse	Numerator 45 · Denominator 134
Transfer of health information to provider	93.94%	95.95% 2 pts worse	Numerator 62 · Denominator 66
Transfer of health information to patient	50%	96.28% 46.3 pts worse	Numerator 21 · Denominator 42
Resident COVID-19 vaccinations up to date	9.64%	25.2% 15.6 pts worse	Numerator 8 · Denominator 83

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.4	2.1 1.3 pts worse	1.9 1.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	1.2 0.6 pts worse	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	97.8% 1.3 pts better	93.4% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 98.9% · Q4 100.0% · 4Q avg 99.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	99.2% 0.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	2.6% 0.6 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.2% · Q4 3.4% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.3%	3.7% 0.6 pts worse	11.4% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 8.2% · Q4 3.5% · 4Q avg 4.3%
Percentage of long-stay residents who lose too much weight	3.6%	5.9% 2.3 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 6.2% · Q4 5.0% · 4Q avg 3.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	10.1%	15.7% 5.6 pts better	19.6% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 12.0% · Q3 10.7% · Q4 7.1% · 4Q avg 10.1%
Percentage of long-stay residents who received an antipsychotic medication	5.9%	9.8% 3.9 pts better	16.7% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.6% · Q3 5.6% · Q4 6.5% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.5%	11.7% 6.8 pts worse	16.3% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 18.7% · Q3 6.0% · Q4 15.8% · 4Q avg 18.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.7%	9.8% 4.9 pts worse	14.9% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 22.4% · Q3 3.8% · Q4 7.6% · 4Q avg 14.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.4% 0.7 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.5%	12.5% 9 pts worse	19.8% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 26.7% · Q3 18.8% · Q4 9.5% · 4Q avg 21.5%
Percentage of long-stay residents with pressure ulcers	10.7%	5.1% 5.6 pts worse	5.1% 5.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 12.9% · Q3 10.9% · Q4 9.4% · 4Q avg 10.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	94.3% 4.6 pts better	81.7% 17.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 99.4% · Q4 98.0% · 4Q avg 98.9%
Percentage of short-stay residents who had an outpatient emergency department visit	14.1%	9.3% 4.8 pts worse	12.0% 2.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 15.2% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.5% 0.5 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.8% · Q3 1.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	94.7% 5.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.1%	26.2% 2.1 pts better	23.9% 0.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 25.3% · Expected 25.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-15 · Fire 2024-08-15

15 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-04-06 · Fire 2023-04-06

8 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2021-10-28 · Fire 2021-10-28

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-13

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-03-07

F · Potential for more than minimal harm 2024-08-15

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-09-16

F · Potential for more than minimal harm 2024-08-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-09-16

F · Potential for more than minimal harm 2023-04-06

E34 · Emergency Preparedness Deficiencies

Fire Safety

Provide a means of sharing information on occupancy/needs.

Corrected 2023-05-16

F · Potential for more than minimal harm 2023-04-06

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-05-16

F · Potential for more than minimal harm 2023-04-06

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-05-16

F · Potential for more than minimal harm 2023-04-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-16

F · Potential for more than minimal harm 2023-04-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-16

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-12

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2026-02-12

D · Potential for more than minimal harm 2025-12-12

F688 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2026-02-12

D · Potential for more than minimal harm 2025-12-12

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2026-02-12

D · Potential for more than minimal harm 2025-11-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2026-01-01

D · Potential for more than minimal harm 2025-11-05

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-11-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2026-01-10

D · Potential for more than minimal harm 2025-06-30

F627 · Resident Rights Deficiencies

Health

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Corrected 2025-08-18

D · Potential for more than minimal harm 2025-02-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-24

F · Potential for more than minimal harm 2024-08-15

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2024-09-16

E · Potential for more than minimal harm 2024-08-15

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-15

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-15

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-09-16

D · Potential for more than minimal harm 2024-08-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-16

C · Minimal harm 2024-08-15

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-09-16

E · Potential for more than minimal harm 2023-04-06