Cycle 1
Health 2025-03-20 · Fire 2025-03-20
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Callaway, FL
Aviata At Emerald Shores
4-star overall rating with 4-star inspections with 3 recent health deficiencies
626 N Tyndall Pkwy, Callaway, FL
(850) 871-6363
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1967-08-21
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
No
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
0.67
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,005
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.39
Baseline 22.11% · Performance 21.15% · Measure score 1.39 · Achievement 0.61 · Improvement 1.39
Healthcare-associated infections
0
Baseline 5.62% · Performance 8.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.17
Baseline 62.02% · Performance 54.80% · Measure score 2.17 · Achievement 2.17 · Improvement 1.44
Adjusted total nurse staffing
2.18
Baseline 3.97 hours · Performance 3.70 hours · Measure score 2.18 · Achievement 2.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.81% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 16.67% · Lower 95% interval 10.17% |
| Discharge to community | 53.55% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 46.45% · Lower 95% interval 43.83% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 181 · Denominator 181 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 181 |
| Discharge self-care score | 55.08% |
53.69%
1.4 pts better
|
Numerator 65 · Denominator 118 |
| Discharge mobility score | 40.68% |
50.94%
10.3 pts worse
|
Numerator 48 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 1.66% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 181 · Adjusted rate 1.43% |
| Healthcare-associated infections requiring hospitalization | 8.14% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 10.48% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 31.25% |
42%
10.8 pts worse
|
Numerator 25 · Denominator 80 |
| Discharge function score | 49.15% |
56.45%
7.3 pts worse
|
Numerator 58 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 105 · Denominator 105 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.04% |
25.2%
23.2 pts worse
|
Numerator 2 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.2
1.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
97.8%
0.5 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 98.4% · Q4 98.3% · 4Q avg 98.3% |
| 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 | 3.5% |
2.6%
0.9 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 4.9% · Q4 6.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
3.7%
0.9 pts worse
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.2% · Q3 1.7% · Q4 7.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.9%
2.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.3% · Q3 4.4% · Q4 2.1% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
15.7%
2 pts worse
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 20.8% · Q3 15.4% · Q4 19.2% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
9.8%
2.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.1% · Q3 8.5% · Q4 7.0% · 4Q avg 6.9% · 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 | 15.9% |
11.7%
4.2 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
9.8%
3 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 8.7% · Q3 4.0% · Q4 0.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.6% |
12.5%
2.1 pts worse
|
19.8%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 20.3% · Q3 9.9% · Q4 7.7% · 4Q avg 14.6% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.1%
1.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.8% · Q3 2.5% · Q4 1.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.3%
3 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 94.9% · Q4 94.9% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
9.3%
5.9 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 16.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.6% · Q3 2.6% · Q4 1.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
94.7%
4.6 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.7% |
26.2%
4.5 pts worse
|
23.9%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 35.5% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-12-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-29
D · Potential for more than minimal harm
2022-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-24
D · Potential for more than minimal harm
2024-12-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-01-10
D · Potential for more than minimal harm
2023-12-21
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 2024-02-10
D · Potential for more than minimal harm
2023-12-21
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-10
D · Potential for more than minimal harm
2023-07-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-11
D · Potential for more than minimal harm
2022-08-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-15
Penalties and ownership
What sits behind the stars
Ownership
Elbataineh, Rezeq
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Wunder, Ann
Operational/Managerial Control · Individual
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#3
St Andrews Bay Skilled Nursing And Rehabilitation
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5-star overall rating with 5-star inspections with 1 recent health deficiencies
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