Cycle 1
Health 2025-05-08 · Fire 2025-05-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Palm Coast, FL
Aviata At Grand Oaks
2-star overall rating with 2-star inspections with $15,646 in total fines with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
3001 Palm Coast Parkway Se, Palm Coast, FL
(386) 446-6060
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1997-05-16
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
0.34
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.47
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
3.35
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.36
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
12,139
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.14
Baseline 22.09% · Performance 21.77% · Measure score 0.14 · Achievement 0 · Improvement 0.14
Healthcare-associated infections
0
Baseline 7.05% · Performance 9.31% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.34
Baseline 69.23% · Performance 43.30% · Measure score 5.34 · Achievement 4.99 · Improvement 5.34
Adjusted total nurse staffing
0
Baseline 3.80 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.22% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 206 · Observed rate 16.02% · Lower 95% interval 10.28% |
| Discharge to community | 60.82% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 50.55% · Lower 95% interval 53.5% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.18% |
95.27%
3.9 pts better
|
Numerator 242 · Denominator 244 |
| Falls with major injury | 0.82% |
0.77%
About the same
|
Numerator 2 · Denominator 244 |
| Discharge self-care score | 40.22% |
53.69%
13.5 pts worse
|
Numerator 72 · Denominator 179 |
| Discharge mobility score | 33.52% |
50.94%
17.4 pts worse
|
Numerator 60 · Denominator 179 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 244 · Adjusted rate 1.97% |
| Healthcare-associated infections requiring hospitalization | 9.31% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 12.5% · Lower 95% interval 6.94% |
| Staff COVID-19 vaccination coverage | 13.46% |
8.2%
5.3 pts better
|
Numerator 14 · Denominator 104 |
| Staff flu vaccination coverage | 19.49% |
42%
22.5 pts worse
|
Numerator 23 · Denominator 118 |
| Discharge function score | 45.25% |
56.45%
11.2 pts worse
|
Numerator 81 · Denominator 179 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 107 · Denominator 107 |
| Transfer of health information to patient | 94.51% |
96.28%
1.8 pts worse
|
Numerator 86 · Denominator 91 |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 24 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.8%
1.8 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 1.9% |
2.6%
0.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 1.6% · Q4 2.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
3.7%
1.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.2% · Q3 0.0% · Q4 1.6% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.9%
0.7 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.9% · Q3 6.2% · Q4 3.7% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
15.7%
0.1 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.4% · Q3 10.4% · Q4 12.7% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
9.8%
6.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.1% · Q3 0.0% · Q4 2.4% · 4Q avg 3.7% · 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 | 15.0% |
11.7%
3.3 pts worse
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 20.9% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
9.8%
2.4 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.8% · Q3 6.7% · Q4 5.8% · 4Q avg 7.4% · 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 | 16.5% |
12.5%
4 pts worse
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 27.5% · Q3 9.9% · Q4 6.1% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.1%
1.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.6% · Q3 2.2% · Q4 2.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
9.3%
5.3 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 4.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.5% · Q4 0.6% · 4Q avg 0.5% · 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 | 16.6% |
26.2%
9.6 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.7% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-03 · Fire 2022-03-03
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-08
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
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 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-15
E · Potential for more than minimal harm
2024-02-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-02-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-15
E · Potential for more than minimal harm
2025-05-08
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-15
J · Immediate jeopardy
2024-06-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-01
J · Immediate jeopardy
2024-06-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-01
E · Potential for more than minimal harm
2024-02-08
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
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 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-03-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-12
E · Potential for more than minimal harm
2022-03-03
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 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
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 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
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 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-04-12
D · Potential for more than minimal harm
2022-03-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-04-12
Penalties and ownership
What sits behind the stars
$7,823
2024-06-07
Fine
Fine · fine $7,823
Fine
$7,823
2024-06-07
Fine
Fine · fine $7,823
Fine
Ownership
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Kinne, Sandford
Operational/Managerial Control · Individual
Mckinney, Kimberly
Operational/Managerial Control · Individual
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