Cycle 1
Health 2023-07-27 · Fire 2023-07-27
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Brandon, FL
Aviata At Oakfield
2-star overall rating with 1-star inspections with $43,222 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1465 Oakfield Dr, Brandon, FL
(813) 655-0404
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1997-05-07
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
0.53
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.03
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
1.18
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.26
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
4,282
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.22
Baseline 26.61% · Performance 22.09% · Measure score 4.22 · Achievement 0 · Improvement 4.22
Healthcare-associated infections
7.08
Baseline 11.89% · Performance 6.66% · Measure score 7.08 · Achievement 3.92 · Improvement 7.08
Total nurse turnover
4.24
Baseline 75.46% · Performance 51.46% · Measure score 4.24 · Achievement 2.99 · Improvement 4.24
Adjusted total nurse staffing
0.70
Baseline 2.87 hours · Performance 3.22 hours · Measure score 0.70 · Achievement 0.51 · Improvement 0.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 13.22% · Lower 95% interval 7.57% |
| Discharge to community | 44.91% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 35.71% · Lower 95% interval 32.4% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.96% |
95.27%
0.3 pts worse
|
Numerator 113 · Denominator 119 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 119 |
| Discharge self-care score | 40.45% |
53.69%
13.2 pts worse
|
Numerator 36 · Denominator 89 |
| Discharge mobility score | 42.7% |
50.94%
8.2 pts worse
|
Numerator 38 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 119 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 9.38% |
42%
32.6 pts worse
|
Numerator 12 · Denominator 128 |
| Discharge function score | 43.82% |
56.45%
12.6 pts worse
|
Numerator 39 · Denominator 89 |
| Transfer of health information to provider | 97.44% |
95.95%
1.5 pts better
|
Numerator 38 · Denominator 39 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 22 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 18.46% |
25.2%
6.7 pts worse
|
Numerator 12 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.1% |
2.6%
0.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 2.4% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
3.7%
1.7 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.9%
1.1 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 8.0% · Q3 5.3% · Q4 3.6% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.0% |
15.7%
6.3 pts worse
|
19.6%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 25.6% · Q3 21.8% · Q4 22.6% · 4Q avg 22.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
9.8%
3.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.8% · Q3 6.0% · Q4 9.4% · 4Q avg 6.6% · 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 | 13.9% |
11.7%
2.2 pts worse
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.2% · Q3 7.6% · Q4 3.6% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
9.8%
2.8 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.1% · Q3 8.5% · Q4 2.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.4%
0.4 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
12.5%
7.1 pts worse
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 31.9% · Q3 12.7% · Q4 6.6% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.1%
3 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.8% · Q3 3.1% · Q4 2.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
94.3%
2.7 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 99.1% · Q3 98.4% · Q4 98.3% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.9% |
9.3%
7.4 pts better
|
12.0%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.9% · Observed 2.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
94.7%
4.9 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
26.2%
About the same
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 28.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-19 · Fire 2021-08-19
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-11-22 · Fire 2019-11-22
19 health deficiencies
Top issue: Resident Assessment and Care Planning (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
2023-07-27
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 2023-08-27
D · Potential for more than minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
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 2023-08-27
D · Potential for more than minimal harm
2023-07-27
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 2023-08-27
D · Potential for more than minimal harm
2023-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-27
D · Potential for more than minimal harm
2021-08-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-05
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 2026-02-05
D · Potential for more than minimal harm
2026-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-05
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2026-02-05
D · Potential for more than minimal harm
2025-06-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-01-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-21
J · Immediate jeopardy
2024-01-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-14
J · Immediate jeopardy
2024-01-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-07-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-27
E · Potential for more than minimal harm
2023-07-27
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 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
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 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-08-27
E · Potential for more than minimal harm
2023-06-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
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 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-03-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-04-08
E · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-08
E · Potential for more than minimal harm
2021-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-19
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 2021-09-17
D · Potential for more than minimal harm
2021-08-19
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 2021-09-17
D · Potential for more than minimal harm
2021-08-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-19
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 2021-09-17
E · Potential for more than minimal harm
2019-11-22
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 2019-12-22
E · Potential for more than minimal harm
2019-11-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-22
D · Potential for more than minimal harm
2019-11-22
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 2019-12-22
Penalties and ownership
What sits behind the stars
$3,418
2024-02-06
Fine
Fine · fine $3,418
Fine
$25,910
2024-01-19
Fine
Fine · fine $25,910
Fine
$13,894
2023-06-08
Fine
Fine · fine $13,894
Fine
$0
2023-06-08
Payment Denial
Payment Denial · denial start 2023-09-08 · 1 days
1 day denial
Ownership
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Narcisse, Sharla
Operational/Managerial Control · Individual
Veve, Vanessa
Operational/Managerial Control · Individual
Nearby options
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Hawthorne Center For Rehabilitation And Healing Of
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Aviata At Central Park
Brandon, FL
2-star overall rating with 2-star inspections with $7,456 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Victoria Crossing Rehabilitation Center
Brandon, FL
0-star overall rating with 0-star inspections
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