Cycle 1
Health 2025-04-24 · Fire 2025-04-24
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Brooksville, FL
Aviata At Spring Hill
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
12170 Cortez Blvd, Brooksville, FL
(352) 597-5100
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1998-10-07
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
0.37
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.92
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
3.35
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
3.11
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.32
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
8,514
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 20.63% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 1.88
Healthcare-associated infections
1.60
Baseline 6.44% · Performance 7.36% · Measure score 1.60 · Achievement 1.60 · Improvement 0
Total nurse turnover
3.76
Baseline 54.47% · Performance 48.30% · Measure score 3.76 · Achievement 3.76 · Improvement 1.58
Adjusted total nurse staffing
1.65
Baseline 3.30 hours · Performance 3.55 hours · Measure score 1.65 · Achievement 1.65 · Improvement 0.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.07% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 7.1% · Lower 95% interval 6.47% |
| Discharge to community | 52.67% |
50.57%
2.1 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 42.5% · Lower 95% interval 43.55% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 69.52% |
95.27%
25.8 pts worse
|
Numerator 130 · Denominator 187 |
| Falls with major injury | 0.53% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 187 |
| Discharge self-care score | 46.09% |
53.69%
7.6 pts worse
|
Numerator 59 · Denominator 128 |
| Discharge mobility score | 39.06% |
50.94%
11.9 pts worse
|
Numerator 50 · Denominator 128 |
| Pressure ulcers or injuries, new or worsened | 3.21% |
2.29%
0.9 pts worse
|
Numerator 6 · Denominator 187 · Adjusted rate 3.31% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 8.05% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 3.38% |
8.2%
4.8 pts worse
|
Numerator 5 · Denominator 148 |
| Staff flu vaccination coverage | 21.16% |
42%
20.8 pts worse
|
Numerator 51 · Denominator 241 |
| Discharge function score | 46.88% |
56.45%
9.6 pts worse
|
Numerator 60 · Denominator 128 |
| Transfer of health information to provider | 95.08% |
95.95%
0.9 pts worse
|
Numerator 58 · Denominator 61 |
| Transfer of health information to patient | 76.79% |
96.28%
19.5 pts worse
|
Numerator 43 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 15.56% |
25.2%
9.6 pts worse
|
Numerator 14 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.6 · 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 1.4 · 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 | 2.2% |
2.6%
0.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.5% · Q4 4.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
3.7%
3.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.9%
0.2 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.6% · Q3 6.7% · Q4 3.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
15.7%
3.1 pts worse
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 14.3% · Q3 21.0% · Q4 20.3% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
9.8%
1.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 15.6% · Q3 7.4% · Q4 6.1% · 4Q avg 8.5% · 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 | 20.9% |
11.7%
9.2 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 28.2% · Q3 8.6% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
9.8%
1.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 9.8% · Q3 3.5% · Q4 8.3% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.4%
About the same
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.0% |
12.5%
0.5 pts worse
|
19.8%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 14.7% · Q3 9.3% · Q4 16.2% · 4Q avg 13.0% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.1%
4 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.2% · Q3 9.5% · Q4 4.3% · 4Q avg 9.1% · 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 95.2% · Q2 100.0% · Q3 100.0% · Q4 92.6% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.3%
1.2 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.3% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.9% · Q3 1.6% · Q4 4.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
94.7%
2.3 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| 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 26.7% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-10
D · Potential for more than minimal harm
2024-02-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-10
D · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-10
F · Potential for more than minimal harm
2022-09-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-09-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-09-01
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-09-01
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 2022-10-07
E · Potential for more than minimal harm
2022-09-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-09-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-09-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-09-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-09-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
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 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-04-24
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 2025-06-03
D · Potential for more than minimal harm
2025-04-24
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 2025-06-03
D · Potential for more than minimal harm
2025-04-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-03
E · Potential for more than minimal harm
2024-02-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-10
E · Potential for more than minimal harm
2024-02-08
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 2024-03-10
E · Potential for more than minimal harm
2024-02-08
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 2024-03-10
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 2024-03-10
D · Potential for more than minimal harm
2024-02-08
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 2024-03-10
D · Potential for more than minimal harm
2024-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-10
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 2024-03-10
D · Potential for more than minimal harm
2024-02-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-10
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 2024-03-10
J · Immediate jeopardy
2022-09-01
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 2022-10-01
J · Immediate jeopardy
2022-09-01
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 2022-10-01
J · Immediate jeopardy
2022-09-01
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-10-01
F · Potential for more than minimal harm
2022-09-01
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 2022-10-01
E · Potential for more than minimal harm
2022-09-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-01
E · Potential for more than minimal harm
2022-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-01
D · Potential for more than minimal harm
2022-09-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-01
Penalties and ownership
What sits behind the stars
Ownership
Diaz, Gabriella
Operational/Managerial Control · Individual
Freund, Nochum
Operational/Managerial Control · Individual
Freund, Nochum
Corporate Officer · Individual
Mann, Stefan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Evergreen Woods
Spring Hill, FL
3-star overall rating with 2-star inspections with $16,153 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Oak Hill Health & Rehabilitation
Brooksville, FL
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Brooksville Healthcare Center
Brooksville, FL
2-star overall rating with 2-star inspections with $37,811 in total fines with 6 recent health deficiencies
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