8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Tallahassee, FL
2-star overall rating with 2-star inspections with $3,728 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
3101 Ginger Dr, Tallahassee, FL
(850) 877-2177
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
142
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aviata Health Group
Operator or chain grouping
Approved since
1983-07-06
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
RN hours / resident day
0.49
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.27
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
3.04
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.32
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
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
12,886
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.19% · Performance 22.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.80% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.09
Baseline 72.94% · Performance 60.49% · Measure score 2.09 · Achievement 0.78 · Improvement 2.09
Adjusted total nurse staffing
1.84
Baseline 3.57 hours · Performance 3.60 hours · Measure score 1.84 · Achievement 1.84 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 94 · Observed rate 11.7% · Lower 95% interval 7.8% |
| Discharge to community | 47.65% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 38.24% · Lower 95% interval 30.13% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 102 · Denominator 104 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 104 |
| Discharge self-care score | 51.47% |
53.69%
2.2 pts worse
|
Numerator 35 · Denominator 68 |
| Discharge mobility score | 29.41% |
50.94%
21.5 pts worse
|
Numerator 20 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 104 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | 7.9% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 174 |
| Staff flu vaccination coverage | 22.83% |
42%
19.2 pts worse
|
Numerator 42 · Denominator 184 |
| Discharge function score | 48.53% |
56.45%
7.9 pts worse
|
Numerator 33 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.08% |
25.2%
22.9 pts better
|
Numerator 25 · Denominator 52 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.9 · 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 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
97.8%
16.6 pts worse
|
93.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 79.3% · Q3 74.3% · Q4 74.6% · 4Q avg 81.2% |
| 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 | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.9% · Q3 2.2% · Q4 0.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
3.7%
2.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.8% · Q3 0.8% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.9%
2.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.7% · Q3 1.6% · Q4 3.6% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.6% |
15.7%
11.1 pts better
|
19.6%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.7% · Q3 5.5% · Q4 6.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
9.8%
4.1 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.6% · Q3 8.9% · Q4 6.0% · 4Q avg 5.7% · 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 | 8.1% |
11.7%
3.6 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 4.1% · Q3 5.5% · Q4 6.0% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
9.8%
0.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 8.8% · Q3 8.3% · Q4 6.4% · 4Q avg 9.3% · 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 1.6% · Q2 0.7% · Q3 1.4% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
12.5%
0.2 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 8.1% · Q3 6.1% · Q4 17.4% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.3% · Q3 5.2% · Q4 3.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.1% |
94.3%
33.2 pts worse
|
81.7%
20.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 58.4% · Q3 52.6% · Q4 58.8% · 4Q avg 61.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
9.3%
0.1 pts worse
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 10.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.8% |
94.7%
30.9 pts worse
|
79.7%
15.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
26.2%
3.3 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 36.2% · Expected 29.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2026-01-23
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2026-01-23
Fire Safety
List the names and contact information of those in the facility.
Corrected 2026-01-23
Fire Safety
Provide family notifications of emergency plan.
Corrected 2026-01-23
Fire Safety
Establish emergency prep training and testing.
Corrected 2026-01-23
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-23
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-01-23
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2026-01-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-03
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-05-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-03
Inspection history
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 2025-11-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-11-22
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 2025-11-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-22
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-22
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 2025-10-18
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 2025-04-17
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-02-04
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-31
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-31
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 2024-07-31
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 2024-07-31
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-07-31
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-31
Health
Keep all essential equipment working safely.
Corrected 2024-07-31
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-31
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-31
Health
Post nurse staffing information every day.
Corrected 2024-07-31
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-27
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-05-08
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-08
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 2023-04-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-23
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 2023-04-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-23
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 2023-04-23
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-23
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 2023-04-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-23
Penalties and ownership
Fine · fine $3,728
Fine
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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