15 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Naples, FL
3-star overall rating with 2-star inspections with 15 recent health deficiencies
875 Retreat Drive, Naples, FL
(239) 431-2100
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
84
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vi Living
Operator or chain grouping
Approved since
2004-12-02
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 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
1.86
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
3.92
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
6.58
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.66
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
5.92
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.33
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
6.42
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
738
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0190
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.81
Baseline 16.48% · Performance 18.74% · Measure score 5.81 · Achievement 5.81 · Improvement 0
Healthcare-associated infections
0
Baseline 5.08% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 27.16% · Performance 21.05% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
10
Baseline 6.29 hours · Performance 5.90 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.14% |
10.72%
2.6 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 2.86% · Lower 95% interval 5.61% |
| Discharge to community | 58.75% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 162 · Observed rate 57.41% · Lower 95% interval 51.08% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 197 · Denominator 197 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 197 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 72 · Denominator 144 |
| Discharge mobility score | 61.11% |
50.94%
10.2 pts better
|
Numerator 88 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 3.05% |
2.29%
0.8 pts worse
|
Numerator 6 · Denominator 197 · Adjusted rate 3.4% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 7.35% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 0.27% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 374 |
| Staff flu vaccination coverage | 7.14% |
42%
34.9 pts worse
|
Numerator 12 · Denominator 168 |
| Discharge function score | 63.19% |
56.45%
6.7 pts better
|
Numerator 91 · Denominator 144 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 99.06% |
96.28%
2.8 pts better
|
Numerator 105 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 34.65% |
25.2%
9.4 pts better
|
Numerator 44 · Denominator 127 |
Quality measures
| 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 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.8%
0.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.3% · Q4 95.2% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
99.2%
5.1 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
2.6%
3.9 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.8% · Q3 2.7% · Q4 4.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 7.0% |
5.9%
1.1 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.5% · Q3 12.0% · Q4 6.5% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
15.7%
8.1 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 12.5% · Q3 3.8% · Q4 6.2% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
9.8%
2 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 8.7% · Q4 6.9% · 4Q avg 7.8% · 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 | 19.0% |
11.7%
7.3 pts worse
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q4 15.0% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
9.8%
6.1 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 12.9% · Q3 8.3% · Q4 16.7% · 4Q avg 15.9% · 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 | 3.0% |
0.8%
2.2 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.3% · Q3 0.0% · Q4 4.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
12.5%
11 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 29.1% · Q3 12.9% · Q4 18.4% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.1%
1.8 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 2.4% · Q4 2.2% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.3% · Q3 98.2% · Q4 96.8% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
9.3%
1 pts worse
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 8.3% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.8% · Q4 0.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
94.7%
0.3 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
26.2%
1.5 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 19.4% · Expected 18.8% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-01
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-29
Inspection history
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-01-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-02
Health
Dispose of garbage and refuse properly.
Corrected 2025-01-02
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-01-02
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-02
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-02
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-02
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-02
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 2025-01-02
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-01-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-02
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-01
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-01
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Naples, FL
3-star overall rating with 2-star inspections with $29,738 in total fines with 9 recent health deficiencies
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3-star overall rating with 2-star inspections with $10,498 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Bonita Springs, FL
3-star overall rating with 4-star inspections with 2 recent health deficiencies
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