Cycle 1
Health 2025-11-20 · Fire 2025-11-20
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cape Coral, FL
Gulf Coast Village
0-star overall rating with 0-star inspections with Special Focus status with $96,018 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1333 Santa Barbara Blvd, Cape Coral, FL
(239) 772-1333
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-08-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.43
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.14
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.07
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.43
CMS adjusted RN staffing hours
Adjusted total hours
5.07
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,648
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.33% · Performance 22.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.51
Baseline 7.38% · Performance 6.49% · Measure score 4.51 · Achievement 4.51 · Improvement 3.23
Total nurse turnover
0
Performance 88.89% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 4.20 hours · Performance 1.38 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 505 · Observed rate 10.3% · Lower 95% interval 8.85% |
| Discharge to community | 57.75% |
50.57%
7.2 pts better
|
Better than the National Rate · Eligible stays 490 · Observed rate 55.1% · Lower 95% interval 53.48% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 317 · Denominator 317 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 317 |
| Discharge self-care score | 43.9% |
53.69%
9.8 pts worse
|
Numerator 90 · Denominator 205 |
| Discharge mobility score | 43.41% |
50.94%
7.5 pts worse
|
Numerator 89 · Denominator 205 |
| Pressure ulcers or injuries, new or worsened | 2.21% |
2.29%
0.1 pts better
|
Numerator 7 · Denominator 317 · Adjusted rate 2.32% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 313 · Observed rate 5.43% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 149 |
| Staff flu vaccination coverage | 13.49% |
42%
28.5 pts worse
|
Numerator 34 · Denominator 252 |
| Discharge function score | 50.24% |
56.45%
6.2 pts worse
|
Numerator 103 · Denominator 205 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 182 · Denominator 182 |
| Transfer of health information to patient | 87.8% |
96.28%
8.5 pts worse
|
Numerator 108 · Denominator 123 |
| Resident COVID-19 vaccinations up to date | 1.36% |
25.2%
23.8 pts worse
|
Numerator 2 · Denominator 147 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
2.1
1.7 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
97.8%
0.3 pts worse
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.2% · Q4 92.9% · 4Q avg 97.5% |
| 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 | 5.9% |
2.6%
3.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.5% · Q3 5.3% · Q4 8.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
3.7%
0.3 pts worse
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.9% · Q3 2.1% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.9%
1 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.3% · Q3 6.5% · Q4 6.8% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.9% |
15.7%
19.2 pts worse
|
19.6%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 36.6% · Q3 37.0% · Q4 29.5% · 4Q avg 34.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
9.8%
3.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 5.1% · Q4 7.9% · 4Q avg 6.1% · 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 | 19.3% |
11.7%
7.6 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.1% |
9.8%
13.3 pts worse
|
14.9%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.3% · Q3 17.5% · Q4 68.2% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
0.8%
2.7 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 1.8% · Q4 7.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
12.5%
9.9 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 9.6% · Q3 19.3% · Q4 37.0% · 4Q avg 22.4% |
| 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 2.2% · Q2 2.5% · Q3 7.2% · Q4 2.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.3%
3.8 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 92.4% · 4Q avg 98.1% |
| 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 9.4% · Expected 10.2% · 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 0.0% · Q2 0.4% · Q3 1.1% · 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 | 32.3% |
26.2%
6.1 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 28.7% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-05-01 · Fire 2025-05-01
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2024-11-07 · Fire 2024-11-07
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-12
F · Potential for more than minimal harm
2025-05-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-22
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-05-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
Inspection history
Recent health citations
G · Actual harm
2025-11-20
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 2026-01-12
F · Potential for more than minimal harm
2025-11-20
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 2026-01-12
E · Potential for more than minimal harm
2025-11-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-12
E · Potential for more than minimal harm
2025-11-20
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 2026-01-12
E · Potential for more than minimal harm
2025-11-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2026-01-12
E · Potential for more than minimal harm
2025-11-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-11-20
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 2026-01-12
D · Potential for more than minimal harm
2025-11-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-11-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-11-20
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 2026-01-12
F · Potential for more than minimal harm
2025-05-01
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 2025-05-28
D · Potential for more than minimal harm
2025-05-01
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 2025-05-01
D · Potential for more than minimal harm
2025-05-01
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 2025-05-30
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
F · Potential for more than minimal harm
2024-11-07
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 2024-12-05
E · Potential for more than minimal harm
2024-11-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-07
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 2024-12-05
D · Potential for more than minimal harm
2024-11-07
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 2024-12-05
D · Potential for more than minimal harm
2024-11-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-07
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 2024-12-05
D · Potential for more than minimal harm
2024-11-07
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-05
K · Immediate jeopardy
2024-04-02
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 2024-04-12
K · Immediate jeopardy
2024-04-02
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 2024-04-12
K · Immediate jeopardy
2024-04-02
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 2024-04-12
K · Immediate jeopardy
2024-04-02
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-12
G · Actual harm
2023-04-18
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 2023-05-17
D · Potential for more than minimal harm
2023-04-18
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 2023-05-17
Penalties and ownership
What sits behind the stars
$8,586
2024-04-02
Fine
Fine · fine $8,586
Fine
$8,586
2024-04-02
Fine
Fine · fine $8,586
Fine
$78,846
2023-04-18
Fine
Fine · fine $78,846
Fine
Ownership
Volunteers Of America
5% Or Greater Direct Ownership Interest · Organization
Ahmadi, Kevin
Corporate Director · Individual
Ahmadi, Kevin
W-2 Managing Employee · Individual
Bennett, Barbara
Corporate Director · Individual
Bennett, Barbara
W-2 Managing Employee · Individual
Bowman, David
Corporate Officer · Individual
Cooper, Wilfred
Corporate Officer · Individual
Dale, Karen
Corporate Officer · Individual
Feldman, Nancy
Corporate Officer · Individual
Grimes, Jennifer
Corporate Director · Individual
Keller, Cynthia
Corporate Officer · Individual
Kikumoto, Charles
Corporate Officer · Individual
Moore, Carol
Corporate Officer · Individual
Morland, John
Corporate Officer · Individual
Schnare, Ann
Corporate Officer · Individual
Sheridan, Patrick
Corporate Officer · Individual
Sullivan, Michael
Corporate Officer · Individual
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#2
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1-star overall rating with 1-star inspections with $32,188 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Aviata At North Fort Myers
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1-star overall rating with 2-star inspections with $14,120 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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