Cycle 1
Health 2024-07-03 · Fire 2024-07-03
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bonita Springs, FL
Renaissance At The Terraces
3-star overall rating with 4-star inspections with 2 recent health deficiencies
26475 South Tamiami Trail, Bonita Springs, FL
(239) 949-7555
Overall
3 / 5
CMS overall stars
Health inspections
4 / 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
40
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-12-05
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
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
743
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.41
Composite VBP score used to determine payment impact.
Payment multiplier
1.0189
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.35
Baseline 23.11% · Performance 21.38% · Measure score 2.35 · Achievement 0 · Improvement 2.35
Healthcare-associated infections
5.79
Baseline 7.11% · Performance 6.10% · Measure score 5.79 · Achievement 5.79 · Improvement 4.27
Total nurse turnover
9.32
Baseline 48.44% · Performance 25.58% · Measure score 9.32 · Achievement 9.32 · Improvement 9
Adjusted total nurse staffing
8.30
Baseline 5.41 hours · Performance 5.44 hours · Measure score 8.30 · Achievement 8.30 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 345 · Observed rate 7.25% · Lower 95% interval 7.28% |
| Discharge to community | 65% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 349 · Observed rate 64.47% · Lower 95% interval 60.86% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 233 · Denominator 236 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 4 · Denominator 236 |
| Discharge self-care score | 74.59% |
53.69%
20.9 pts better
|
Numerator 135 · Denominator 181 |
| Discharge mobility score | 66.85% |
50.94%
15.9 pts better
|
Numerator 121 · Denominator 181 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 236 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 196 · Observed rate 4.08% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0.91% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 110 |
| Staff flu vaccination coverage | 13.27% |
42%
28.7 pts worse
|
Numerator 15 · Denominator 113 |
| Discharge function score | 79.01% |
56.45%
22.6 pts better
|
Numerator 143 · Denominator 181 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | 98.2% |
96.28%
1.9 pts better
|
Numerator 164 · Denominator 167 |
| Resident COVID-19 vaccinations up to date | 24.43% |
25.2%
0.8 pts worse
|
Numerator 32 · Denominator 131 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · 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 · 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 | 3.0% |
2.6%
0.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.9%
3.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
15.7%
8.2 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
9.8%
9.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.4% |
9.8%
22.6 pts worse
|
14.9%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.4% |
0.8%
8.6 pts worse
|
1.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
12.5%
13.8 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.1%
5.2 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
9.3%
0.4 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.1% · Expected 10.1% · 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 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
26.2%
1.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 23.3% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-18 · Fire 2023-05-18
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-09-23 · Fire 2021-09-23
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-05-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-06
F · Potential for more than minimal harm
2021-09-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-10-23
F · Potential for more than minimal harm
2021-09-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-10-23
E · Potential for more than minimal harm
2021-09-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-10-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-03
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 2024-07-25
D · Potential for more than minimal harm
2024-07-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-25
D · Potential for more than minimal harm
2023-05-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-06
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
Penalties and ownership
What sits behind the stars
Ownership
Bonita Springs Retirement Village Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement-Life Communities Management, LLC
Operational/Managerial Control · Organization
Ahern, Susan
Operational/Managerial Control · Individual
Ahern, Susan
Corporate Officer · Individual
Bonita Springs Retirement Village Inc
Operational/Managerial Control · Organization
Bonita Springs Retirement Village Inc
5% Or Greater Mortgage Interest · Organization
Christiansen, Karen
Operational/Managerial Control · Individual
Christiansen, Karen
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Fox, Glenn
Operational/Managerial Control · Individual
Fox, Glenn
Corporate Officer · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Glynn, James
Corporate Director · Individual
Grant, Gerald
Operational/Managerial Control · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Jonathan
Operational/Managerial Control · Individual
Grant, Jonathan
Corporate Officer · Individual
Moreland, Dave
Corporate Director · Individual
Valdivia, Peggy
Operational/Managerial Control · Individual
Valdivia, Peggy
Corporate Officer · Individual
Weiss, Rita
Corporate Director · Individual
Nearby options
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#3
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