Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At North Fort Myers during CMS and state inspections, most recent first.
Food Storage and Labeling Deficiency: Surveyors observed multiple undated food items in the beverage refrigerator and walk-in refrigerator, including egg sandwiches, facility-made salads, fortified puddings, open dairy items, syrup, shredded cheese, and hash browns. The DM verified the items were not dated and/or disposed of according to facility policy and FDA Food Code guidance.
A resident with diagnoses including malnutrition, dysphagia, epilepsy, and cerebrovascular disease had a care plan requiring meal intake to be monitored and recorded every meal. CNA documentation for March and April showed 44 of 117 meal percentages were not recorded, and the DON confirmed the missing documentation and stated meal intake and/or refusals should be documented for every meal.
Failure to implement fall prevention interventions for a resident with severely impaired cognition and repeated falls. The resident had diagnoses including COPD, lupus, syncope, and a prior humerus fracture, and required significant assistance with transfers and mobility. Although the care plan included bilateral floor mats and a scoop mattress, the CNA Kardex did not list the mats, and staff observed the mats folded against the wall while the resident was in bed. Staff confirmed the mats should have been in place whenever the resident was in bed.
Incomplete dialysis communication and shunt site documentation. A resident with ESRD and CKD stage 5 had orders for hemodialysis three times weekly, but the facility repeatedly failed to complete the dialysis communication forms as required. Documentation was missing for pre-dialysis meds, shunt site assessments at the dialysis center, and post-dialysis shunt site assessments, and one dialysis exchange was documented only on a note pad with vital signs and weight.
Missing CNA performance evaluation documentation. The facility failed to maintain an annual performance evaluation and related in-service education for 1 of 4 CNAs reviewed. Review of the CNA’s file showed no annual performance evaluation since hire, and both the HR Director and NHA confirmed the documentation could not be found.
Missing dementia training documentation was identified for two CNAs reviewed. Their employee files showed assigned Dementia Care: Effective Communication training that remained not started, with no other annual dementia training documented. The HR Director verified that neither CNA completed the assigned training, and the NHA confirmed both CNAs had not completed dementia training for the year.
The facility did not maintain an effective pest control program, resulting in ongoing infestations of ants and roaches in resident rooms, common areas, and the kitchen. Multiple staff and residents reported persistent pest issues, and pest control logs and inspection reports documented repeated sightings and structural problems that contributed to the infestation.
Surveyors found extensive failures in housekeeping, maintenance, and pest control, including unlabeled and uncovered personal care items stored unsafely, live insects in resident rooms and common areas, broken furniture, damaged walls, malfunctioning equipment, and unsanitary kitchen conditions. Staff and residents reported ongoing pest issues, and cleaning protocols were inconsistently followed, resulting in an environment that was not clean, comfortable, or homelike.
A resident with chronic kidney disease and dependence on hemodialysis did not receive adequate care at an LTC facility. The facility failed to document coordination with the dialysis center and did not adhere to the resident's renal diet, providing meals high in sodium and phosphorus. Additionally, the prescribed medication Renvela was not administered with meals as ordered. The activity department provided non-compliant snacks, and staff were unaware of the resident's dietary needs.
A resident with impaired cognition and mobility was found with a leg fracture and discoloration, but the facility failed to report the injury of unknown origin to the Agency for Health Care Administration within the required two-hour timeframe. The delay in reporting was acknowledged by the facility's administration.
A resident with a history of localized enlarged lymph nodes and muscle weakness did not receive a necessary follow-up medical appointment for a biopsy after an inconclusive mammogram. Despite the resident's clear communication of her needs, the facility failed to document and secure the required consultation, as per their policy. Staff interviews revealed an alleged refusal by a cancer center to see the resident, but this was not documented, and the DON and Administrator confirmed the lack of documentation.
A resident with diabetes mellitus did not receive the required blood sugar checks and insulin administration as ordered by the physician. The facility's records showed only eight blood sugar checks for April 2024, with no documentation of insulin administration for elevated levels. Staff interviews revealed confusion and lack of documentation, and the DON discovered that the sliding scale insulin order was incorrectly entered as PRN.
Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store food in accordance with its policy and FDA Food Code guidance requiring Time/Temperature Control for Safety foods to be wrapped or kept in covered containers, labeled and dated, and arranged to prevent cross contamination. During an initial kitchen tour with the Dietary Manager, surveyors observed multiple food items in the beverage refrigerator that were not dated, including 2 egg sandwiches in clear plastic wrap, 2 facility-made salads, and 12 fortified puddings in a bowl with a clear lid. In the walk-in refrigerator, surveyors observed additional items that were either dated beyond the facility’s labeling expectations or were open and undated, including a soup-based container dated 2/26, a jar of grape jelly dated 2/19, half of a block of margarine/butter without a date, an open and half-empty bottle of pancake syrup without a date, 2 open bags of shredded cheese without dates, and an open undated bag of hash browns. The Dietary Manager verified that the observed items in both refrigerators were not dated and/or disposed of according to facility policy.
Incomplete Meal Intake Documentation
Penalty
Summary
The facility failed to ensure the clinical record for one resident was completely and accurately documented. The resident had an admission date of 10/31/22 and diagnoses that included acute gastric ulcer with hemorrhage, traumatic subdural hemorrhage with loss of consciousness, mild protein-calorie malnutrition, dysphagia, epilepsy, and cerebrovascular disease. The Quarterly MDS assessment showed a Brief Interview for Mental Status score of 14, indicating intact cognition, and noted the resident required setup or clean-up assistance for eating. The care plan identified the resident as at risk for malnutrition related to multiple medical conditions and factors, with goals for consuming greater than 50-75% of meals and fluids and approaches to provide the ordered diet and monitor and record intake every meal. Review of CNA documentation for March and April 2026 showed meal intake was not documented for 44 of 117 meals, including multiple missed breakfast and lunch entries and one missed supper entry. During an interview on 4/9/26, the DON confirmed the CNAs did not document 44 meal percentages as required and stated that meal intake and/or refusals should be documented for every meal.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented for one resident who had multiple falls. The resident was admitted with diagnoses including COPD, systemic lupus, a displaced fracture of the left humerus, syncope, and collapse. The 5-day MDS showed severely impaired cognition and the resident required substantial to maximal assistance with toileting, bathing, and transfers, and partial to moderate assistance with dressing, sit-to-stand, and bed mobility. After an initial fall, the resident was documented as having unsteady gait, and the care plan was updated with a PT consultation, bilateral fall mats, and later a scoop mattress. An IDT note stated the resident became anxious at night and attempted to climb out of bed, and also noted the resident had no trunk control and could not stand up. Despite the documented interventions, the CNA Kardex did not include the bilateral fall mats under safety, and the mats were later observed folded up against the wall while the resident was in bed on multiple occasions. Staff interviews confirmed that the resident should always have bilateral floor mats placed on the floor whenever he was in bed, and the DON verified the mats were not listed on the Kardex due to an error when the care plan was written. The record also showed repeated falls, including being found sitting on the side of the bed and later sitting on the floor by the bed, while some change-of-condition notes did not include details of the falls.
Incomplete Dialysis Communication and Shunt Site Documentation
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident receiving hemodialysis, as required by its Coordination of Hemodialysis Services policy. Resident #128 was admitted with a history of ESRD and CKD stage 5 and had physician orders for hemodialysis every Tuesday, Thursday, and Saturday. Review of the resident’s Dialysis Communication Record forms showed repeated missing or incomplete documentation related to whether ordered medications were given before transport to dialysis, assessment of the dialysis shunt site at the dialysis center, and assessment of the shunt site when the resident returned to the facility. The record review identified incomplete documentation on multiple dialysis communication forms, including forms dated 3/14/26, 3/28/26, 4/2/26, 4/4/26, 4/7/26, and an undated form. One entry for 4/4/26 was written on a note pad and documented only pre- and post-dialysis vital signs and weight, with no completed Dialysis Communication Record form and no documentation of shunt site assessment before, during, or after dialysis. RN staff, a Unit Manager, and the DON confirmed the forms were incomplete and did not contain the required documentation.
Missing CNA Performance Evaluation Documentation
Penalty
Summary
The facility failed to maintain documentation of an annual performance evaluation and related in-service education for 1 of 4 CNAs reviewed, Staff E. Review of Staff E’s employee file on 4/8/26 showed a hire date of 9/11/24, but the file did not contain documentation of an annual performance evaluation for 2025. During an interview the same day, the Human Resources Director reviewed the file and confirmed that no annual performance evaluation had been completed since Staff E’s original hire date. On 4/9/26, the Nursing Home Administrator also verified that Staff E had been employed at the facility since 9/11/24 and stated that they were unable to find an annual performance evaluation for Staff E.
Missing Dementia Training Documentation for Two CNAs
Penalty
Summary
The facility failed to have documentation of dementia management training for 2 of 4 CNAs reviewed, Staff E and Staff D. Review of Staff E’s employee file showed that the assigned Dementia Care: Effective Communication training from 9/11/24 had a status of not started, and there was no other annual dementia training in the record. Review of Staff D’s employee file showed that the assigned Dementia Care: Effective Communication training from 9/1/23 also had a status of not started, with no other annual dementia training documented. During interviews on 4/8/26, the Human Resources Director stated that the education transcripts for Staff D and Staff E did not include dementia training and verified that neither CNA completed the assigned training. The Nursing Home Administrator later confirmed that Staff D and Staff E had not completed dementia training for 2025.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in ongoing issues with pests such as ants, roaches, and other insects in resident rooms, common areas, and the kitchen. Direct observations included live insects in resident bathrooms, hallways, and on clean linen carts, as well as ants crawling in a resident's bed and on the walls near the nurse's station. Multiple staff and residents confirmed persistent problems with ants and roaches, with one staff member reporting the recent killing of 13 roaches on their assigned unit. Pest sightings were consistently documented in the facility's pest control logs over several months, indicating a recurring problem. Pest control company inspection reports corroborated these findings, noting dead and live roaches in the kitchen storage area and ongoing issues with ants in resident rooms. Structural issues, such as cracks and lifting tiles in the kitchen flooring, were identified as contributing factors, providing hiding places for pests. The facility's administrator acknowledged that the current pest control program had not been effective in containing household pests, and the facility had a history of noncompliance with pest control requirements as identified in a previous recertification survey.
Widespread Environmental and Sanitation Deficiencies
Penalty
Summary
Surveyors observed multiple failures in housekeeping and maintenance services across three of four units, resulting in an environment that was not clean, comfortable, or pest-free. Numerous resident rooms and shared bathrooms contained unlabeled and uncovered wash basins, urinals, and emesis basins stored on toilet tanks or floors, with photographic evidence obtained. There were also instances of live insects, including ants and roaches, in resident rooms and common areas, as well as reports from residents and staff of ongoing pest issues. Maintenance issues included rusty raised toilet seats, broken furniture, torn wheelchair armrests, holes and gouges in walls, and malfunctioning bed controls. Extension cords not approved for use were found in resident rooms, and some personal care items and urinary catheter drainage bags were not stored in a sanitary manner. The Infection Preventionist and Maintenance Director confirmed these observations and acknowledged lapses in identifying and addressing these concerns. Pest control logs and inspection reports documented recurrent sightings of roaches and ants in various facility locations over several months, including resident rooms, the kitchen, and activity areas. The pest control technician confirmed ongoing problems with ants and roaches, attributing some issues to food in resident rooms and structural problems such as cracks in floors and damaged areas that serve as pest harborage. Housekeeping staff and supervisors reported that cleaning checklists were not consistently used, and some areas, such as grout around toilets and windowsills, were not adequately cleaned. Linen carts were found with ants crawling on clean linen, and direct care staff corroborated the persistent pest issues. In the kitchen, the walk-in refrigerator and freezer were found in unsanitary conditions, with soiled floors, black substance buildup, frost accumulation, condensation, and water pooling on the floor. There were also holes in the walls and soiled seals. The cleaning schedule was not consistently documented, and there was no log to verify completion of cleaning tasks. Communal shower rooms had missing or non-functioning shower heads, rusted metal holders, and opened bottles of body wash and shampoo stored inappropriately. Alcohol-based hand sanitizer dispensers in two units were empty and not functioning. These combined deficiencies resulted in a failure to provide a safe, clean, comfortable, and homelike environment for residents.
Inadequate Dialysis Care and Dietary Management for Resident
Penalty
Summary
The facility failed to provide adequate dialysis care and services for a resident with chronic kidney disease and dependence on renal hemodialysis. The facility's policy required coordination with an external dialysis center, including the use of a Dialysis Communication form to document and communicate treatment information. However, there was a lack of documentation for multiple dialysis sessions, and the Director of Nursing admitted to not documenting communications with the dialysis center. The dialysis center reported concerns about fluid overload and the facility's failure to adhere to the resident's renal diet. The resident was prescribed a controlled carbohydrate renal diet, but the facility did not consistently provide meals that complied with this diet. On dialysis days, the resident received meals high in sodium and phosphorus, such as ham and cheese sandwiches, which were not suitable for her dietary restrictions. The facility's Registered Dietitian had consulted with the dialysis center and provided dietary guidelines, but the resident frequently consumed non-compliant foods, some of which were obtained from the activity department. The activity staff were unaware of the specific dietary requirements, leading to the provision of inappropriate snacks. Additionally, the facility did not administer the resident's prescribed medication, Renvela, as ordered. The medication was intended to be taken with meals to control phosphorus levels, but the Medication Administration Records showed it was not given with dinner meals or lunch on dialysis days. The Director of Nursing and Regional Nurse Consultant confirmed the medication was administered at times that did not align with the physician's orders, further contributing to the deficiency in care for the resident.
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report a resident's injury of unknown origin to the Agency for Health Care Administration within the required time frame. The facility's policy mandates that any employee or contracted service provider who witnesses or has knowledge of an act of abuse, neglect, or injury of unknown source must report it immediately, but no later than two hours after the allegation is made. In this case, the Director of Nursing and the Administrator were notified of the resident's injury on the afternoon of August 12, 2024, but the preliminary report was not submitted to the Agency until the following morning, exceeding the two-hour reporting requirement. The resident involved had moderately impaired cognition and required substantial assistance for transfers. On August 12, 2024, the resident was found with a blue discoloration and swelling on the right foot and leg, and later an X-ray confirmed a fracture. Despite the resident's inability to clearly recall how the injury occurred, the facility's delay in reporting the incident was acknowledged by the Administrator and the Regional Nurse Consultant during an interview, confirming that the initial reporting should have been made within the stipulated time frame.
Failure to Secure Follow-Up Medical Appointment for Resident
Penalty
Summary
The facility failed to obtain a necessary medical follow-up appointment for a resident who required a biopsy after an inconclusive mammogram. The resident, who had a history of localized enlarged lymph nodes and muscle weakness, expressed distress over the lack of follow-up, stating that she had informed staff about her breast pain and the need for a biopsy. Despite the resident's intact cognition and clear communication of her needs, the facility did not secure the required medical consultation. The facility's policy required nursing staff to initiate a consultation request and document the process, but this was not followed. The APRN noted the need for a biopsy and provided referrals to breast surgeons, but there was no documentation of follow-up appointments being made. Staff interviews revealed that the cancer center allegedly refused to see the resident while she was in the facility, but this was not documented. The DON and Administrator confirmed the lack of documentation and expected staff to record all attempts to schedule appointments in the resident's clinical record.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to follow physician orders to ensure the health and safety of a resident with diabetes mellitus, leading to significant medication errors. The resident, who had intact cognition and a history of diabetes, was admitted for post-CVA care. The physician's order required blood sugar checks four times daily and insulin administration based on a sliding scale. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2024 showed only eight blood sugar checks, with no documentation of insulin administration for elevated blood sugar levels. Interviews with staff revealed confusion and lack of documentation regarding the resident's blood sugar monitoring and insulin administration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the issue until it was brought to their attention by the surveyor. The DON later discovered that the sliding scale insulin order was incorrectly entered into the system as PRN (as needed), leading to missed blood sugar checks and insulin doses. The Primary Care Physician Assistant confirmed the order for daily blood sugar monitoring and insulin coverage but was unaware of the lapses in care. The facility initiated a Performance Improvement Project (PIP) to address the issue after it was identified by the surveyor.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near N Ft Myers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Santa Barbara | 3.5 mi | ★★★★★ | 33 | 8 |
| Lee Memorial Hospital Skilled Nursing Unit | 4.1 mi | ★★★★★ | 0 | 0 |
| Gulf Coast Village | 4.3 mi | — | 15 | 0 |
| Rehab & Healthcare Center Of Cape Coral | 4.6 mi | ★★★★★ | 0 | 0 |
| Aspire At Evans | 5.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.