Tag 0561 · Severity D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-111120 W Donegan Ave, Kissimmee, FL 34741
(407) 847-2854 · Aviata Health Group
| Ownership | For profit - Corporation | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 96.6% | Latest inspection | 2026-01-15 |
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 5 of 5 | 3.5 of 5 | 3 of 5 |
| Health-inspection score | 24.0 points | 40.5 points | 38.5 points |
| Total nurse staffing | 3.39 hours/day | 3.51 hours/day | 3.63 hours/day |
| RN staffing | 0.89 hours/day | 0.80 hours/day | 0.62 hours/day |
| Staff turnover | 32.0% | 35.4% | 41.8% |
| Latest health deficiencies | 3 deficiencies | 6 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Immediate-jeopardy citations: 0
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2026-02-11Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-02-11Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2026-02-11Immediate-jeopardy citations: 0
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2024-05-18Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2024-05-18Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-05-18Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-05-18Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-05-18Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-18Provide 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-18Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-05-18Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-05-18Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2024-05-18Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-05-18Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · Deficient, Provider has date of correction 2024-05-18Immediate-jeopardy citations: 0
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-11-24Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-11-24Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-11-24Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · Deficient, Provider has date of correction 2023-11-24Reported averages, not a real-time staffing schedule.
These group measures do not predict an individual resident’s experience.
How are antipsychotic medications reviewed, reduced when appropriate, and discussed with families?
Suggested because of: antipsychotic useHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.1025 |
| Lpn hours | 0.39659 |
| Rn hours | 0.89071 |
| Reported total hours | 3.38981 |
| Weekend total hours | 3.1969 |
| Weekend rn hours | 0.73264 |
| Adjusted total hours | 3.51844 |
| Total turnover percent | 32 |
| Rn turnover percent | 24 |
| Administrators left | 0 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
| Name | Role | Share |
|---|---|---|
| WEST DONEGAN SNF PARENT LLC | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| KEYSTONE SNF HOLDCO LLC | INDIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| FREUND, NOCHUM | CORPORATE OFFICER | NOT APPLICABLE |
| FREUND, NOCHUM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MISHRA, ABHISHEK | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| STEPTOE, CHANEL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| DAGAN, AMITAI | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| GOLDBERGER, ABRAHAM | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| GOLDBERGER, FAIGY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| HERSKOWITZ, ELIEZER | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| HERSKOWITZ, YAAKOV | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| TRAVITSKY, AARON | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| ASPIRE MGT LLC | ADP OF THE SNF | NOT APPLICABLE |
| MISHRA, ABHISHEK | ADP OF THE SNF | NOT APPLICABLE |
| STEPTOE, CHANEL | ADP OF THE SNF | NOT APPLICABLE |
Educational information, not medical or legal advice. Data & methodology