The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Aspire At Evans are:
F-0689 · July 20, 2026 · Grade G — Actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Found during a complaint investigation. Status: Deficient, Provider has no plan of correction
F-0600 · July 7, 2025 · Grade G — Actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date July 12, 2025
F-0600 · June 12, 2025 · Grade G — Actual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date July 12, 2025
F-0689 · August 21, 2024 · Grade G — Actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date September 20, 2024
F-0812 · August 21, 2024 · Grade F — Potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Status: Deficient, Provider has date of correction · correction date September 20, 2024
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Aspire At Evans, 15 subject areas appear across health and fire-safety inspections.
Quality of life and daily care
15 citations between March 10, 2021 and July 20, 2026. The most serious was graded G — actual harm, affecting one or a very small number of residents. Surveyors found that a resident was actually harmed by the failure, though it was not classed as immediate jeopardy. 6 of these citations came out of complaint investigations. Correction record: 14 citations show a recorded correction date; 1 had a plan of correction on file at the last data release.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0689 · July 20, 2026 · Grade G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0689 · August 21, 2024 · Grade G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0692 · January 9, 2025 · Grade E — Provide enough food/fluids to maintain a resident's health.
Freedom from abuse, neglect, and exploitation
2 citations between June 12, 2025 and July 7, 2025. The most serious was graded G (actual harm). 2 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0600 · July 7, 2025 · Grade G — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-0600 · June 12, 2025 · Grade G — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Fire, smoke, and emergency safety
5 citations between March 10, 2021 and August 21, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 5 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0345 · August 21, 2024 · Grade F — Have approved installation, maintenance and testing program for fire alarm systems.
K-0351 · August 21, 2024 · Grade F — Install an approved automatic sprinkler system.
K-0353 · August 21, 2024 · Grade F — Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems
3 citations between March 10, 2021 and August 21, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0918 · May 30, 2024 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0918 · March 10, 2021 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0915 · August 21, 2024 · Grade E — Have proper power supply for life support equipment.
Food, nutrition, and hydration
2 citations between March 10, 2021 and August 21, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0812 · August 21, 2024 · Grade F — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-0812 · March 10, 2021 · Grade D — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Egress
2 citations between October 24, 2022 and August 21, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0291 · August 21, 2024 · Grade F — Install emergency lighting that can last at least 1 1/2 hours.
K-0211 · October 24, 2022 · Grade D — Keep aisles, corridors, and exits free of obstruction in case of emergency.
Fire, smoke, and emergency safety
2 citations between March 10, 2021 and May 30, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
E-0041 · May 30, 2024 · Grade F — Implement emergency and standby power systems.
E-0004 · March 10, 2021 · Grade C — Develop and maintain an Emergency Preparedness Program (EP).
Services
1 citation between August 21, 2024 and August 21, 2024. The most serious was graded F (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · August 21, 2024 · Grade F — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Resident rights
8 citations between March 10, 2021 and June 12, 2025. The most serious was graded E (potential for more than minimal harm). 2 of these citations came out of complaint investigations. Correction record: 8 citations show a recorded correction date.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0628 · June 12, 2025 · Grade E — Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F-0627 · June 12, 2025 · Grade D — Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
F-0550 · August 21, 2024 · Grade D — Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Assessments and care planning
3 citations between March 10, 2021 and February 26, 2026. The most serious was graded E (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 3 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0655 · February 26, 2026 · Grade E — Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F-0655 · August 21, 2024 · Grade D — Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F-0656 · March 10, 2021 · Grade D — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services
2 citations between August 21, 2024 and September 5, 2025. The most serious was graded E (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
F-0947 · August 21, 2024 · Grade E — Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F-0725 · September 5, 2025 · Grade D — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Miscellaneous
2 citations between October 24, 2022 and August 21, 2024. The most serious was graded E (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0761 · August 21, 2024 · Grade E — To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K-0753 · October 24, 2022 · Grade D — Have restrictions on the use of highly flammable decorations.
Physical environment and safety
1 citation between September 5, 2025 and September 5, 2025. The most serious was graded E (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 1 citation shows a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0925 · September 5, 2025 · Grade E — Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Medication and pharmacy services
2 citations between March 10, 2021 and October 24, 2022. The most serious was graded D (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0761 · October 24, 2022 · Grade D — 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.
F-0760 · March 10, 2021 · Grade D — Ensure that residents are free from significant medication errors.
Infection prevention and control
1 citation between August 21, 2024 and August 21, 2024. The most serious was graded D (potential for more than minimal harm). Correction record: 1 citation shows a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · August 21, 2024 · Grade D — Provide and implement an infection prevention and control program.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Aspire At Evans appears in CMS data on 14 survey dates between March 10, 2021 and July 20, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
July 20, 2026
Complaint health survey — 1 citation, worst grade G (actual harm)
February 26, 2026
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
September 5, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
July 7, 2025
Complaint health survey — 1 citation, worst grade G (actual harm)
June 12, 2025
Complaint health survey — 4 citations, worst grade G (actual harm)
January 9, 2025
Complaint health survey — 1 citation, worst grade E (potential for more than minimal harm)
August 21, 2024
Health survey including complaint investigations — 11 citations, worst grade G (actual harm)
August 21, 2024
Fire-safety survey — 8 citations, worst grade F (potential for more than minimal harm)
May 30, 2024
Fire-safety survey — 2 citations, worst grade F (potential for more than minimal harm)
April 2, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
October 24, 2022
Standard health survey — 3 citations, worst grade E (potential for more than minimal harm)
October 24, 2022
Fire-safety survey — 2 citations, worst grade D (potential for more than minimal harm)
March 10, 2021
Standard health survey — 10 citations, worst grade E (potential for more than minimal harm)
March 10, 2021
Fire-safety survey — 3 citations, worst grade F (potential for more than minimal harm)
Penalties imposed
June 12, 2025 — Fine of $29,819
August 21, 2024 — Fine of $10,033
August 21, 2024 — Fine of $10,176
August 21, 2024 — Payment denial · Medicare/Medicaid payments denied for 17 days from October 31, 2024
Payment denials are the stronger federal sanction: CMS stops paying for new admissions until the home corrects the problems. Aspire At Evans has 1 denial period on record totalling 17 days.
How Aspire At Evans compares with peer homes
Raw citation counts mean more in context. The table below compares Aspire At Evans with the median reviewed facility in Lee County (8 homes in this research set) and across Florida (156 homes), using the same CMS data. On health citations alone, Aspire At Evans sits above 71% of its reviewed county peers — in the worse half of the county.
Measure
Aspire At Evans
Lee Co. median
Florida median
Health citations on record
36
32
30
Citations from complaint investigations
13
9
7
Citations at actual-harm level or worse
4
5
3
Immediate-jeopardy citations
0
4
2
Total fines in CMS penalty records
$50,028
$103,824
$59,961
Penalty records (fines + payment denials)
4
3
2
What families should ask Aspire At Evans
- Ask why CMS flags Aspire At Evans with its abuse icon, which citations produced the flag, and what staffing or supervision changes followed.
- Ask for the plan of correction and follow-up monitoring for the quality of life and daily care citations — most recently F-0689 on August 21, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the freedom from abuse, neglect, and exploitation citations — most recently F-0600 on June 12, 2025 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the food, nutrition, and hydration citations — most recently F-0812 on August 21, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the resident rights citations — most recently F-0628 on June 12, 2025 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 3 totalling $50,028, the most recent dated June 12, 2025 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Aspire At Evans first document the change?
- Were recent complaint-related citations at Aspire At Evans connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
106000
Legal business name
EVANS AVENUE OPCO LLC
Ownership type
For profit - Corporation
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
December 14, 1998
Chain name
AVIATA HEALTH GROUP
Certified beds
120
Average residents per day
103.3
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
2 star
Reported nurse staffing hours per resident day
3.37370
Total nursing staff turnover
42.6%
Public records are a starting point, not a conclusion
This profile of Aspire At Evans uses official CMS provider data as a research starting point. It does not state that Aspire At Evans abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Legal help resource
Suspect nursing home abuse or neglect?
Public records are only part of the picture. If your family believes a Florida nursing home harmed your loved one, you can speak with a nursing home abuse lawyers in Florida about what happened and what options your family may have. Senior Justice Help is not a law firm and is not affiliated with any law firm; this link is provided as a resource only.
Injury and neglect guides
When a Florida care injury may involve negligence
Inspection records show what regulators found; they do not by themselves prove a legal claim. If your family is looking back at a serious injury or death in a Florida nursing home or care facility, these guides explain the deadlines, procedures, records, and questions that apply in Florida:
- Stroke misdiagnosis lawyer information in Florida
- Falls and fractures in Florida care facilities: legal information
- Pressure injuries and bedsores: Florida legal information
- Sepsis from infection in Florida care facilities: legal information
- Medication errors in Florida care facilities: legal information
- Wrongful death in a Florida care facility: legal information
Sources for Aspire At Evans
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.