Complaint Investigation

Aspire At Evans

February 26, 2026 · Fort Myers, FL · 3735 Evans Ave

Citations 2

CMS Rating 1/5

Beds 120

Provider ID 106000

Healthcare Facility

Aspire At Evans

Fort Myers, FL · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

ASPIRE AT EVANS in FORT MYERS, FL — inspection on February 26, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0655

Resident Assessment and Care Planning Deficiencies

applicable, and other areas needed to provide effective care of the resident that met professional

Care Plan, she confirmed they were incomplete and did not identify the required goals and their

Care was completed for that resident.

106000 02/26/2026

Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901

FF0825

Quality of Life and Care Deficiencies

residents reviewed with admission orders for an occupational, physical, and speech therapy

physician to evaluate the need for therapy and to treat as indicated by the assessment.

The findings included:On 2/25/26 a review of Resident #1's medical record revealed the Medical Certification for Medicaid Long-Term Care and Services and Patient Transfer Form dated 1/14/26 stated Resident #1's primary diagnosis at the time of discharge from the hospital was a closed head injury and he was being discharged to a skilled facility for rehabilitation. Resident #1 was transferred to the skilled nursing facility on 1/15/26 with Physician Orders dated 1/16/26, for occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated. On 2/25/26 at around 11:30 a.m. in a phone interview with Resident #1's daughter, she said her father was admitted to the hospital after falling at home and was discharged to the skilled nursing facility to receive rehabilitation therapy prior to going home but was informed by Resident #1 and her mother, the rehabilitation therapy would not be started until 2/02/26. On 2/25/26 at 12:35 p.m. in an interview with the Director of Therapy, she confirmed Resident #1 was admitted to the facility on [DATE] with physician orders dated 1/16/26 for occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated.

She said when a resident was admitted to the facility with orders for a therapy evaluation and treatment, the therapy department would normally complete the ordered evaluation within 48 hours.

She said they had conducted a wheelchair evaluation for Resident #1 on 1/16/26 and provided him with a wheelchair on 1/16/26.

She said they did not conduct a therapy evaluation for physical, occupational, and speech therapy as ordered on 1/16/26 but had scheduled those evaluations to be completed on 2/02/26.

She said she had spoken to Resident #1 and his wife after his admission to the facility, and they agreed to conduct Resident #1 physical, occupational, and speech therapy evaluations on 2/02/26.

She said the physical, occupational and speech therapy evaluations were not completed on 2/02/26 because Resident #1 was sent to the hospital on 2/02/26 for a change in mental status.

She confirmed the therapy evaluations were not conducted as ordered on 1/16/26.On 2/25/26 at 1:35 p.m. in an interview with the Director of Nursing (DON), she confirmed Resident #1 was admitted to the facility on [DATE] after having a fall at home in December 2025.

She confirmed Resident #1 had physician orders dated 1/16/26 to include occupational therapy, physical therapy, and speech therapy evaluations and to treat as indicated which were acknowledged by Resident #1's primary care physician on 1/21/26.

She confirmed Resident #1's Physician Orders for occupational therapy, physical therapy, and speech therapy evaluations were not completed as ordered by the physician.

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORT MYERS, FL, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ASPIRE AT EVANS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.