Life Care Center Of Altamonte Springs
989 Orienta Ave, Altamonte Springs, FL 32701 · For profit - Corporation · 228 certified beds · (407) 831-3446 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 6 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- about 20% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.5% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.1% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.2% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.4% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.7% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.2% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.5% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.1% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.4% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.9% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.72 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 386 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 83.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 111 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.9%CMS range 54.0–62.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 7.7–13.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 83.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 76.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 73.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.9%CMS range 6.5–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 228 beds and averages 211.7 residents a day — about 93% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.59 hrs/resident/day on weekends vs 4.23 on weekdays — 15% thinner on weekends. RN hours go from 0.79 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 18 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · K2023-08-18 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide post fall neurologic assessment and monitoring, failure to immediately notify the physician of changes in condition post fall, (#4); failure to implement fall management protocols to ensure residents received necessary care, equipment, and services to prevent falls and avoid major injuries; and failure to maintain processes that supported effective interdisciplinary team (IDT) functions to meet the safety and care needs for 6 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). These failures contributed to falls with major injuries for residents #1 and #9, who required hospitalization, surgery, and rehabilitation for hip fractures. There was likelihood residents #1 and #9 suffered excruciating pain, were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain. On [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2023-08-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and implement effective fall prevention approaches including equipment, adequate assistance, and increased supervision for vulnerable, physically and cognitively impaired residents, to avoid falls and falls with injuries for 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). This failure contributed to numerous unwitnessed falls which resulted in injuries such as fractures, head injuries, and lacerations. There was likelihood residents #1 and #9 who sustained hip fractures suffered excruciating pain, and were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain. Between 3/01/23 and 8/16/23, the facility recorded 221 falls, of which 190 were unwitnessed. Resident #1 fell four times during self-transfers without necessary staff assistance and supervision. She suffered a hip fracture as a result of the fourth fall. Resident #9 fell nine times,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2023-08-18 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility's administration failed to recognize and address trends related to repeated unwitnessed falls and fall-related injuries; and failed to direct its resources to provide adequate clinical oversight of the fall incident review process and implementation of fall management protocols to ensure the safety and well-being of 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). These failures contributed to falls with major injuries for residents #1 and #9, who required hospitalization, surgical intervention, and rehabilitation for hip fractures. There was likelihood residents #1 and #9 suffered excruciating pain, and were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain; and likelihood residents #8, #11, and #12 would suffer repeated falls with injuries. Between 3/01/23 and 8/16/23, the facility recorded 221 falls, of which 190 were unwitnessed. Resident #1 fell four times during self-transfers without necessary staff assistance and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-08-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure licensed nurses provided neurological assessments after an unwitnessed fall and failed to ensure licensed nurses notified a physician of changes in condition post-fall per professional standards of practice for post fall monitoring for 1 of 8 residents reviewed for falls, of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found her notified assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injuries, no change in range of motion and was to have continued monitoring. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor of the physician or family being notified after the fall. The next day, at the end of her night shift on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2023-08-18 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure licensed and agency nurses were knowledgeable and competent in initiating and performing neurological assessments after an unwitnessed fall, and in notifying the physician and oncoming staff of a resident's fall and changes in condition for 1 of 8 residents reviewed for falls of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found resident #4 notified assigned Registered Nurse (RN) H of resident #4's fall. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injury, no change in range of motion and for continued monitoring, although there was no documentation that specified what monitoring was to be continued. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-08-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the medical record was complete and accurate and included post fall reporting, notifying and monitoring for 1 of 8 residents reviewed for falls, of a total sample of 13 residents (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found her notified assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injuries, no change in range of motion and was to have continued monitoring. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor of the physician or family being notified after the fall. The next day, at the end of her night shift on [DATE] at 7:55 AM, RN F documented resident #4's CNA had stated she was not herself, had a headache and was alert, but confused. RN F…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-08-21 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide timely assessment, treatment, and management of pain for 1 of 1 resident reviewed for pain, of a total sample of 63 residents, (#228). The facility's failure to follow the physician's orders and treat pain and discomfort resulted in actual harm.Findings:Review of the medical record revealed resident #228 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of the third lumbar vertebra, low back pain, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/11/25 revealed resident#228's Brief Interview for Mental Status score was 15 out of 15 indicating intact cognition. The MDS assessment noted no behaviors or rejection of evaluation or care necessary to obtain goals for health and well-being. The MDS assessment noted she received PRN (as needed) and scheduled pain medications in the last five days. The assessment noted pain was present daily, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-08-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound treatments as ordered by the physician and failed to notify the physician of lab results in a timely manner for wound infection for 1 out of 3 residents reviewed for wound care of a total sample of 13 residents, (#2). Findings: Resident #2 was re-admitted to the facility on [DATE] with diagnoses that included fracture to the right leg with surgical repair, dementia with mood disturbance, and contractures of both knees. The Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed resident #2 had moderately impaired cognition and no behavioral symptoms during the look back period. The MDS assessment for skin conditions indicated resident #2 had surgical wounds, moisture associated skin damage and an unhealed pressure ulcer. The skin assessment indicated resident #2 had one unstageable suspected deep tissue injury in process that was not present upon admission or re-entry to the facility. Review of the undated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report an allegation involving serious bodily injury and an injury of unknown source to the state Agency for Health Care Administration (AHCA) within the required timeframes for 1 of 2 residents reviewed for abuse, of a total sample of 5 residents, (#1).Findings: Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, muscle weakness, lack of coordination, abnormalities of gait and mobility, history of falls, and mild cognitive impairment. Resident #1 was transferred to the hospital on 5/16/26 due to chest pain and readmitted to the facility on [DATE]. Upon readmission, new diagnoses included multiple right rib fractures, Alzheimer's disease, and dementia. Review of the hospital Discharge summary dated [DATE] revealed diagnoses including multiple right rib fractures. The hospital course documented the resident was admitted from a skilled nursing facility with chest pain.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview, the facility failed to thoroughly investigate and document a skin injury that occurred for 1 of 3 residents sampled for non-pressure related skin conditions, (#124), of a total sample of 63 residents.Findings:Review of resident #124's medical record revealed an admission date of 3/27/25. Her diagnoses included rheumatoid arthritis, unspecified; other lack of coordination, unspecified abnormalities of gait and mobility, and hemiplegia (paralysis) and hemiparesis (muscle weakness) following nontraumatic intracerebral hemorrhage (stroke) affecting left dominant side. Review of resident #124's Quarterly Brief Interview for Mental Status (BIMS) score dated 6/30/25 was a 12/15, which indicated moderate cognitive impairment. Review of the facility's incident list revealed resident #124 sustained a skin related injury incident on 4/15/25.Review of the skin related injury incident dated 4/15/25 at 6:55 PM, revealed the description indicated it occurred around 4:55 PM, when the nurse was asked by a certified nursing assistant (CNA) to assess resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the medical record reflected the correct site for blood pressure (BP) measurement for 1 of 2 residents reviewed for dialysis, of a total sample of 63 residents, (#10).Findings: Review of the medical record revealed resident #10 was admitted to the facility on [DATE] with diagnoses including end stage renal disease requiring dialysis, type 2 diabetes, and bacteremia. Review of the Order Summary Report revealed a physician order dated 1/07/25 which included resident #10 received dialysis on Monday, Wednesday, and Friday and specified no BP on the right arm with fistula/shunt. Review of the Blood Pressure Summary report from 7/19/25 to 8/19/25 revealed documentation of BP obtained on the right arm 13 times: 7/19/25 at 3:10 PM, 7/22/25 at 9:00 PM, 7/25/25 at 6:07 PM, 7/26/25 at 9:21 AM, 7/26/25 at 5:47 PM, 7/27/25 at 9:41 AM, 8/02/25 at 9:38 AM, 8/02/25 at 4:56 PM, 8/03/25 at 5:31 PM, 8/08/25 at 9:01 PM, 8/10/25 at 4:00 PM, 8/18/25 at 9:04 PM, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was able to call for staff assistance through a call bell system for 1 of 1 resident reviewed for call bells, of a total sample of 63 residents, (#229).Findings: Review of resident #229's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included secondary malignant neoplasm of the brain, mobility abnormalities, muscle weakness, need for assistance with personal care, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 8/06/25 revealed resident #229's Brief Interview for Mental Status score was 14 out of 15 which indicated she was cognitively intact. The MDS assessment noted no behaviors or rejection of evaluation or care necessary to obtain goals for health and well-being. The assessment showed no vision, hearing or speech impairment. Resident #229 had functional limitation in range of motion (ROM) on an upper extremity and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-16 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide documented evidence that grievances were resolved promptly, and residents/family members were apprised of progress toward a resolution of grievances for 1 of 3 residents reviewed for grievances, of a total sample of four residents, (#2).Resident #2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, muscle weakness, abnormalities of gait and mobility, depression, dependence on supplemental oxygen and need for assistance with personal care. Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 14/15 which indicated she was cognitively intact. The assessment indicated she needed substantial to maximum assistance from the staff to perform her activities of daily living, was frequently incontinent of urine and occasionally of bowel. On 7/15/25 at 9:30 AM, resident #2 was sitting up in bed, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer Oxygen (O2) therapy as ordered by the physician for 2 of 2 residents reviewed for respiratory care, of a total sample of 4 residents, (#2 and #4).1. Resident #2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), muscle weakness, hypertension, dependence on supplemental oxygen and need for assistance with personal care. Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date (ARD) of 6/03/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated she was cognitively intact. The MDS assessment noted the resident required substantial to maximum staff assistance with dressing/personal hygiene care and received oxygen therapy. The assessment also noted the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and wellbeing. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-17 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the acquisition and/or timely administration of physician-ordered medications for 2 of 4 residents reviewed for medication administration, out of a total sample of 8 residents, (#1 and #3). Findings: 1. Review of the medical record revealed resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included peptic ulcer disease, difficulty swallowing, and gastrostomy status. Resident #1 was discharged home on 7/16/24. A peptic ulcer is an open sore found on the lining of the stomach or in the first section of the small intestine. These ulcers are often caused by an overproduction of stomach acid and common treatment options focus on medications that reduce the production of stomach acid (retrieved on 7/25/24 from www.hopkinsmedicine.org/health/conditions-and-diseases/peptic-ulcer-disease). A gastrostomy is a surgical procedure in which a tube is inserted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-17 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medical record accurately represented medication administered for 1 of 4 residents reviewed for medication administration, out of a total sample of 8 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included peptic ulcer disease, difficulty swallowing, and gastrostomy status. Review of resident #1's Order Summary Report for July 2024 revealed a physician order dated 7/01/24 for Protonix Oral Delayed Release 20 milligrams (mg) once daily for acid reflux. Review of the pharmacy's Proof of Delivery form for resident #1 for the period 6/01/24 to 7/16/24 revealed Protonix 20 mg was never shipped to the facility. Review of the resident #1's Medication Administration Record (MAR) for July 2024 revealed the physician order for Protonix Oral Delayed Release 20 mg was transcribed to the document and scheduled for daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-18 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement its policies and procedures to prohibit Neglect related to conducting thorough incident investigations and/or reporting fall-related injuries for 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12); and failed to ensure Risk Management processes included identification of potential Neglect for all residents in the facility who were at risk for falls. Findings: Cross reference to F600, F684, F689, F726, F835, F842 Review of the facility's incident log from 3/01/23 to 8/16/23 revealed there were 221 resident falls reported in less than six months, and at least seven resulted in major injuries. The log showed 190 of the total falls were unwitnessed by staff. Review of the facility's reportable incident log from March to August 2023 revealed no documentation to show identification and investigation of potential neglect related to unwitnessed falls for resident #9's fall with hip fracture on 5/20/23, resident #11's fall with leg fracture on 7/08/23, resident #1's fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement person-centered care plans to provide care and services deemed necessary for the health and well-being of 2 of 4 residents reviewed for falls, of a total sample of 7 residents, (#20 and #22). Findings: 1. Review of the medical record revealed resident #20 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, a history of falling, unsteadiness on her feet, and difficulty walking. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 9/06/23 revealed resident #20 required limited assistance from one staff member for bed mobility, transfers, walking, and toilet use. The MDS assessment showed the resident had unsteady balance, was only able to stabilize with staff assistance, and used a walker and wheelchair for mobility. Resident #20 had two or more falls with no injuries and one fall with an injury since admission or the prior assessment. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 10 citations
- Potential for harm · E2021-12-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a home like environment for comfortable television viewing for 2 of 5 sampled residents of a total of 63 residents, (#34 and #94). Findings: On 11/29/21 at 11:30 AM, residents #34 and #94 were in their room watching television (TV). Both TVs were noted to have fuzzy to snow like picture on all channels. Both residents stated they were not satisfied with the picture quality on their televisions and noted the fuzzy picture quality had been like this since they came to this room in August 2021. Resident #34 recalled the maintenance staff had tried to fix the TVs and replaced lines outside which did not improve the situation to date. On 11/30/21 at 10:33 AM, residents #34 and #94 were observed in their room watching television with snowy/fuzzy picture. Resident #34 stated he liked to watch basketball and football but did not enjoy the games on his present TV. Resident #94 changed the channels on his TV that showed all channels were fuzzy and some of the higher channels were difficult to see at all. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-02 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident had been assessed to safely self-administer medications out of a total sample of 63 residents, (#58). Findings: Review of resident #58's medical record (MR) documented she was admitted to the facility on [DATE] with diagnoses including Hypertension, Chronic Pain, Hyperlipidemia, Osteoporosis, Vitamin D Deficiency, Hypothyroidism, and Depressive Disorder. The MR contained no Self-Administration of Medication Assessment. On 11/29/21 10:45 AM, a plastic cup that contained several medication tablets was noted on the resident's bedside table. On 11/29/21 at 11:00 AM, the B Wing Unit Manager (UM) stated there were no residents on the B Wing who were able to self-administer their own medications. The UM acknowledged there were 12 medication tablets in a cup on the resident's bedside table. She stated, Medications are never to be left at a resident's bedside. On 11/29/21 at 11:15 AM, Licensed Practical Nurse (LPN) B stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-02 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers as per resident's preference for 1 of 4 residents reviewed for choices of a total sample of 63 residents, (#26). Findings: Resident #26 was admitted to the facility on [DATE] with diagnoses of stroke, encephalopathy, Parkinson's Disease, muscle weakness and diabetes type II. The resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date 8/23/21, revealed the resident's cognition was moderately impaired, with a Brief Interview of Mental Status score of 10/15. The assessment noted the resident did not reject care, required extensive assistance from staff for bed mobility, dressing, personal hygiene, and was totally dependent on staff for toilet use and bathing. On 11/29/21 at 11 AM, resident #26 said she received bed baths and had not received showers twice per week as per her preference. Resident #26 pointed to a sign on the wall across from her bed that indicated she was to have showers on Monday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) related to hair and nail care for 2 of 7 residents reviewed for ADLs, of a total sample of 63 residents, (#121 and #14). Findings: 1. Resident #121 was admitted to the facility on [DATE] with diagnoses including paralysis, stroke, dementia and muscle weakness. The Minimum Data Set (MDS) Significant Change in Status assessment with Assessment Reference Date (ARD) of 10/11/21 revealed resident #121 had severely impaired cognitive skills for daily decision making. The MDS assessment indicated resident #121 did not reject care that was necessary for her health and well-being. The resident had functional limitation in range of motion in all extremities, and was totally dependent on staff for personal hygiene including combing her hair. Review of resident #121's care plan for ADL deficits, initiated on 4/23/21, revealed a goal that the resident would maintain a sense of dignity by being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for skin rash (#30) and failed to identify and report bruises and skin tears of unknown origin (#39) for 2 of 3 residents reviewed for non-pressure related skin conditions out of a total sample of 63 residents. Findings: 1. Review of resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus (DM), Major Depressive Disorder, Psychosis, Delusional Disorders and Anxiety. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] documented she was cognitively intact and needed supervision with her personal hygiene and bathing. Review of the resident's care plan dated 04/10/20 revealed she was at risk for impaired skin. Interventions included to observe skin integrity during care, report any new areas of abnormalities to nurse including but not limited to (skin tears, cuts, lacerations, rashes, redness, bruises). The Activities of Daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent complications related to an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheters, of a total sample of 63 residents, (#90). Findings: Resident #90 was admitted to the facility on [DATE] with diagnoses including chronic urinary retention, enlarged prostate, and need for assistance with personal care. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 9/17/21 revealed resident #90 had a Brief Interview for Mental Status score of 8 which indicated he had moderate cognitive impairment. The resident required extensive assist for bed mobility, toilet use and personal hygiene, and did not reject evaluation and care. The MDS assessment showed he had an indwelling catheter. An indwelling urinary catheter is a tube inserted through the urethra into the bladder. Urine drains freely from the bladder through tubing attached to a urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide appropriate care and service for oxygen therapy for 3 of 6 residents reviewed for respiratory care out of 63 sampled residents, (#439, #135, #25). Findings: 1. Resident #439 was most recently admitted to the facility on [DATE] from an acute care hospital with diagnoses including chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), and dependence on supplemental oxygen. On 11/29/21 at 12:29 PM, resident #439 was in her room and wore a nasal cannula connected to a concentrator set to deliver oxygen (O2) at 2 liters per minute (L/min). On 11/29/21 at 4:35 PM, resident #439 was in her wheelchair across from the D Wing nurses' station. She wore a nasal cannula connected to a concentrator set to deliver oxygen at 2 L/min. On 11/29/21 at 4:39 PM, Registered Nurse (RN) Y stated resident #439 should be on 2 liters of oxygen. She explained nurses knew the required oxygen flow rate from the physician's orders. RN Y…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-02 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately manage pain for 1 of 1 resident reviewed for pain management out of a total sample of 63 residents, (#126). Findings: Resident #126 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, major depressive disorder and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment with assessment reference date 10/13/21 revealed resident #126 had moderately impaired cognition and received scheduled pain medication due to frequent, moderate pain. A review of the current physician's orders dated 01/14/21 read, Lidoderm Patch 5% (Lidocaine), apply to left shoulder topically in the morning for shoulder pain. The Nursing Pain Evaluation Tool dated 04/17/21 indicated resident #126 had pain level of 3 on left shoulder, making the pain worse upon movement. It also indicated pain medication or pain patch would make the pain better. On 11/29/21 at 10:10 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medical record accurately reflected the resuscitation status for 1 of 1 resident reviewed for Advanced Directives of a total sample of 63 residents, (#439). Findings: Resident #439 was re-admitted to the facility on [DATE] from an acute care hospital with diagnoses including chronic lung disease, diabetes, and chronic respiratory failure. Review of resident #439's Minimum Data Set (MDS) admission assessment with Assessment Reference Date of 11/17/21 revealed she had a Brief Interview for Mental Status score of 8 which indicated moderate cognitive impairment. A care plan for Advanced Directives related to cardiopulmonary resuscitation or full code, initiated on 11/12/21 revealed resident #439 had a goal for her Advanced Directives to be honored. Interventions included a quarterly review of her code status and more often as needed. The care plan reflected a decision for full code status. Review of resident #439's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent the potential for infection by failing to practice proper hand hygiene and donning of gloves when administering eye drops for 1 of 3 residents reviewed for medication administration, (#120). Findings: On 11/30/21 at 9:15 AM an observation was conducted during medication administration with Registered Nurse (RN) N and resident #120. RN N prepared total of 9 by mouth (PO) and 1 eye drop medication. The nurse entered the room and identified the resident who was alert and able to take the oral medications without any difficulty. RN N then proceeded to give the eye drop medication/artificial tears 1 drop to each eye. RN N performed hand hygiene upon entry to the room but she did not don gloves between giving the oral medications and the eye drops. She used her bare hands to keep the resident's right eye open and instilled 1 drop into the right eye and then did the same on the left. On 11/30/21 at 11:01 AM, an interview was conducted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PRESTON, FORREST | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/06/1976 |
| GONZALEZ, FRANCISCO | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/04/2025 |
| MOORMAN, TERESITA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2005 |
| PRESTON, AARON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 11/01/2018 |
| FLETCHER, TODD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2021 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2022 |
| ZIEGLER, JAMES | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 08/16/1999 |
| CROSS, CINDY | Individual | CORPORATE OFFICER; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/21/1994 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/15/1976 |
| CHAUDHRY, AZHAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2022 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 11/27/2024 |
CMS files one row per role, so the 33 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.3M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105365. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.