Regents Park At Aventura
18905 NE 25th Ave, Aventura, FL 33180 · For profit - Corporation · 180 certified beds · (305) 932-6360 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $64,981 in federal fines (most recent 2024-08-01)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 19% 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 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 | 4 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 improved from 1 to 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 | 3.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.9% | 5.5% | 5.4% | typical |
| 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 | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.4% | 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 | 3.3% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 2.4% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.0% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 3.3% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.1% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.76 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.59 | 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.
37.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 196 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 74.5% 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 145 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 0.56 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% 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 | 37.7%CMS range 28.0–47.7 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 8.2–13.4 | 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 | 74.5% | 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 | 76.5% | 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 | 56.5% | 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 | 95.8% | 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 | 1.1% | 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 | 8.6%CMS range 5.9–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.35 | 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 180 beds and averages 173.8 residents a day — about 97% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 is below 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 3.20 hrs/resident/day on weekends vs 3.63 on weekdays — 12% thinner on weekends. RN hours go from 0.58 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 19% 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 fewer than at the previous inspection — improving. 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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · J2024-09-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, interviews and record review the facility failed to protect Resident #1's right to be free from Neglect by the facility's staff. Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to safely transfer Resident #1 from her bed to the chair with a Mechanical Lift. The facility neglected to effectively inspect and operate the Mechanical Lift in a safe manner during the transfer of Resident #1. This failure to operate the mechanical lift in a safe manner on [DATE] at 9:57 AM Staff A and Staff B who reported that during the transfer the Mechanical lift kept rising and when Staff B grabbed the lift pad to stop it from going higher Resident #1 suddenly fell from the Mechanical lift and landed face down on the floor sustaining injuries to her head. Resident #1 expired at the hospital approximately four hours later. There were 60 residents residing in the facility that required use of a mechanical lift for transfer. Refer to F 689, F 867, and F 908. The findings included: 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.
- Immediate jeopardy · Jcited before2024-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, interviews and record review the facility's Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to ensure Resident #1 was safely transferred from the bed to the chair with a mechanical lift. The facility failed to effectively inspect, complete accurate safety check and maintain the mechanical lift to ensure it is safely operating during the transfer of Resident #1. This failure to ensure the mechanical lift is operating in a safe manner resulted in Resident # 1 falling from the mechanical lift on [DATE] at 9:57 AM while Certified Nursing Assistants (CNAs) Staff A and Staff B were transferring Resident #1 from bed to chair, Staff A and Staff B reported that during the transfer the mechanical lift kept rising and when Staff B grabbed the lift pad to stop it from going higher, Resident #1 suddenly fell from the lift and landed face down on the floor sustaining injuries to the head. Resident # 1 expired at the hospital approximately four (4) hours after the fall. There were 60…
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 before2026-01-08 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the staff failed to keep residents' information confidential at one of the two nursing stations on the second floor. As evidenced by an unattended computer with an open screen displayed a resident's confidential health care information at the 2 [NAME] Nursing station. There were 173 residents residing in the facility at the time of the survey. The findings include.Observations on 01/06/2026 at 12:56 PM revealed an unattended computer with the screen open displaying residents' health care information at the 2 west Nursing Station. (Photographic evidence). Interview on 01/07/2026 at 09:30 AM, Staff B, Licensed Practical Nurse (LPN), stated, I understood HIPAA (Health Insurance Portability and Accountability Act) as it is related to protecting the privacy of patient information. Patient confidentiality mean not discussing resident information over the phone and only sharing information with individuals who were authorized and listed in the chart. When walking away from a computer, I made sure it was not left open or visible to…
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 before2025-11-05 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to provide adequate privacy during hygiene and catheter care for one resident (Resident #7) out of three residents sampled with an indwelling urinary catheter. Resident #7's roommate entered the room while Resident #7 was exposed. At the time of the survey, nine residents with an indwelling urinary catheter resided in the facility. The findings include. During an observation on November 5, 2025, at 9:45 AM, Staff A, Licensed Practical Nurse (LPN), performed hygiene care for Resident #7. The privacy curtain did not completely extend around the bed, leaving Resident #7 exposed. Additionally, the roommate entered the room while care was ongoing.In an interview conducted on November 5, 2025, at 12:33 PM, Staff A, LPN, was asked about the facility's protocol related to providing privacy during personal care. Staff A acknowledged, I was aware that the curtain did not extend around the resident, but I did not want to stop because I did not want the resident to refuse care.During an interview on November 5, 2025, 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.
- Potential for harm · D2025-11-05 · 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 observations, record review and interviews facility failed to provide appropriate catheter care to facilitate the flow of urine for one (Resident#7) out of three sampled residents who had indwelling urinary catheter, as evidenced by during catheter care Resident#7's indwelling urinary catheter drainage collection bag and tubing were positioned on top of bed with backflowing urine noted in the tubing. This deficient practice prevented the free flowing of urine that would be accumulated in the bladder causing discomfort and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were nine residents with indwelling urinary catheters residing in the facility at the time of this survey.The findings include. During an observation on 11/05/25 at 9:45 AM, Staff A, a Licensed Practical Nurse (LPN), performed hygiene and catheter care for Resident #7. The urinary drainage bag and tubing noted with urine were positioned on the bed next to the resident's feet in…
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 before2024-09-19 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F689-Free of Accident Hazards/Supervision/Devices. As evidenced by: F689 was cited during a complaint survey ending 12/14/23 when the facility failed to provide adequate supervision and additional interventions to ensure the safety of vulnerable residents and to prevent repeated falls that resulted in injuries and during the recertification survey with exit dated 08/21/24 razors were observed on Resident #382 's nightstand The findings included: Record review of the facility's survey history revealed, during a recertification conducted on July 29, 2024, through August 1, 2024, at the facility, F689-Free of Accident Hazards/Supervision/Devices was cited as the facility failed to ensure resident's room was free of accident hazards (razors at bedside) for 1 of 40 sampled residents (Resident #382). Review of the facility policy and procedures titled…
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 · Fcited before2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with 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, it was determined that the facility failed to store prepare, distribute and serve food in accordance with professional standards for food service safety that potentially effects 164 of the facility residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 07/29/24 at 9:00 AM and accompanied with the facility's Food Service Director (FSD), the following were noted: (a) A large section of the ceiling (8 feet) was noted to be dripping heavily on to the floor area in front of food production table/surfaces and reach-in refrigerators (3). The floor covered in a large area of contaminated water. It was noted that staff were walking through the water and cases of recent food deliveries were also in contact with the water. The FSD stated that the dripping ceiling water was from broken air-conditioning pipes and had been an issue for the past 2 weeks. The surveyor requested that the cases of food be moved to a safe area…
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 · E2024-08-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, orderly, and comfortable interior on the facility's first floor, second floor residential units, third floor residential units, maintenance department, and laundry area. The findings included: During the initial resident screenings conducted by the surveyors on 07/29/24 to 7/30/24 and environment rounds conducted on 07/31/24 and 08/01/24 accompanied with the facility's Director Of Housekeeping and Corporate Director of Housekeeping, the following were noted: 1) First Floor: Hallway - Ceiling mounted air -conditioning vents (4) noted to be covered with condensation and dripping onto hallway floor near skilled therapy department. Maintenance Department - During the 08/01/24 tour it was noted that the entry door to the room was proper fully open and no staff within the room and area. Noted that residents have access to hallway where 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.
- Potential for harm · E2024-08-01 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that portion sizes documented on the approved menu were not followed and potentially effected 88 of the facility residents with physician ordered Regular diet. The findings included: During the observation of the lunch meal in the main kitchen on 07//31/24 at 11:45 AM, it was noted that the entree serving of roast turkey appeared insufficient. Further observation noted that all of the individual portions of Roast Turkey (approximately 40) located in steam table appeared insufficient. A review of the facility's approved menu for the lunch meal of 07/31/24 noted documentation that a minimum 3-ounce portion of Roast Turkey was to be served. A portion of the Roast Turkey that was plated to be served was selected by the surveyor to be weighed by the Food Service Director (FSD). The turkey portion weighed on the facility's calibrated food scale was recorded at 2.46 ounces. The surveyor reviewed the approved lunch menu with the FSD that indicated a requirement of 3 ounces minimum turkey portion. It was then requested…
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 before2024-08-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 observations, interviews and record review the facility failed to treat residents in a dignified manner who wear adult briefs for 2 out of 40 sampled residents (Residents #72 and Resident #136 and failed to ensure that residents are treated in a dignified manner with bedding while in bed for 1 out of 40 sampled residents (Resident #154) and failed to treat residents in a dignified manner during dining observation (Resident #6). The findings included: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated 03/2020 included in part the following: 8. Ensure the resident receives the proper tray. 11. Allow adequate time that resident requires to complete meal. Do not rush. 12. Allow resident time needed to complete as much as desired of the meal. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity with a revised date of 04/2023 included in part the following: It is the practice of this facility to protect and promote resident rights…
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 · D2024-08-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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, it was determined that the facility failed to provide necessary care and services so that activities of daily living do not diminish for 1 (Resident #64) of 5 sampled resident for nutrition review for independence in self-feeding and 1 (Resident #177) of 1 sampled resident for daily dental care. The findings included: 1) Observation of the breakfast meal on 07/31/24 at 7:45 AM noted breakfast tray delivered to the room of Resident #64. Mechanical Soft tray served and set up on overbed table in front of resident. Resident not positioned and noted to be in almost a lying position in front of the meal tray. Resident noted to be attempting to feed self with hands and spilling foods on chest/gown. Resident unable to reach beverages on tray and could not drink liquids (juices, milk, coffee) provided on the meal tray. Resident noted with no supervision or assistance from staff during the entire meal observation and consumed less than 50% of the meal and 0% of fluids.…
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 before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, interviews, and record reviews the facility failed to ensure resident's room free of accident hazards (razors at bedside) for 1 of 40 sampled residents (Resident #382). The findings included: Review of the facility's policy/procedure titled, Safety Awareness (Sharp Objects) dated 03/01/21 included in part: To ensure the safety and well-being of residents, staff, and visitors by regulating the possession and use of sharp objects and razors within the nursing home facility. For the safety of all individuals within the nursing home, the possession and use of sharp objects and razors by residents are strictly regulated. Sharp objects and razors pose a significant risk of injury and must be managed according to the guidelines outlined below: Definitions: Razors: Bladed instruments used for shaving or cutting hair. Guidelines: 1. Prohibited items: Residents are not permitted to possess or use sharp objects or razors independently within the nursing home. Sharp objects and razors include, but are…
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 15 citations
- Potential for harm · D2024-08-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 observations, interviews, and record review the facility failed to monitor weights and identify weight loss in a timely manner for 1 of 10 residents sampled for nutrition (Resident #162). The findings included: Review of the facility's policy titled, Weights (Nutrition) dated 03/01/21 included in part the following: It is the policy of the facility to obtain a weight on all residents at set time intervals and per resident need (daily, weekly, monthly). All residents will be weighed within 24 hours of admission or re-admission and weekly thereafter for an additional 3 weeks, for a total of 4 weeks. The dietician will determine which residents have had a significant weight change (>/= 5% loss/gain in 1 month and /or >/= 10% loss/gain in 6 months) and a clinical nutrition weight evaluation note will be written in the EMR (Electronic Medical Record). Record review for Resident #162 revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included: Cerebral Atherosclerosis,…
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 before2024-08-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
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 observations, interviews, and record reviews the facility failed to ensure medications secured in med room for one of two med rooms observed and failed to secure medication for 3 of 40 sampled residents (Resident #136, Resident #120, and Resident #382.) The findings included: Review of the facility's policy titled, Labeling of Medications Storage of Drugs and Biologicals with an implemented date of 11/28/19 included in part: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. 1 On 07/30/24 at 3:55 PM Staff H Registered Nurse (RN) lead surveyor to show where additional isolation gowns were kept, she entered an unlocked room containing multiple over the counter medications including Acetaminophen, zinc, aspirin, Vitamin B12, and ferrous sulfate, in an unlocked treatment cart in the unlocked medication room containing Hydrocortisone Acetate 1%, and in an adjoining room inside…
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 · D2024-08-01 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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, it was determined that the facility failed to prepare food in a form to designed to meet the individual needs for 31 residents out of which eight included eight sampled residents (Resident #6, Resident #22, Resident #50, Resident #111, Resident #118, Resident #144, Resident #154, Resident #177), and failed to provide 43 residents with physician ordered Mechanical Soft that included sampled Resident #161. The findings included: Review of the facility's Approved Diet Manual (2019) on 07/30/24 noted the following: * Dysphagia Pureed Diet: The diet is used for severe chewing and/or swallowing problems. All foods are pureed to stimulate a a food bolus , eliminating the whole chewing phase. All foods must be the consistency of moist mashed potatoes and/or pudding like consistency. * Mechanical Soft Diet: The diet is used for individuals with mild and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to…
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 before2024-08-01 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) with appropriate plans of action. The facility failed to regularly review and analyze data and act on available data to make improvements regarding 4 out of 4 federal repeated deficiencies (F550, F761, F812 and F867). The findings included: A review of the facility QAPI Plan (no date) revealed the following: We will set short-term achievable goals in quarterly increments to allow review of our progress towards our annual long-term goal. We will continually monitor to sustain the goals we have met. Each Performance Improvement Project subcommittee will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Data will be collected during this process and then analyzed to determine the effectiveness of change. Upon conclusion of each Performance Improvement Project, the subcommittee will provide the QAPI Committee with a summary report, analysis 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 · D2024-08-01 · 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
Based on observations, interview and record review the facility failed to follow facility policy for 2 out of 31 residents on Enhanced Barrier Precautions (EBP) Residents #177 and #69 as evidenced by no isolation gowns at the residents' doors and failed to ensure that food trash/soiled residents food trays are covered during transportation. The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with a revised date of 04/01/24 included in part: EBP is intended for nursing homes to prevent the spread of novel or targeted Multi-Drug Resistant Organism (MDRO)s when resident have an infection or colonization with a MDRO or if the resident has a wound or indwelling medical device, regardless of MDRO infection or colonization. Review of the Center for Disease Control (CDC) guidelines documented, in part, that for residents on EBPs that PPE (gowns and gloves) are to be located at the residents' doors. The CDC website is CDC_Implementation_Of_Personal_Protective_Equipment_(PPE…
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 before2023-03-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review the facility failed to ensure a thermometer was in the ice cream box. This has the potential to affect 154 out of 171 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the facility's Dietary Food Storage Policy and Procedure (no written date) documented: Policy: It is the policy of the facility to provide care and services related to the storage of food in the dietary department in accordance to State and Federal regulation; Procedure: 10) Freezer temperatures will remain below 0 degrees Fahrenheit (F); 11) The use of a thermometer, which shows that the proper temperature is being maintained will be used. Initial kitchen observation of the ice cream box with the Food Service Director (FSD) on 2/27/2023 at 6:54 AM revealed the thermometer missing and two frozen water bottles in the bottom of the ice cream box. Interview with the FSD on 2/27/2023 at 6:55 AM. He stated, The thermometer should be in there and the water bottles should not be in there.
- Potential for harm · Dcited before2023-03-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 observations, record reviews, and interviews, the facility failed to ensure residents are treated with respect and dignity for three residents (Resident #87, Resident #104, Resident #143) out of three residents who were observed during dining, as evidenced by staff members were observed standing while feeding residents. This deficient practice has a potential to affect 24 residents who need assistance with eating of the 154 resident who eat orally. The findings included: 1) During observation on 02/27/2023 at 08:24 AM, Resident #87 was in bed, alert. The Certified Nursing Assistant (CNA), Staff D sanitized her hands then proceeded to set up the resident's breakfast tray, the resident's bed was in a low position and Staff D, CNA was standing up while feeding the resident. When the surveyor asked Staff D if this was how she usually positioned herself to help residents who needed assistance with eating, she stated sometimes this is how I feed the residents, standing up. On 02/28/2023 at 08:09 AM, 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 · D2023-03-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for three (Resident # 133, Resident #143, Resident #122) out of seven residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were a total of 171 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Advanced Directives Policy and Procedures dated 3/01/2021 documented: Policy-It is the policy of this facility to honor Advance Directives in accordance to State and Federal regulations; Procedure: 4) The facility will provide each adult individual, at the time of the admission as a resident, with written information concerning the nursing home's policies respecting advance directives and provide documentation of the existence of an advance directive within the medical record. 1) Record review…
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 · D2023-03-02 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 record review and interview, the facility failed to ensure the electronic transmittal requirements for the Minimum Data Set was implemented related to a resident discharge return not anticipated for 1 (Resident #156) out of 1 sampled for resident assessment. Record review of Resident #156's clinical records revealed the resident was admitted to the facility on [DATE] and discharged to an Acute Care hospital on [DATE]. Medical Diagnoses included, but were not limited to, Sepsis, Unspecified Organism, Type 2 Diabetes Mellitus without Complications, Malignant Neoplasm of prostate, Hypothyroidism Unspecified, Bipolar Disorder, Current Episode Mixed, Unspecified Extended Spectrum Beta Lactamase (ESBL) Resistance, Dysphagia, Oropharyngeal Phase, Other Abnormalities of Gait and Mobility and Fracture of unspecified Metatarsal Bone(s), Left Foot. Review of Resident #156's Care Plan initiated on 09/21/2022 and completed on 10/02/2022 revealed the resident desired to return home. Goal: The resident and his…
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 · D2023-03-02 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II for serious mental illness (SMI) or intellectual disability (ID) was requested at the time of admission for resident one (Resident #94) and Level I PASRR was not completed for six residents (Resident # 21, Resident # 133, Resident #36, Resident # 51, Resident # 74, and Resident #54) out of seven residents whose PASRR was reviewed. This deficiency had the potential to affect 172 residents residing in the facility at the time of the survey. The findings included: 1) Observation of Resident # 94 on 02/27/2023 at 8:24 AM; revealed the resident seated on her bed having breakfast. Resident #94 asked what the surveyor was doing at her room and yelled at the staff. When explained the reason for the surveyor being in the room the resident asked the surveyor to get out of the room. Resident was noted very anxious. Observation of Resident # 94 on 03/01/2023 at 10:15 AM, revealed…
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 · D2023-03-02 · 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, record review and interview, the facility failed to ensure a resident's comprehensive care plan was followed related to the use of splints for a resident with a left hand contracture for one (Resident #130) out of one resident reviewed for position and mobility out of thirty-eight residents with contractures. There were a total of 171 residents residing in the facility at the time of this survey. The findings included: An initial observation of Resident # 130 was conducted on 2/27/2023 at 09:44 AM. The resident was sitting in a reclining chair with the television on, tube feeding machine on and had a left hand contracture. No splint or hand roll was observed in the resident's hand. Second observation of Resident # 130 was conducted on 2/28/2023 at 11:01 AM. The resident was sitting in a reclining chair with the television on, tube feeding machine on and had a left hand contracture. No splint or hand roll was observed in the resident's hand. Third observation of Resident #130 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.
- Potential for harm · D2023-03-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 that a left hand splint was worn to prevent worsening hand contracture for one (Resident #130) out of one resident reviewed for position and mobility out of thirty-eight residents with contractures. There were a total of 171 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Restorative Programs Policy and Procedure (Issued December 2020) documented: Policy-It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Policy Explanation and Compliance Guidelines-1) Physical functioning of all residents will be assessed in accordance with the facility's assessment protocols; 2) The interdisciplinary team, with the support of and guidance from the physician, will assure the ongoing review, evaluation and decision making regarding the services needed to maintain…
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 before2023-03-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to properly store medications. This affected 1 (Resident #91) out of 1 residents observed for Glucose Monitoring. This practice has the potential to affect the 154 residents admitted to the facility. The findings included: 1. During observation of medication Cart B on 2 [NAME] on 02/27/2023 at 10:47 AM with Staff M, a Registered Nurse, to observe Glucose Monitoring for resident #91. Staff B was observed to clean the glucose monitoring equipment before use and the residents glucose level was 208. Staff B cleaned the glucose monitoring equipment after it was used. Staff B prepared 2 units of insulin and took the insulin syringe and supplies to the resident's bedside. Resident #91 was sitting on the side of the bed. Staff B left the insulin at the bedside and went into the bathroom to wash her. Staff B could not see the medication while she was in the bathroom. Staff B came out of the bathroom, put on gloves and administered the insulin into resident #91's left lower abdomen. Continued observation of the cart…
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 · D2023-03-02 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review the facility failed to assure the garbage and refuse area was clean and expired water jugs and cardboard boxes were properly disposed and contained on the facility grounds. The findings included: Record review of the facility's Dietary Disposal of Garbage and Rubbish Policy and Procedure (dated 3/01/2021) documented: Policy: It is the policy of the facility to provide care and services related to the disposal of garbage and rubbish in accordance with State Requirements; Procedure: 7) Garbage should not accumulate or be left outside the dumpster. Observation of the garbage and refuse area with the Food Service Director (FSD) on 2/27/2023 at 6:57 AM. The area had three garbage bins with two used for garbage and one for recyclables. There were four cartons with four one gallon water jugs of soon to be expired water in each on the ground. There were also, two cardboard boxes flattened lying on the ground. The soon to be expired waters and flattened cardboard boxes were not contained in a garbage bin. Photographic evidence submitted.…
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 before2023-03-02 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in problem area related to repeated deficient practices for F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directives related to the facility failure to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for three residents (Resident # 122, Resident #133, Resident # 143) out of seven residents investigated, and F812 Food Procurement Store/Prepare/Serve/Sanitary as evidenced by the facility failed to ensure a thermometer was in the ice cream box. There were 171 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated November 5, 2021, the facility was cited for Request /Refuse/Discontinue Treatment; Formulate Advance Directives was cited related to 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.
“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
$64,981 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $64,981 — penalty dated 2024-08-01
- Medicare payment denial — starting 2024-10-30 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to VENTURA SERVICES — 14 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 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 13 homes this chain runs (chain average 3.2★, per CMS)
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 | Share | Since |
|---|---|---|---|---|
| AVENTURA OP HOLDING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2021 |
| AGRP 2011 TRUST | Organization | INDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 11/08/2021 |
| DEBORAH PHILIPSON 2011 FAMILY TRUST | Organization | INDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 11/08/2021 |
| PHILIPSON FAMILY LIMITED LIABILITY COMPANY, LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 11/08/2021 |
| KRAUS, ABRAHAM | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/08/2021 |
| PARITZKY, JEREMIE | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/08/2021 |
| BENGIO, JACOB | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/08/2021 |
| CHERISCAR, WINIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/27/2024 |
| PHILIPSON, BENT | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/10/2025 |
| PHILIPSON, GABRIELLE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/16/2025 |
| PHILIPSON, RAQUEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 07/16/2025 |
| RICHARDS MITCHELL & CROSS PA | Organization | ADP OF THE SNF | — | since 11/08/2021 |
| VENTURA SERVICES - FLORIDA, LLC | Organization | ADP OF THE SNF | — | since 11/08/2021 |
| OJEDA, MANUEL | Individual | ADP OF THE SNF | — | since 08/01/2023 |
CMS files one row per role, so the 23 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners 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.
This home reported $4.2M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 105596. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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 →
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