Royal Care Of Avon Park
1213 W Stratford Rd, Avon Park, FL 33825 · For profit - Limited Liability company · 90 certified beds · (863) 453-6674 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)
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,342 in federal fines (most recent 2024-05-09)
- 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)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 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 | 6.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.8% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 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 | 2.5% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.7% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.7% | 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 | 2.3% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 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 | 5.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.7% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.7% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.2% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.64 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.30 | 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.
53.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 204 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.6% 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 125 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 0.55 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 54% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | 53.5%CMS range 47.1–60.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 7.0–11.8 | 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 | 41.6% | 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 | 43.2% | 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 | 28.8% | 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 | 92.3% | 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 | 94.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 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 | 4.8% | 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 | 10.7%CMS range 7.2–14.3 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 90 beds and averages 77.2 residents a day — about 86% occupied, or roughly 13 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 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 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 3.47 hrs/resident/day on weekends vs 4.42 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.94 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2024-05-09 · 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 observations, resident and staff interviews, and record review, the facility failed to identify a new area of skin impairment, until it was an advanced stage pressure ulcer for one resident (#58) of two residents reviewed for pressure ulcers. This failure resulted in actual harm because a facility-acquired unstageable pressure ulcer, which is an advanced stage of skin breakdown that is full-thickness tissue loss is difficult to heal, at increased risk for infection, and disfiguring. The findings included: On 5/7/24 at 10:45 AM, Resident #58 was cycling in the therapy gym. He said that he got a Stage 4 pressure ulcer on his back because the facility didn't do anything after they discovered the pressure ulcer. When they first discovered a wound, they just told him to lie on his side. He said the facility didn't give him any treatment, and then the wound became a stage 4. They sent a photo to the doctor and he immediately sent him to the hospital because the wound had an infection. Now the wound still…
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 · D2026-02-19 · 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, record review, and interview, the facility failed to provide supervision to prevent resident to resident abuse for two (#2 and #3) of eight sampled residents. Findings included: A review of Resident #2's clinical chart, the admission record, documented an admission of 06/13/2024, readmission [DATE]. The diagnoses list included but not limited to: abnormalities of gait and mobility, muscle weakness, need or assistance with personal care, and type 2 diabetes mellites without complications. A review of a Brief Interview for Mental status (BIMS) assessment, dated 02/10/2026, documented a score of 15 which indicated the resident was cognitively intact. An observation conducted on 02/19/2026 at 9:38 a.m. of Resident #2, in the resident's room. Resident #2 was observed in bed, her eyes closed, sheet up to her shoulders, sleeping. A second observation was conducted at 11:45 a.m. of Resident #2, in bed sleeping. Her roommate stated the resident has been in and out sleeping, she still is not feeling…
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 · F2024-05-09 · tag F0867 — failed to act on quality-improvement findings — widespreadSet 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to ensure a medication administration error rate of less than 5%. A total of forty-three medication administration opportunities were observed with twenty-two errors for three (#5, #10, and #12) of five residents observed (F759). This resulted in a medication administration error rate of 51.16% during the revisit survey conducted 7/17/2024. Findings included: A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. A review of Resident #5's physician orders revealed the following orders: - An order, dated 6/10/2024, for allopurinol 100 milligrams (mg) one tablet by mouth (PO) once a day at 8:00 AM. - An order, dated 6/10/2024, for calcitrol 0.5 micrograms (mcg) one capsule PO once a day at 8:00…
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 · E2024-05-09 · 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 and interview, the facility failed to provide a clean and homelike environment, in that the facility was not free from offensive odors. This involved the front lobby area, the area in front of the [NAME] nurses' station, and four resident rooms (Rm103, Rm107, Rm109 and Rm110) out of 18 resident rooms on the [NAME] unit. Findings included: On 5/6/24 at 9:00 a.m. the lobby smelled of old urine when the survey team entered the facility. At 11:10 a.m. the area in front of the [NAME] nurses' station smelled of old urine. On 5/6/24 at 2:31 p.m. room [ROOM NUMBER] had a very offensive odor in the room, that was not urine. On 5/7/24 at 10:03 a.m. room [ROOM NUMBER] had an offensive odor that was not urine. On 5/7/24 at 10:38 a.m. room [ROOM NUMBER]'s bathroom had a strong urine odor in it. On 5/8/24 at 7:43 a.m. room [ROOM NUMBER] had a strong odor of urine. On 5/8/24 at 8:21 a.m. room [ROOM NUMBER] room had a strange offensive odor that was not urine, but it was improved from the day before. 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 · E2024-05-09 · tag F0645 — patternPASARR 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 record review, interview, and review of the facility's policy the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents (#15, #26, #28, #38) of 17 residents sampled for PASARR review. Findings included: Review of the electronic medical record (EMR) revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia severe, bipolar disorder, and major depressive disorder. Review of the Level I PASARR, dated 7/31/23, showed qualifying diagnoses were not checked or indicated, and that no Level II PASARR was required. Review of the EMR revealed Resident #26 was initially admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, and anxiety disorder. Review of the Level I PASARR, dated 7/28/20, showed qualifying diagnoses of depressive disorder and anxiety were checked, bipolar disorder was not checked and that no Level II…
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 before2024-05-09 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 observations, interviews, and record reviews, the facility failed to provide wound care and treatment in accordance with professional standards of practice for four (#67, #328, #177, and #36) of five residents sampled for skin conditions, and failed to ensure physician's orders were obtained for application of splints for one (#41) of one resident sampled for range of motion. Findings included: 1. A review of Resident #67's medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of sepsis and arthroscopic surgical procedure converted to open procedure. An interview was conducted on 5/7/2024 at 12:07 PM with Resident #67 in the resident's room. Resident #67 stated he had a procedure done on his right knee prior to his admission at the facility, which resulted in a wound infection to the area and required dressing changes to the wound. An observation of Resident #67's wound dressing to the upper right leg revealed no documented date on the wound dressing. A 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 · Ecited before2024-05-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observations and interviews, the facility failed to ensure proper storage of drugs and biologicals related to 1.) failing to ensure treatment carts remained locked and secured when not in use on one (South) of three units of the facility on two of four days during the survey and 2.) failing to ensure medications were stored in facility medication carts and not inside of resident rooms for one (#26) of five residents observed during medication administration. Findings included: During a tour of the South unit on 5/7/2024 at 9:29 AM, a treatment cart was observed unlocked in the unit hallway without staff present at the treatment cart. Staff U, Registered Nurse (RN) was observed conducting medication administration in the unit hallway. Staff U, RN stated she just unlocked the treatment cart because items from pharmacy were delivered that morning, which she put in the treatment cart. Staff U, RN addressed she left the treatment cart unlocked and stated she was going to lock the cart. Staff U, RN was observed locking the treatment cart before continuing with medication…
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 · E2024-05-09 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain food safety standards, such as maintaining clean floors and walls; not store ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food too long; thawing frozen TCS food (meat) properly under cold running water; and maintaining equipment in good condition. These findings have the potential to cause foodborne illness for 74 out of 76 residents who consume the facility's food. Findings included: During the initial brief tour of the kitchen on 5/06/24 at 9:29 a.m., the perimeter of the floor in the walk-in refrigerator had black soil. In addition, at 9:46 a.m., the perimeter of the floor in the walk-in freezer had black soil. (Photographic Evidence Obtained) Also, during the kitchen tour at 9:51 a.m. there was a quart container of egg salad in the [vendor name] double door reach-in refrigerator in the food preparation area. The container of egg salad had a label with a date that was written use by 5/4/24. The egg salad was made on the premises. (Photographic Evidence Obtained) The Kitchen…
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 before2024-05-09 · tag F0880 — failed to prevent and control infections — patternProvide 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 observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by 1.) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for four residents (#326, #64, #328, and #67) of seven residents with COVID-19 infection in the facility, 2.) failed to ensure staff doffed PPE before exiting the rooms of residents under transmission based precautions for two residents (#328 and #67) of seven residents with COVID-19 infection in the facility, 3.) failed to ensure residents were assisted with hand hygiene before meals during observation of meal service, and 4.) failed to ensure urinary catheters were stored in a sanitary manner for one resident (#30) of one resident sampled for urinary catheter use. Findings included: During a tour of the South unit on 5/6/2024 at 11:30 AM, a call light was observed 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 · E2024-05-09 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
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 equip corridors with securely affixed handrails on 2 of 3 units of the facility (West and South). Findings included: During a tour conducted on 5/6/2024 at 9:48 AM on the facility's [NAME] unit, a handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. A tour conducted on 5/6/2024 at 10:59 AM on the facility's South unit revealed the following: - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. - A handrail between rooms [ROOM NUMBERS] was observed to be loose and not firmly secured to the wall. An interview was conducted on 5/6/2024 at 11:11 AM with Staff I, Licensed Practical Nurse (LPN) on the facility's South unit. Staff I, LPN stated if a maintenance concern was identified on the unit, she would communicate the concern to the Unit…
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 · D2024-05-09 · 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
Based on observation, record review, and interview the facility failed to maintain dignity and a homelike dining experience in one (West) of two dining/common areas related to staff not removing dinnerware from trays when serving residents. Findings included: On 5/6/24 at 12:38 p.m. the noon meal service was observed on the [NAME] unit. The observation revealed two tables in the dining/common area with two residents sitting at one table and three residents sitting at the second table, one female resident was sitting in front of the television with an overbed table next to her and one male resident was sitting nearby with an overbed table next to him. The observation revealed one out of three residents at one table was served and the female resident sitting in front of the television was served. The observation revealed on 5/6/24 at 12:40 p.m., the second of the three residents sitting at the table was served and at 12:41 p.m., the male resident sitting in front of the television was served. The continued observation, at 12:42 p.m. showed the third resident was served with 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 15 citations
- Potential for harm · D2024-05-09 · tag F0641 — isolatedEnsure each resident receives an accurate 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 observation, interview and record review, including resident assessments, the facility failed to accurately reflect the resident's dental status for one of one resident (#17) reviewed for dental status and services. Findings included: During an observation on 5/6/24 at 1:18 p.m., Resident #17 was observed to have several broken, chipped teeth and dental caries (cavities/tooth decay). On 5/8/24 at 8:40 a.m. Resident #17 was observed during breakfast with multiple chipped teeth, one front tooth was a sliver. She said she fell backwards with a shopping cart and it hit her mouth. She had black gums around several teeth. She was on a regular diet. Review of the Face Sheet revealed Resident #17 was admitted to the facility on [DATE]. Her pertinent diagnoses included hypothyroidism; local infection of the skin and subcutaneous tissue; Vitamin D Deficiency; contracture, left hand; encounter for attention to colostomy; and essential hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference…
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 · D2024-05-09 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 observations, interviews, and record reviews, the facility failed to provide administration of intravenous medication in accordance with professional standards of practice for one (#54) of one resident sampled for intravenous medication administration. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and infection and inflammatory reaction due to internal left knee prosthesis. A review of Resident #54's physician's orders revealed an order, dated 5/5/2024, for vancomycin 1 gram per 250 milliliters (ml), infuse 250 ml intravenously (IV) over 90 minutes at a rate of 166 ml per hour every other day for a diagnoses of infection and inflammatory reaction d/t internal left knee prosthesis. An observation was conducted on 5/6/2024 at 4:00 PM of Resident #54 in the resident's room. Resident #54 was observed resting in bed, positioned on his right side. An IV pole was observed in Resident #54's room. A…
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 · D2024-05-09 · 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 observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided in accordance with professional standards related to 1.) failed to ensure proper storage of respiratory equipment for one (#54) of two residents sampled for oxygen therapy, 2.) failed to ensure physician's orders for oxygen therapy were obtained for one (#54) of two residents sampled for oxygen therapy, 3.) failed to ensure oxygen tubing was changed in accordance with physician's orders for one (#126) of two residents sampled for oxygen therapy, and 4.) failed to ensure signage indicating oxygen was in use outside of resident rooms for one (#126) of two residents sampled for oxygen therapy. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE]. Resident #54's diagnoses included Parkinson's Disease and need for assistance with personal care. An interview was conducted on 5/6/2024 at 4:00 PM with Resident #54 in the resident's room.…
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 · D2024-05-09 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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, record reviews, and interviews the facility failed to provide medications for one (#178) out of five residents sampled for unnecessary medications related to antihypertensive medications. Findings included: Review of Resident #178's Face Sheet revealed the resident was admitted on [DATE] and included diagnoses Type 2 Diabetes Mellitus with hyperglycemia, Unspecified cirrhosis of liver non-alcoholic, and essential (primary) hypertension. Review of Resident #178's May Medication Administration Record (MAR) revealed the following: - Losartan 25 milligram (mg) oral tablet once a day. Hold for systolic blood pressure (SBP) under 120, pulse under 60. The medication was administered on 5/5 for a documented blood pressure of 113/62 and on 5/7 for a blood pressure of 96/60. - Diltiazem 30 mg oral tablet three times a day. Hold for SBP less than 110 or pulse less than 60. The medication was administered on 5/1 at 9:00 p.m. for a blood pressure of 98/62 and held on 5/2 at 9:00 p.m. for blood pressure…
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 · D2024-05-09 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and six (6) errors were identified for two (#8 and #126) of five residents observed. These errors constituted a 21.43% medication error rate. Findings included: 1. On 5/8/24 at 8:11 a.m., an observation of medication administration with Staff R, Registered Nurse (RN), was conducted with Resident #8. The staff member obtained a blood pressure of 119/70 and a radial pulse of 65. Staff R returned to the medication cart parked in the hallway and dispensed the following medications: - Vitamin D3 50 microgram (mcg) (2000 international units) - 2 over the counter (otc) tablets - Vitamin D 25 microgram (mcg) otc tablet - Eliquis 5 milligram (mg) tablet - Metoprolol Succinate Extended-Release 25 mg tablet - Multi-Vitamin otc tablet - Oxybutynin Extended-Release tablet - ClearLax mixed with approximately 4 ounces of water. - Tramadol 50 mg tablet Staff R confirmed dispensing 8 tablets,…
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 before2024-05-09 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 one (#54) of one resident sampled for intravenous medication administration was free from significant medication errors. Findings included: A review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and infection and inflammatory reaction due to internal left knee prosthesis. A review of Resident #54's physician's orders revealed an order, dated 5/5/2024, for vancomycin 1 gram per 250 milliliters (ml), infuse 250 ml intravenously (IV) over 90 minutes at a rate of 166 ml per hour every other day for a diagnoses of infection and inflammatory reaction d/t internal left knee prosthesis. An observation was conducted on 5/6/2024 at 4:00 PM of Resident #54 in the resident's room. Resident #54 was observed resting in bed, positioned on his right side. An IV pole was observed in Resident #54's room. A 250 ml bag of vancomycin was observed hanging from 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 · D2024-05-09 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
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 assist one (Resident #17) of one resident in obtaining routine dental care. The findings included: During an observation on 5/6/24 at 1:18 PM, Resident #17 was observed to have several broken, chipped teeth and dental caries. On 5/8/24 at 8:40 AM, Resident #17 was observed during breakfast with multiple chipped teeth, one front tooth was a sliver. She said she fell backwards with a shopping cart and it hit her mouth. She had black gums around several teeth. She was on a regular diet. Resident #17 was admitted to the facility on [DATE]. She was [AGE] years old. Her pertinent diagnoses included Hypothyroidism; Local infection of the skin and subcutaneous tissue; Vitamin D Deficiency; Contracture, left hand; Encounter for attention to colostomy; and essential hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 4/26/24 documented the resident's Brief Interview for Mental Status (BIMS) score of 14, indicating…
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 · D2021-12-22 · 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 the splinting program was clarified and implemented as physician ordered for one (Resident #61)) of six residents on the restorative nursing splinting program. Findings included, An interview on Monday 12/20/21 at 11:18 a.m., with Resident #61's Responsible Party, revealed the resident was completely numb on the left side of the body and was unable to move very much. The Responsible Party stated the resident had a splint, however, I have not seen a brace (splint) in a while on [Resident #61]. An observation of Resident #61 on Monday 12/20/21 at 11:38 a.m., revealed the resident lying in bed curled onto the left side of her body with the left leg tucked underneath her right leg and the left hand curled into a fist. Resident #61 was not wearing splints on any part of the body during the observation. Resident #61 did not respond to English, however, upon asking how the resident was feeling in Spanish, Resident #61 responded in Spanish…
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 · D2021-12-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 ensure breakfast was delivered to one (Resident #25) of one hemodialysis resident within a timely manner prior to leaving to the dialysis center on one of one observable survey days. Findings included, During an interview on 12/20/21 at 11:55 a.m., Resident #25 stated he went to the dialysis center to receive treatment three days a week: Tuesdays, Thursdays, and Saturdays. Resident #25 stated he left early in the morning and did not always get a meal or snack when going to the dialysis center for treatment. The resident stated upon returning from the dialysis center he was normally really hungry. Resident #25 said, [I] wish that was fixed because I come back starving. Resident #25's Resident Face Sheet revealed medical diagnoses of end stage renal disease, type 2 diabetes, muscle weakness, unspecified protein-calorie malnutrition, and metabolic encephalopathy. Resident #25's MDS, dated [DATE] revealed the resident had a BIMS score of 9,…
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 before2020-03-13 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 one dialysis resident (#10), of three sampled dialysis residents, was free from a significant medication error by failing to obtain and dispense a dialysis medication from January 17, 2020 to March 13, 2020. Findings included: A review of the Face Sheet for Resident #10 revealed that she was admitted on [DATE] with diagnoses to include acute and chronic diastolic heart failure, dementia, anorexia, end stage renal disease, and dependence on renal dialysis. On 3/11/20 at 5:06 p.m. during an interview with the Resident #10, she confirmed she received dialysis and she stated that she does not get medication while at dialysis. Review of the Physician Progress Note from the dialysis center dated 2/6/20 reflected the resident's parathyroid level goal was not met after a review of labs obtained 1/23/20. It reflected the parathyroid hormone level was 1096 and the phosphorus level on 2/4/20 was 6.3. The intervention reflected Sensipar 60 mg (milligrams)…
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 before2020-03-13 · 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 assess and treat skin conditions for two residents (#72 and #39) of three sampled residents. Findings included: 1. During observation and interview with Resident #72 on 3/10/20 at 1:41 p.m. the resident was observed with scabs all over his face. The resident stated he is unsure of what the scabs are from or how long he had them. During an interview on 3/12/20 at 4:17 p.m. with Staff F, Licensed Practical Nurse (LPN) she stated he has ointment on his bedside table the daughter brings him for his extremely dry skin and doxycycline for his ear. She confirmed he had scabs all over his face and some newer ones around his mouth. Staff F, LPN lifted the covers and looked at his feet after removing his soft boots. Both heels were free of wounds, the right foot had black scabs on top of four toes where the sheets would rub on the foot. Staff F, LPN stated the wound care nurse would take care of those. During an interview on 3/12/20 at 4:52 p.m.…
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 · D2020-03-13 · 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 record review, observations, interviews, policy review, and the State Agency Surveyor Guidance for Hot Water Temperatures related to the Federal regulations, the facility did not ensure water temperatures were maintained at a safe level for four resident bathrooms of twelve resident bathrooms sampled, and for one nursing unit (300 hallway) of two nursing units, with the potential to affect six residents (#56, #47, #139, #50, #140, #65) of eight residents who were capable of using the bathroom. Findings included: 1. Resident #56 was admitted to the facility with a diagnosis of CKD (chronic kidney disease) stage 5 according to the admission record. The Minimum Data Set (MD) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #56 was cognitively intact. Further review of the MDS assessment, Section G, Functional Status, indicated Resident #56 required extensive assistance of one person to use the toilet, bathe, and perform personal hygiene…
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 · D2020-03-13 · 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 interview and record review, the facility failed to effectively monitor bowel elimination and patterns for one resident (#35) of three sampled residents. Findings included: A review of the Face Sheet for Resident #35 revealed and admission date of [DATE] and that the resident was receiving hospice services. Diagnoses included Parkinson's disease, unspecified dementia and constipation. An alert was documented as refusal of treatment waiver, no intubation, no ventilation, no CPR, no tube feeding, no daily, weekly, or monthly weights. A review of Resident #35's Vital Results recording in the medical record from [DATE] to [DATE] reflected the resident's bowel movements (BM) from [DATE] to [DATE] as None. Further review of the Vital Results recording showed: -[DATE] a small bowel movement was documented at 2:03 p.m. -[DATE] at 2:57 a.m. reflected a small bowel movement and at 2:21 p.m. reflected a small bowel movement -[DATE] at 12:10 a.m. a bowel movement of none/120 ml (milliliter) was documented and 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 · Dcited before2020-03-13 · 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 and interview the facility failed to ensure safe and secure storage and labeling of medications related to 1. high-risk medications were stored at the resident bedside for one resident (#192) of a total sample of 31 residents, 2. one medication cart (Northwest) and one treatment cart (300-hall) were unlocked while unattended, 3. eye drops were stored with oral medications in two medication carts(Southwest and Northwest) of four medication carts, and 4. high risk medications stored in an unlabeled bag in one medication room of two medication rooms. Findings included: 1. On 3/10/20 at 1:05 p.m., two pre-filled syringes were observed in plastic packaging lying on an over-the-bed table of Resident #192. The resident was sitting in a wheelchair with the table in front of the wheelchair and the syringes were within reach of the resident. Staff D, Licensed Practical Nurse (LPN), confirmed the pre-filled syringe with a yellow cap was Heparin and the white capped syringe was normal saline. The staff member stated Heparin syringes were not stored at the bedside, they 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.
- Potential for harm · Dcited before2020-03-13 · 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 observations, interviews, and record review the facility did not ensure appropriate infection prevention measures were maintained related to maintaining a nasal cannula, oxygen tubing, a wound vacuum and wound vacuum tubing off the floor for one resident (#140) of two residents reviewed for infections. Findings included: Resident #140 was admitted to the facility with a diagnosis of cutaneous abscess of groin, AAA (abdominal aortic aneurysm) surgery, s/p (status post) right groin surgery infection with E coli, and COPD (chronic obstructive pulmonary disease), according to the face sheet in the admission record. A review of Resident #140's Physician Order Report for 2/24/20 to 3/12/20 in the medical record revealed the following: 2/24/20 ensure left groin surgical site is functioning properly at 125 mm (millimeter) HG continuous suction. May apply N.S. (normal saline) wet to dry dressing prn (as needed) if unable to get machine to function properly. 2/24/20 O2 (oxygen) at 2L (liters) via nc (nasal…
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
$17,342 in federal fines across 2 penalties.
- $4,017 — penalty dated 2024-05-09
- $13,325 — penalty dated 2024-05-09
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STROHLI, ELI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/25/2007 |
| GELDART, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2002 |
| MATHEIS, PAMELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/07/2003 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 105812. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-09, 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.