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Yamato Nursing And Rehabilitation Center

375 NW 51st Street, Boca Raton, FL 33431 · Non profit - Corporation · 180 certified beds · (561) 997-8111 Medicare & Medicaid certified

Call the home — (561) 997-8111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 29 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 3 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4705 N Federal Hwy · (561) 405-9610 · Call to confirm hours
Pharmacy
4802 NW 2nd Ave · (561) 241-7711 · Call to confirm hours
Grocery
Aldi0.6 mi
4901 N Federal Hwy · (855) 955-2534 · Call to confirm hours
Park
300 Newcastle St · (561) 393-7810 · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.2%8.7%15.4%better
Long-stay residents who lose too much weight6.1%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.6%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened10.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.5%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.7%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control6.1%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 table12.9%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission35.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit11.2%9.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.502.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.161.151.80better

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.

45.7% 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 137 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.7%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 52.5% 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 120 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.7%CMS range 38.6–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.2–17.110.7%Oct 2022–Sep 2024no 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 discharge52.5%56.6%Oct 2024–Sep 2025CMS 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 discharge38.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.8%50.0%Oct 2024–Sep 2025CMS 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 identified97.4%98.7%Oct 2024–Sep 2025CMS 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 setting98.5%100.0%Oct 2024–Sep 2025CMS 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 discharge97.3%98.7%Oct 2024–Sep 2025CMS 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 stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.9%CMS range 5.6–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS 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

0.76
RN hours/ resident / day
0.64
LPN hours/ resident / day
2.17
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.65
RN hoursweekends
24.6%
Total nursing turnover
53.5%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 172.3 residents a day — about 96% occupied, or roughly 8 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 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.42 hrs/resident/day on weekends vs 3.64 on weekdays — 6% thinner on weekends. RN hours go from 0.81 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% is below the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

10
deficiencies at the latest standard inspection (2023-04-19)
10
at the previous standard inspection (2022-01-13)

Deficiencies are unchanged from the previous inspection. 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 3 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.

ABCDEFGHIJKL

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.

29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.

  • Potential for harm · Fcited before2023-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 store, prepare, distribute and serve food in accordance with professional standards for the food service safety. The findings included; 1. During the initial kitchen / food service sanitation tour conducted in the main kitchen on 04/16/23 at 9 AM and accompanied with the Morning Cook, the following was noted: (a) Observation of the cooks 2-compartment preparation sink noted that the left side sink contained 6-5 pound cook portions of Pot Roast. Further observation noted that a small stream of warm water was running onto 2 portions of the beef. The right sink was noted to contained approximately 40 portions of commercially packaged raw fish. Further observation noted the fish was not being covered in cold running water. An interview conducted with the lunch cook at the time of the observation noted the surveyor to state the roast and fish were not being thawed according to regulation. It was discussed with staff that both the beef and fish need to be resting in cold water with run-over drain and also cold…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 4 residential living areas (Williamsburg, [NAME], Cambridge, and [NAME]); and failed to ensure it stored and processed linens in the laundry area in a proper manner. The findings included: During the resident screenings conducted on 04/16-17/23 and the environment tour conducted on 04/19/23 at 10 AM, accompanied with the Director of Maintenance and Corporate Director of Maintenance, the following was noted: 1. Williamsburg Unit: room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Exterior of room entry door in disrepair. room [ROOM NUMBER]: Exterior of entry door damaged and in disrepair. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [ROOM NUMBER]: Peeling room wallpaper, and damage and disrepair to room walls. room [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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-19 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 review of policy and procedure, observation, interview and record review, the facility failed to ensure secure storage of medications in an unlocked Wound treatment cart; ointment in an unoccupied resident room; medications at the bedside for Resident #126, Resident #305, Resident #9, Resident #122; loose tablet on a medication cart; one (1) tablet disposed of into a garbage can; two (2) loose tablets in two (2) medication carts; and one (1) expired medication in a medication refrigerator. The findings included: Review of the facility policy and procedure on [DATE] at 1:30 PM, titled, Medication Storage, provided by the Director of Nursing (DON) reviewed 2022, documented in part, in the Policy Statement: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-19 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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, the facility failed to follow the approved menu for Pureed Diets that included 16 of 16 aampled residents, Residents #10, #16 #18, #29, #31, #37, #63, #69, #72, #99, #121, #132, #137, #202, #212, and #299. The findings included: 1. During the review of the approved menu for the lunch meal of 04/16/23, the following documentation was noted: *Regular Diets - Fresh Potatoes and Onion (4 ounce serving portion) *Pureed Diet - Pureed Fresh Potatoes and Onions (#10 scoop portion) During the observation of the lunch meal in the main kitchen on 04/16/23 at 11:30 AM, it was noted that the Fresh Potatoes and Onions were prepared and located on the steam table for Regular Diet. Further observation noted that Pureed Fresh Potatoes and Onions were not prepared. Further observation noted that instant Mashed Potatoes were prepared for Pureed Diet. Interview with the Certified Dietary Manager (CDM) and facility's Registered Dietitan (RD) at the time of the observation noted that staff failed to review the approved menu for pureed diet. It was…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-19 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to dispose of garbage and refuse properly. The findings included: During observation of the facility's dumpster / refuse area on 04/16/23 at 10:30 AM, it was noted that there were 2 commercial dumpster's (1-garbage / refuse and 1 cardboard / paper waste) located in the courtyard outside of the dietary department. Further observation of the garbage / refuse dumpster noted that door to the unit was not closed and the interior of the dumpster was filled with open bags (10) and exposed garbage food/trash waste. The unit was noted to be full of flying insects and the smell was overwhelming. Photographic Evidence Obtained. Observation of the cardboard / paper dumpster also noted that the the unit was full of open garage and expose garbage waste. The administrator and Director of Maintenance were notified that the garbage storage area was not being maintained in a sanitary condition to prevent the harborage and the feeding of pests. Photographic Evidence Obtained. It was also discussed that there was the potential health threat from…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-19 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 have an effective pest control program, as evidenced by observations of live and dead roaches in multiple areas of the facility. The findings included: During an observation on 04/16/23 at 10:37 AM in room [ROOM NUMBER], a Germán roach-like insect ran across the floor towards the underside of the resident's bed with Staff I, Certified Nursing Assistant (CNA), present. During an interview conducted on 04/16/23 at 10:40 AM with Staff I, he acknowledged an insect ran across the floor towards the underside of resident's bed in room [ROOM NUMBER]. When asked how or who does he reports the bug sighting incident, he stated he would tell the nurse or the Administrator. On 04/16/23 at 2:14 PM, during an interview with the resident in room [ROOM NUMBER], when asked about the presence of pests, the resident replied, roaches the size of elephants in the closet. At the conclusion of the interview, with Resident #13's permission to tour her room, live…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 each resident with dignity equally for 21 of 34 sampled residents reviewed for dignity, as evidenced by: utilizing a gown as a clothing protector (Resident #58), lack of personal care request related to hair (Resident #97), not providing proper clothing (Resident #32), and for placing meal tray trash on residents' beds for resident rooms #100 through #119, which affected 19 randomly observed facility residents during meals (that included sampled Residents #32 #66, #202 and #205). The census at the time of the survey was 165. The findings included: Review of the facility's policy, titled, Resident Rights, with no date implemented and no revised date documented, in part: The facility will inform the resident both orally and in writing, in a language the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the [NAME] in the facility. All residents will be…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 provide medically related social services in a timely manner for 1 of 2 sampled residents reviewed for social services (Resident #80). The findings included: Resident #80 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #80 had a medical history significant for a Stroke, Heart Failure, Muscle Weakness, Hypertension, Atrial Fibrillation, Insomnia, Major Depressive Disorder, Paranoid Schizophrenia, Dementia, Blood Clot, Anxiety, and Chronic Pain. Review of Resident #80's Physician Orders revealed an initial order for a Psychiatric Consult was written on 12/28/22, despite Resident #80 being admitted in November 2022 with a significant psychiatric history. Review of the admission Minimum Data Set (MDS) of 11/17/22, documented in part: Under Section A for Identification Information, this MDS documented Resident #80 was not currently considered by the state Level II Preadmission Screening and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 be free of a medication error rate of 5% or more, and the medication error rate was 9.68 %. Three (3) medication errors were identified [NAME] observing a total of 31 opportunities, affecting Resdient #42 and a resident in room [ROOM NUMBER]. The findings included: 1. A medication administration observation was conducted on 04/17/23 at 9:15 AM with Staff A, Registered Nurse (RN) for a resident in room [ROOM NUMBER]. Staff A gathered and administered the following medications: a. Aspirin 81 milligram (mg) 1 tablet given b. Docusate 100mg 1 capsule given c. Eliquis 5mg 1 tablet given d. Valsartan 80mg 1 tablet given e. Vitamin C 500mg 1 tablet given f. Vitamin D3 1000 international unit (iU) 1 tablet given. Review of the resident's physician orders and Medication Administration Record (MAR) revealed the resident should have received 2 tablets each for the Vitamin C 500mg and Vitamin D3 1000IU. 2. A medication administration observation…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to screen for eligibility to receive pneumococcal immunization and failed to offer pneumococcal immunization for 1 of 5 sampled residents reviewed for immunizations, Resident #300. The findings included: Record review for Resident #300 revealed the resident was admitted to the facility on [DATE]. There was no Pneumococcal screening for Resident #300. There was no documentation of the Pneumococcal vaccine offered to Resident #300. During an interview conducted on 04/19/23 at 11:00 AM with the Infection Preventionist revealed she started working at the facility during the end of November 2022 as the Infection Preventionist. When asked about immunizations being offered to residents, she stated all residents are screened on admission and readmission for Pneumococcal, Influenza and Covid immunization, and based on the screening, the immunizations are then offered to each resident if applicable.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Fcited before2022-01-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: During the initial tour of the kitchen conducted on 01/10/22 at 8:44 AM, accompanied by Staff J, Cook, Regional Registered Dietitian (RD), and Food Service Director (FSD), the following was noted: 1. During the breakfast tray line, Staff M, Diet Aide, placed her bare hands in her pockets. She then removed her hands from her pockets and proceeded to touch clean utensils and place them on meal trays without performing hand hygiene. Staff N, Diet Aide, was observed grabbing a plate of food with her bare hands to place on the meal tray. It was noted that her thumb had touched the top of the plate. 2. During the breakfast tray line, a plate of eggs, bacon, and toast was observed on the counter above the hot holding unit when the surveyors…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-13 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 have an effective pest control program. The findings included: 1. In an interview conducted on 01/10/22 at 10:46 with Resident #61, she said can you move the blanket, I think I have something on my feet. In this interview, an alive roach was noted crawling across Resident's #61 feet (Photographic evidence Obtained). Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #61 had a Brief Interview of Mental Status (BIMS) score of 07 which is cognitively impaired. 2. In an interview conducted on 01/10/22 at 11:00 AM, with Resident #18, she stated that they have bugs and roaches in their room, and it is always a problem. She did not remember when the last time someone came into the room to spray for bugs. Record review of the Quarterly MDS dated [DATE] showed that Resident #18 had a BIMS score of 10 which is slightly cognitively impaired. 3. In an interview conducted on 01/10/22 at 10:45 AM with 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-13 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure 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 observations, interviews, and record review, the facility failed to follow the approved menu and approved portions for 24 residents on pureed diets, which included 8 sampled residents (Resident #90, Resident #109, Resident #59, Resident #604, Resident #45, Resident #22, Resident #88, Resident #145). The findings included: Review of the approved lunch menu for pureed diets for 01/12/22 documented that the following was to be served: #12 scoop (2.5 ounces) of pureed squash casserole and ½ cup of rosy applesauce. During an observation of the lunch tray line conducted on 01/12/22 at 11:24 AM, accompanied by the Food Service Director (FSD), it was noted that pureed cauliflower had been substituted for the pureed squash casserole. It was further noted that a #16 scoop (2 ounces) was used to plate the pureed cauliflower. This showed that residents on pureed diets were receiving a 2 ounce portion of pureed cauliflower instead of a 2.5 ounce portion. The FSD acknowledged that the approved portion sizes for the pureed diets were not being followed and stated that a #12 scoop should…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 observations and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment in resident rooms. The findings included: During a tour of the facility conducted on 01/13/22 at 9:08 AM, accompanied by the Director of Maintenance and the Environmental Services Director, the following was noted: 1. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. 2. room [ROOM NUMBER]: The wall underneath the television had an unpainted white patch. The Environmental Services Director stated that the wall was spackled last week. He further stated that this was an ongoing issue and would be observed in multiple resident rooms. 3. room [ROOM NUMBER]: The wallpaper was peeling from the wall located near the resident's bed. The stand for the overbed table was rusted. The dresser drawers had multiple scratches. The wall near the room door had an unpainted white patch. 4. room [ROOM NUMBER]: The wall near the bathroom door had an unpainted white…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 revise, follow, and update the care plan for eating assistance for 3 of 12 sampled Residents reviewed for nutrition (Residents #51, #86, and #75). The findings included: 1. Chart review showed that Resident #51 was admitted on [DATE] with diagnoses of cerebral infarction and anxiety disorders. A review of the Physician's orders showed that Resident #51 is on a Mechanical soft diet with ground meats which was dated 01/03/22. The care plan dated 11/23/21 showed that Resident #51 needs encouragement and assistance with his meals and fluids. The Minimum Data Set (MDS), Quarterly dated 11/11/21 showed that for section G, eating, Resident #51 needs supervision with set up only. Section C showed that he has a Brief Interview of Mental Status (BIMS) score of 06 which indicates the resident is cognitively impaired. In an observation conducted on 01/11/22 at 8:00 AM, the meal cart arrived on the unit. At 8:05 AM, the staff brought the breakfast…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Review of the record showed that Resident #75 was re-admitted to the facility on [DATE] with the following diagnoses: Sarcopenia, Muscle Weakness, and Cognitive Communication Deficit. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #75 had a Brief Interview for Mental Status of 10, which showed that he was moderately cognitively impaired. Review of Section G of the Quarterly MDS dated [DATE] documented that Resident #75 required extensive assistance with one person physical assist for personal hygiene. Review of the Care Plan dated 11/30/21 documented that Resident #75 had an activities of daily living self-care deficit related to physical limitations and weakness. Interventions were to assist with daily hygiene, grooming, dressing, oral care and eating as needed. During an observation conducted on 01/10/22 at 11:15 AM, Resident #75's fingernails were long and went past his fingertips. Closer observation showed that there was brown residue underneath 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's 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 observations, interviews, and record reviews the facility failed to provide activities for 3 of 3 residents observed (#119, #82, and #43). Findings included: Review of the facility policy titled Activity and Recreation Program Provision dated July 2019 revealed the use of structure in providing an activity and recreation program is vital to patient enjoyment and engagement. The structural components for providing a successful recreation program include preparation, presentation, closure, and evaluation. Before each program, it is necessary to plan appropriate set-up and preparation. The program may be listed on the center calendar, posted daily, as well as being posted on the in-room calendar. Preparation steps may include setting up supplies or audio-visual equipment. When working with patients who are experiencing sensory and cognitive losses, the program should enhance their abilities, as well as the activity and recreation staff offering structure and direction for the group. The activity and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 follow the Tube Feeding regimen as per the Physician's orders for 1 of 2 residents reviewed for tube feeding (Resident #114). The findings included: Record review showed that Resident #114 was readmitted on [DATE] with a diagnosis of type 2 diabetes, hemiplegia, and hypertension. A review of physicians' orders showed an order for tube feeding Glucerna 1.5 running at 50 ml an hour until 1000 ml is infused. It further showed to start at 4:00 PM which was dated 03/20/21. In an observation conducted on 01/10/22 at 10:10 AM, in Resident #114's room, a tube feeding formula (Glucerna 1.5) was noted on hold. Closer observation showed that the tube feeding bottle was at the 500 milliliters (mL) mark out of a 1000 ml bottle (photographic evidence obtained). The bottle showed a start date of 01/09/22 at 4:00 PM. The tube feeding bottle running at 50 ml an hour until 1000 ml infused should have been at the 100 ml mark at 10:00 AM the next day. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 secure 2 of 5 medication carts while unattended, facility failed to ensure that bedside medications were secured for 2 Residents (#85 and #59), facility failed to ensure that bedside medications were secured and discarded for Resident #13, the Nursing Center should ensure that drugs and biologicals for expired or discharged residents are stored separately, away from use, until destroyed or returned to the Pharmacy; and the Nursing Center should destroy or return all discontinued, outdated/expired, or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. Findings included: Review of policy titled Medication Administration: Self-Administration of Medications dated 11/2017 revealed the decision to allow a patient to self-administer medications is subject to periodic assessment by the intradisciplinary team (IDT)based on changes in the patient's medical and decision-making status. Medications, if…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 staff failed to follow infection control isolation precautions for positive COVID-19 Resident (#22); the facility failed to assure that isolation precautions were being followed for Resident with Clostridium Difficile colitis (C.Diff) (Resident #76); facility failed to ensure that orders were provided for PICC line on Resident #90, and the facility failed to properly contain dirty laundry in the sorting room. The findings included: A review of the CDC guidance, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which was updated Sept. 10, 2021, showed the following: Health Care Professional (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-01-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This included; foods properly labeled and dated, proper cleaning and sanitizing of food preparation equipment and food preparation surfaces, maintenance and cleaning of refrigeration units, regulatory holding temperatures of cold foods, maintenance of ventilation and ceiling areas, and elimination of dented foods cans. The findings included: 1. During the initial kitchen/food service observation tour conducted on 01/04/21 at 9:30 AM, and accompanied with the facility's Corporate Registered Dietitian (RD), the following were noted: a) During an observation of the serving station outside of the main kitchen it was noted that the wall area contained large areas of dried matter, uncovered trash/garbage, and a uncovered soiled resident food tray placed on a clean serving counter. The surveyor requested to the RD that the tray be moved immediately and the surface sanitized, as well as covering 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-01-07 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, it was determined that the facility failed to dispose of garbage and refuse in a sanitary manner. The findings included: During the initial Kitchen/Food Service Tour conducted on 01/04/21 at 9:30 AM, accompanied with the facility's Registered Dietitian, an observation was conducted of the garbage/trash dumpster area. The observation noted that there were 2 commercial containers dedicated to only paper/cardboard materials. Further observation noted that 1 of the container lids was fully open and further observation noted that the interior contained open trash bags, unsecured garbage/trash, and soiled personal protection equipment (PPE). It was also noted that the ground area around the container was littered with trash and soiled PPE's. It was confirmed with the Dietitian at the time of the observation that no facility trash is to be put into the cardboard/paper container, and that ground area should be maintained on a daily basis.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-01-07 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 4 resident wings ([NAME], Cambridge, [NAME], and [NAME]). The findings included: During the Environment Tour conducted on 01/07/21 at 10:30 AM and accompanied with the facility's Director of Environment and Director of Maintenance, the following was noted: First Floor- Williamsburg and [NAME] Units: room [ROOM NUMBER] - Room wallpaper peeling away from room walls, and shower stall floor was highly soiled. room [ROOM NUMBER]- Room Window (1) was noted to be covered in a white film. room [ROOM NUMBER] - Room Window (1) was noted to be covered in a white film. room [ROOM NUMBER] - Room wallpaper peeling away from walls and bathroom toilet requires recaulking to the floor area. room [ROOM NUMBER] - Room Window (1) was noted to be covered in a white film. room [ROOM NUMBER] - Room Window (1) was noted to be covered…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 interview, observation and record review, the facility failed to provide assistance with alternative means of communication for 1 of 2 sampled residents (Resident #109) to facilitate the resident's commuication needs. The findings included: Resident #109 was admitted to the facility on [DATE] with diagnoses including, Anemia; Hypertension; End Stage Renal Disease; Diabetes Mellitus Type II; Hyperlipidemia; Thyroid Disorder, and Dementia among others. R Review of the most recent MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMs (Brief Interview for Mental Status) score of 10 of 15, indicating moderate impairment cognitive impairment. On 01/04/21 at 11:16 AM, an interview with Resident #109 revealed that she had a very difficult time understanding English and would speak a foreign language to answer the questions she was asked. Consequently, the surveyor used Google translate to facilitate the communication with Resident #109. On 01/04/21 at 11:27 AM, during a phone interview with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-07 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement the grievance policy by failure to address a missing items concern and failure to complete a concern form for all reported missing items. This action or lack thereof negatively impacted 1 of 2 sampled residents (Residents #92). The findings included: Resident #92 was admitted to the facility on [DATE] with diagnoses including, Hypertension; Anxiety Disorder; and Psychotic Disorder. Review of the most recent MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMs (Brief Interview for Mental Status) score of 10 of 15, indicating moderate impairment cognitive impairment. During an interview on 01/04/21 at 11:52 AM, Resident #92 reported that she had a few clothes and garments missing and had reported the issue to the laundry lady and the desk clerk. Resident #92 reported that it has been a week and half since the following items were missing: Three brassieres, three pairs of sweat pants, and a green hoody zip-up. She said her husband…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop care plans that included measurable objectives, interventions and timeframes for how staff will meet resident's needs for 3 of 28 sampled residents reviewed for care plans. (Resident #54, #74 and #125) The findings included: 1. During record review it was noted that Resident #54 was admitted to the facility on [DATE]. Resident #54's diagnosis include but are not limited to Multiple Sclerosis, Dementia, Dysphasia, and Gastrostomy. Resident #54's Minimum Data Set (MDS) of 10/28/2020 Brief Interview for Mental Status (BIMS) was documented as 2 out of 15, which indicated Resident #54 is severely cognitively impaired. Review of Resident #54's care plan revealed a focused activity need that Resident #54 desires to participate in outdoor activities, Resident #54 is at risk for complications related to health conditions, and Resident #54 may go outside with assistance and supervision. Resident #54's focused activity need was initiated on 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-01-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 1 of 28 dependent sampled residents (Resident #34) received personal hygienic care and grooming. The findings included: During observation and interview conducted on 01/04/21 at 12:31 PM revealed that Resident #34's hair was disheveled, uncombed and she had overgrown facial hair. The resident said that she did not remember the last time they combed her hair or when she was last shaved. She also indicated that she would like for the staff to groom her. On 01/05/21 at 1:51 PM, the resident's hair was still uncombed and she was not shaved. On 01/06/21 at 1:50 PM, a final observation revealed the resident was still not shaved and her hair was not combed and/or washed. An inquiry was made with the Unit Manager (UM of Cambridge Unit) on 01/06/21 at 1:54 PM to find out the reason why Resident #34 was not groomed. The UM was made aware of the concerns identified and she said that she would immediately address them. Review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-01-07 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's 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 To ensure that facilities implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). Based on observation, interview and record review, the facility failed to implement and maintain an ongoing resident centered activities program that reflects resident identified interests and needs for 2 of 8 sampled residents reviewed for activities (Resident #54 and #74). The findings included: 1. Record review revealed Resident #54 was admitted to the facility 08/15/13. Resident #54's diagnoses include but are not limited to Multiple Sclerosis, Dementia, Dysphasia, and Gastrostomy. Resident #54's Minimum Data Set (MDS) of 10/28/2020 assess…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-01-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to consistently document controlled substances for 3 of 8 sampled residents (Resident #23, Resident #33 and Resident #443) whose records were reviewed for the Medication Storage facility task. The findings included: 1. On 01/07/21 at 12:30 PM a narcotic record review was conducted with Staff A, a Registered Nurse (RN) on the Williamsburg Unit. Staff A was assigned to Cart 2 on the Williamsburg Unit. Staff A randomly selected Resident #23 for one of the residents for whom a record review was conducted. Resident #23 was prescribed Tramadol 50 mg tablets. The directions stated to take one tablet by mouth every 4 hours as needed for pain. When comparing the narcotic log page for Resident #23 against the Electronic Medication Administration Record (eMAR) the following discrepancies were identified: On 12/20/20 at 8:00 PM there was an entry for administration of the medication on the narcotic log sheet, but there was no corresponding entry on the eMAR for that date; On 12/28/20 at 8:12 PM there was an entry on 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to EXCELSIOR CARE GROUP — 33 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 →

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 4 of 52.3+1.7 vs chain
Quality measures 3 of 54.2-1.2 vs chain
The other 32 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Ambassador Healthcare At College ParkFort Myers, FL 1 of 5Briarcliff Manor Center For Rehab And Nursing CareBriarcliff Manor, NY 1 of 5Charlotte Bay Rehab And Care CenterPort Charlotte, FL 1 of 5Live Oak Healthcare And Rehabilitation CenterLive Oak, FL 1 of 5Melbourne Healthcare And Rehabilitation CenterMelbourne, FL 1 of 5River Front Rehabilitation And Healthcare CenterPennsauken, NJ 1 of 5Space Coast Healthcare And Rehabilitation CenterMerritt Island, FL 1 of 5West Delray Nursing & Rehab CenterDelray Beach, FL 2 of 5Alliance Care Rehabilitation And Nursing CenterIrvington, NJ 2 of 5Azure Shores RehabMiami, FL 2 of 5Beach Breeze Rehab And Care CenterWest Palm Beach, FL 2 of 5Boca Circle Rehabilitation CenterBoca Raton, FL 2 of 5Breezy Hills Rehab And Care CenterLakeland, FL 2 of 5Charming Lakes RehabLakeland, FL 2 of 5Lake City Healthcare And Rehabilitation CenterLake City, FL 2 of 5Lake Eustis Healthcare And Rehabilitation CenterEustis, FL 2 of 5Seagate Rehabilitation And Nursing CenterBrooklyn, NY 2 of 5West Volusia Healthcare And Rehabilitation CenterDeltona, FL 3 of 5Arnold Walter Nursing & Rehabilitation CenterHazlet, NJ 3 of 5Heartland Nursing & Rehab CenterBoynton Beach, FL 3 of 5Nassau Rehabilitation & Nursing CenterHempstead, NY 3 of 5Palm Beach Nursing CenterLake Worth, FL 3 of 5Throgs Neck Rehabilitation & Nursing CenterBronx, NY 4 of 5Acclaim Rehabilitation And Nursing CenterJersey City, NJ 4 of 5Adroit Care Rehabilitation And Nursing CenterRahway, NJ 4 of 5Anchor Care and Rehabilitation CenterHazlet, NJ 4 of 5Atrium Center for Rehabilitation and NursingBrooklyn, NY 4 of 5Isles Of Boynton Nursing And Rehab CenterBoynton Beach, FL 4 of 5Sun Harbor HealthcarePort Charlotte, FL 4 of 5Victoria Crossing Rehabilitation CenterBrandon, FL 5 of 5Cypress Garden Center for Nursing and RehabilitatiFlushing, NY 5 of 5Staten Island Care CenterStaten Island, NY

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 / managerTypeRoleShareSince
BOCA INTERMEDIATE OPCO HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2023
FLNHO CAPITAL GROUP LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2023
PALM BEACH HEALTH PARTNERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2023
FISCHEL, MAYERIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2023
VARGHESE, MATHEWIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/01/2023
LANDA, BENJAMINIndividualCORPORATE OFFICERsince 04/01/2023
GORDON-FORBES, CAMERONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2025
OJEDA, MANUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/16/2026

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$13.6M
Net patient revenuemost recent cost report
-13.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 4%Medicare 7%Other / private 89%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$347per resident / day
operating cost
$10,539per month
≈ monthly operating cost
$306per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

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 105481. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-04-19, 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.

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