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Isles Of Boynton Nursing And Rehab Center

3001 South Congress Avenue, Boynton Beach, FL 33426 · For profit - Limited Liability company · 180 certified beds · (561) 737-5600 Medicare & Medicaid certified

Call the home — (561) 737-5600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20252 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$16,152 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • 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 $16,152 in federal fines (most recent 2025-01-08)
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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
3200 S Congress Ave · (561) 336-4776 · Call to confirm hours
Pharmacy
3800 S Congress Ave · (561) 736-5161 · Call to confirm hours
Grocery
1520 Neptune Dr · (561) 731-4440 · Call to confirm hours
Park
3111 S Congress Ave · (561) 742-6575 · Typically dawn to dusk
Place of worship
3015 S Congress Ave · (561) 710-8448

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 fell from 5 to 4 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 rating4★
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 increased3.1%8.7%15.4%better
Long-stay residents who lose too much weight9.4%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 symptoms0.7%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 injury0.8%2.5%3.3%better
Long-stay residents whose ability to walk worsened3.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.2%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.2%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control2.7%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 table7.1%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.7%94.7%79.4%better
Short-stay residents rehospitalized after admission31.5%26.1%22.6%worse
Short-stay residents with an outpatient ER visit5.9%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.182.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.581.151.80better

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.

53.0% 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 161 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.0%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
50.4%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 50.4% 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 129 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% 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 SNF53.0%CMS range 43.9–60.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.3–14.610.7%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 discharge50.4%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 discharge51.9%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 discharge41.9%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 identified97.5%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 setting83.7%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 discharge88.9%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 stay0.4%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 worsened0.8%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 hospitalization8.7%CMS range 5.5–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

0.91
RN hours/ resident / day
0.53
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.64
RN hoursweekends
27.8%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 171.0 residents a day — about 95% occupied, or roughly 9 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.28 hrs/resident/day on weekends vs 3.72 on weekdays — 12% thinner on weekends. RN hours go from 1.02 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below the national median of 45%. 4 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

7
deficiencies at the latest standard inspection (2026-02-12)
9
at the previous standard inspection (2024-08-29)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2025-01-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interview, record review and observation, the facility failed to protect the residents' right to be free from neglect by failing to provide appropriate supervision to meet the needs 1 of 3 sampled residents (Resident #1), who displayed exit seeking behaviors. The deficient practice allowed Resident #1, on 12/25/24 between 7:15 AM and 7:20 AM, after he removed the right window panel from the window frame in his room, to fall from the window approximately 20 ft to the ground. Resident #1 was found on the ground, in an area approximately three feet wide, between the building and a mature palm tree. Resident #1 was transferred to the hospital by ambulance for evaluation and treatment after suffering from serious injuries. The findings include: Record review revealed the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation, dated October 2019, defined Neglect as follows: Neglect means the failure of the center, its associates or service providers, to provide goods…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Jcited before2025-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 interview, record review and observation, the facility failed to provide appropriate supervision to prevent 1 of 1 sampled resident, Resident #1, from falling from a second-floor window. The deficient practice allowed Resident #1, on 12/25/24 at between 7:15 AM and 7:20 AM, after he removed the right window panel from the window frame in his room, to fall from the window approximately 20 ft to the ground. Resident #1 was found on the ground, in an area approximately three feet wide, between the building and a mature palm tree. Resident #1 was transferred to the hospital by ambulance for evaluation and treatment after suffering from serious injuries. The findings include: Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included, Traumatic Subarachnoid Hemorrhage without a Loss of Consciousness, History of Falling, Major Depressive Disorder, Alcohol use with Intoxication, and Scalp Laceration without foreign body. The Minimum Data Set (MDS) assessment dated…

    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 · Past Non-Compliance
  • Potential for harm · Dcited before2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observations interviews and record review the facility failed to ensure correct medications were given as per physician's orders for 1 out of 25 opportunities for medication administration affecting Resident #155. The findings included: Review of the facility's policy titled, Clinical-Medication Administration with a revised date of 12/10/25 included in part the following: Guidelines for Medication Administration: Have a working knowledge of the medication you are administering; common dosage, common uses, common side effects, and reason the medication is being given to the resident. Use available resources such as drug handbooks, medication package inserts, medication websites, the provider, or the pharmacist if unfamiliar with the medication. Observe the Rights of Medication Administration: Right Medicine. Record review for Resident #155 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Displaced Avulsion Fracture (Chip Fracture) of Left…

    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 · D2026-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, interviews and record review the facility failed to ensure resident received wound care in a manner consistent with professional standards of practice to promote the healing of pressure ulcers for 1 of 1 sampled resident observed for wound care (Resident #21). The findings included:Review of the facility's policy titled, Dressing -Dry/Clean with an effective date of 04/01/22 included in part the following: Perform hand hygiene, put on clean gloves, Use no-touch technique. Use sterile tongue blades (depressor) and applicators to remove ointment and creams from containers. Apply the ordered dressing and secure with tape or bordered dressing per order. Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Quadriplegia, Chronic Osteomyelitis Left Thigh, Pressure Ulcer of Unspecified Site, Severe Protein Calorie Malnutrition, and Major Depressive Disorder.…

    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 before2026-02-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure securing a device in place for 1 of 6 sampled residents with an indwelling catheter (Resident #21). The findings included:Review of the facility's policy titled, Nursing - Physician's Orders with a revised date of 03/10/23 that included in part the following: Treatment orders: all treatments should include the treatment to be used and location of where the treatment should be placed, frequency and if appropriate, how the area should be cleaned and how it should be covered. Reason for the treatment required (diagnosis). Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Quadriplegia, Chronic Osteomyelitis Left Thigh, Pressure Ulcer of Unspecified Site, Severe Protein Calorie Malnutrition, and Major Depressive Disorder. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview…

    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 · D2026-02-12 · tag F0694 — isolated
    Provide 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 observation, interview, and record review the facility failed to maintain Intravenous (IV) access dressing in a sanitary manner and failed to change an IV access dressing as per facility policy for 1 of 1 sampled resident reviewed for IV access, (Resident #194). The findings included: Review of the facility policy titled Policy and Procedure: Clinical-Medication Administration revised 12/05/2025 documented Purpose: To administer medications as per provider's order and in accordance with regulatory guidelines and practice standards. Intravenous Medication or Fluids (IV therapy): . complete dressing changes as ordered and as needed to the insertion site. Review of the record revealed Resident #194 was admitted to the facility 01/20/26 with a diagnosis of Heart Failure. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #194 had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide respiratory care in a manner consistent with physician orders and facility policy for 1 of 1 sampled resident reviewed for tracheostomy care (Residents #223.) The findings included: Review of the facility's policy titled Policy: Nursing- Tracheostomy Care dated 04/01/22 documented .Equipment and Supplies 1.Gloves (clean and Sterile) 2.Mask and eyewear (as indicated).Procedure Guidelines: 1. Verify Physicians orders.8. Assess patient HR (Heart Rate)/RR (Respiration Rate)/ SaO2 Lung sounds 9.Remove and discard soiled dressing, note drainage and assess stoma site suction trach if necessary.25.Reasses the patient. Using the procedure for tracheostomy suction, suction the resident if needed. Review of the record revealed Resident #223 was admitted to the facility 01/27/26 with diagnoses of Anoxic Brain Damage (when the brain is completely deprived of oxygen, causing brain cells to begin dying)and acute respiratory failure with hypoxia.…

    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 before2026-02-12 · 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 review, the facility failed to ensure only authorized staff have access to treatment carts for 6 out of 6 treatment carts, failed to ensure med carts are locked at all times for 1 out of 8 med carts, and failed to ensure mediations were secured at the bedside for 1 of 39 sampled residents (Resident #155). The findings included:Review of the facility's policy titled, Clinical - Medication Storage and Labeling with a revised date of 12/09/25 included in part the following: Medications and biologicals in medication rooms, carts, boxes, and refrigerators are to be maintained within secured (locked) locations, accessible only to designated staff. 1) On 02/11/26 at 9:30 AM an observation of wound care performed by Staff A Wound Care Registered Nurse (WCRN) who was assisted by Staff B, Certified Nursing Assistant (CNA), for Resident #21. Upon completion of the wound care, Staff A, WCRN, gave his keys (with keys to all med treatment carts) to Staff B, CNA, to stock 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
  • Potential for harm · D2026-02-12 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to serve ground meats, per the physician's diet order. This had the potential to affect 1 of 1 sampled resident, who was on a regular texture diet with ground meats (Resident #103). The findings included:A record review revealed that Resident #103 was admitted to the facility on [DATE]. He has received Hospice services since 09/09/2022. His admitting diagnoses included Cerebral Atherosclerosis, Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, and Sarcopenia (muscle wasting). The resident's diet listed in the electronic medical records was for a Regular diet, with Regular texture food, Regular/Thin Liquids consistency, and Ground Meat since 08/06/25. A nutrition progress note dated 08/06/25 revealed that Resident #103's daughter requested that ground meats were added to his diet for ease of chewing. A record review of the Resident #103's diet in the meat ticket program's listing (Dietary List) of diets showed…

    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 · D2025-06-05 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 issue a refund due to the resident or resident representative within 30 days from the resident's date of discharge from the facility, for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3), reviewed for refunds. The findings included: 1. Record review revealed Resident #1 was admitted to the facility on [DATE]. Further record review revealed on 02/20/25 he was discharged to an assisted living facility. During an interview on 06/05/25 at 11:15 AM, Resident #1's family member confirmed the resident was discharged from the facility on 02/20/25, and they still have not received the money owed to them. He explained that they paid privately for his stay through 02/28/25. The family member said he called the Business Office Manager (BOM) more than 2 times, and he also sent emails regarding the refund. During an interview with the BOM (Business Office Manager) on 06/05/25 at 3:45 PM, she said that she sent a request for a refund on 04/21/25…

    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 · D2024-08-29 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 investigate an injury of unknown origin for 1 of 3 sampled residents reviewed for accidents (Resident #121). The findings included: A review of the facility's policy titled, Exception Reports dated 11/2019, documented: The Charge Nurse or designee must conduct an investigation of the accident/incident by way of completing the Exception Report and adding any additional information to determine the cause of the incident/accident. Resident #121 was admitted to the facility on [DATE]. A record review revealed a comprehensive assessment dated [DATE] that documented the resident had severe cognitive impairment and was dependent on staff for activities of daily living. A progress note dated 07/02/24 documented: The Nurse Practitioner (NP) aware of the positive knee X-ray results. The NP ordered the patient to the hospital ER (emergency room) for further evaluation. This writer informed the family that the patient c/o (complained of) pain to her knee upon…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0645 — isolated
    PASARR 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 observation, interview, record and policy review, the facility failed to obtain a Level I PASSAR (Preadmission Screening and Resident Review) for 2 of 6 residents reviewed for a Level 1 PASARR (Resident #67 and #90). The findings included: Record review revealed the facility's policy titled, Preadmission Screening (PASSAR/PASSR) dated March 2020 documented It is the policy of the center to follow the Federal and State regulations with regards to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. 1. Resident #67 was admitted to the facility post hospitalization on 10/17/23 with diagnoses that included Cerebral Atherosclerosis, Vascular Dementia, Anxiety and Dysphagia. According to the resident's admission Minimum Data Set (MDS) assessment dated [DATE], she was unable to answer the questions on the Brief Interview for Mental Status. This indicated the resident had severe cognitive impairment. On 08/28/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 address a resident's discomfort in a timely manner for 1 of 1 sampled resident (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE]. A review of the resident's admission Nursing Data Collection, dated 08/23/24 at 4:04 AM, documented Resident #246 was alert and oriented to person, place, time, and situation. The collection data further documented the resident was admitted with a urinary catheter. An interview was conducted with Resident #246 on 08/26/24 at 1:00 PM. The resident stated her urinary catheter was changed on the night of 08/24/24, due to the catheter being clogged. The resident stated there was a large amount of sediment in the catheter, and her genitals were itching/burning due to what she believed was a yeast infection. Resident #246 stated she told the nurse about the itching/burning of her genitals, and the nurse stated she would get an order for an ointment. The resident stated she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 record review and interview, the facility failed to obtain the results of a urinalysis for a resident with a Urinary Tract Infection (UTI) in a timely manner for 1 of 1 sampled resident (Resident #247), resulting in a delay of treatment for a UTI. The findings included: Resident #247 was admitted to the facility on [DATE]. Record review revealed a comprehensive assessment dated [DATE] documented the resident was cognitively intact and was frequently incontinent of urine. Record review revealed an order for Urinalysis Culture and Sensitivity on 12/22/23. Further record review did not reveal any documentation for the reason for the urinalysis order, or any signs or symptoms/condition of Resident #247. A review of Resident #247's urinalysis results revealed the resident's urine was collected and received on 12/23/23. Further review of the results of the Urinalysis Culture and Sensitivity was resulted on 12/27/23, with a specific bacteria. Resident #247 was ordered an antibiotic on 12/27/23. A review or 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 · D2024-08-29 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide behavior monitoring for 2 of 5 residents sampled for unnecessary medications (Resident # 63 and #105). The findings included: 1) Resident #105 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Unspecified dementia, and Major Depressive Disorder. The Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date of 07/07/24. This indicated the resident had severe cognitive impairment. On 05/13/24 physician orders revealed the resident was started on an antipsychotic medication called Seroquel 50 milligrams 1 by mouth 2 times a day for depression. Seroquel is an antipsychotic that can be used to treat major depression. A review for behavior monitoring for this medication revealed there was no behavior monitoring done. On 08/28/24 at 12:59 PM, an interview was conducted with Staff G, a Licensed Practical Nurse (LPN). Staff G was asked where…

    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 · Dcited before2024-08-29 · 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 — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to to secure a resident's medications for 1 of 1 sampled resident (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE]. A review of the resident's admission Nursing Data Collection, dated 08/23/24 at 4:04 AM, documented Resident #246 was alert and oriented to person, place, time, and situation. An interview was conducted with Resident #246 on 08/26/24 at 1:00 PM. The resident stated she was using an antibiotic cream, prescribed for her toe, on her genitals for some relief of itching/burning. The resident pulled out a tube of Gentamycin ointment from her bedside drawer. An interview was conducted with the Unit Manager (UM) on 08/26/24 at 3:00 PM. The UM acknowledged Resident #246 should not have any medications unsecured at bedside.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a 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 coordinate care with nursing staff related to use of hoyer lift and specialized chair for 1 of 4 residents reviewed for rehabilitation services (Resident #245). The findings included: Resident #245 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required total assistance with activities of daily living (ADL). Resident #245 was care planned for ADL self care deficit as evidenced by laminectomy and physical limitations. An interview was conducted with Resident #245 on 08/28/24 at 1:00 PM. The resident stated he had not been out of bed since admission (14 days). The resident stated he would love to get out of bed. An interview was conducted with the Rehabilitation Director on 08/29/24 at 10:00 AM. The Director stated according to the resident's therapy notes, the resident is seen at bedside. The Director stated the therapy notes did not document why 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 · D2024-08-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately document physician ordered vital signs and cough secretions monitoring for 1of 1 sampled resident (Resident #440). The findings included: Resident # 440 was readmitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Overactive Bladder, Fracture of the neck of right femur, Musculoskeletal weakness, and History of falling. Review of Section C of the MDS (Minimum Data Set) assessment showed a BIMS (Brief Interview of Mental Status) score of 12 on 07/16/23, indicating moderately impaired cognitive function. There was no updated BIMS score as of 08/26/24. Record review of Physician orders dated 08/23/24 revealed Resident #440 was to perform cough and deep breathing exercises for 5 minutes, 4 times daily. It indicated to document the patients tolerance and sputum production after each exercise four times a day for 10 Days. Further record review on 08/27/24 revealed a physician order dated 08/23/24 stating to take vital…

    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 · D2024-08-29 · 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 observation, interview, and record review, the facility failed to implement CDC (Center for Disease Control and Prevention) guidelines and recommendations for Contact Precautions for 2 of 2 sampled residents (Resident # 442 and Resident #12); and for Enhanced Barrier Precautions for 1 of 32 sampled residents (Resident # 440). The findings included: CDC Contact Precautions revealed the following: Clean hands before entering and when leaving the room. Providers and Staff must also wear gloves before room entry. Discard gloves before room exit: Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. https://www.cdc.gov/infection-control/media/pdfs/contact-precautions-sign-P.pdf. CDC Enhanced Barrier Precautions revealed the following: Everyone must clean their hands including when both entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following:…

    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 · D2024-02-01 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and administrative record review, the facility failed to ensure that one of two hallways on the Medbridge Unit is maintained and did not have an offensive odor of urine. The findings included: An observation on the Medbridge Unit on 01/31/24 beginning at 1:00 PM revealed the smell of a lingering strong urine odor was noted in the hallway from rooms 172-173 to 178-179. The smell was noted to be the strongest in rooms 176 - 179. An interview was conducted on 01/31/24 at approximately 1:05 PM with the Registered Nurse, Staff C, who confirmed the presence of the offensive odor, by stating, I know. The staff member then returned to her medication cart. An interview was conducted on 01/31/24 at approximately 1:07 PM with the Unit Manager, who also confirmed the presence of the odor and stated she knew who it was. An interview was conducted on 01/31/24 at approximately 1:15 PM with the Housekeeping Director, who reported that they clean the rooms and mop the floor. However, when 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-25 · 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, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior located on the First and Second Floors. The findings included: During the initial resident screenings conducted by the survey team on 05/22/23 and the Environment Tour conducted on 05/23/23 at 12:25 PM and accompanied with the facility's Director of Maintenance and Director of Housekeeping, the following were noted: First Floor: room [ROOM NUMBER]: The room walls were covered with large areas of black scuff marks, in disrepair and in need of re-painting. Resident care signs were posted on the wall above the D-bed of the resident. room [ROOM NUMBER]: The exterior of the bathroom door was damaged and in disrepair. Areas of peeling wallpaper. room [ROOM NUMBER]: Resident complaining of continued roach sightings at nighttime. room [ROOM NUMBER]: The room walls were covered with large areas of black scuff marks, in disrepair and in need 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained free of accidents hazards due to excessive hot water temperatures on 1 (Wing C- 20 resident rooms) ) of 3 residential wings located on the first floor. The findings included: During the initial screening of residents on 05/22/23 at 10 :30 AM that located on the First Floor C Wing (Rooms #101 - #119), it was noted that the hot water temperature in the bathroom of room [ROOM NUMBER] was very hot to the touch. The surveyor asked the two residents (2) residing in the room if there were any issues with the hot water temperature and the response from both residents was no. At the request of the surveyor, a digital food thermometer from the dietary department was obtained. The thermometer was calibrated and the hot water temperature in the bathroom of room [ROOM NUMBER] was recorded at 119 degrees Fahrenheit (F). At the surveyor's request, additional rooms located on First Floor C Wing were taken…

    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 · D2023-05-25 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to maintain resident's independence with eating for 2 of sampled 13 residents reviewed for nutrition, Residents #23 and #104. The findings included: 1. Record review for Resident #104 revealed the resident was admitted to the facility on [DATE] with most recent readmission date of 05/18/23 with diagnoses that included: Multiple Sclerosis, Syncope and Collapse, Dysarthria and Anarthria, and Seizures. Review of the Minimum Data Set (MDS) for Resident #104, dated 04/20/23, revealed in Section C a Brief Interview of Mental Status (BIMs) score of 14, indicating cognition is intact. Section G revealed for bed mobility and eating both had a self-performance of extensive assist with support of one person assist; and transfers, dressing and personal hygiene all had a self-performance of total dependence with support of two plus person assist. Review of the physician's orders for Resident #104 included an…

    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 · D2023-05-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to address significant weight loss in a timely manner for 1 of sampled 13 residents reviewed for nutrition, Resident #76. The findings included: Record review for Resident #76 revealed the resident was admitted to the facility on [DATE], left the faciity on [DATE] and was readmitted to the facility on [DATE]. Diagnoses included: Aftercare Following Joint Replacement Surgery, Noninfective Gastroenteritis and Colitis, Abdominal Pain, Chronic Kidney Disease Stage 3, Type 2 Diabetes Mellitus, Presence of Cardiac Pacemaker, Alcohol Abuse, Gastroesophageal Reflux Disease without Esophagitis, Nausea, Localized Edema. Review of the Minimum Data Set (MDS) for Resident #76 with a date of 03/14/23 revealed in Section C a Brief Interview of Mental Status score of 10 indicating the resident had moderate cognitive impairment. Section G revealed for bed mobility, transfers, toilet use, and personal hygiene all had a self-performance of extensive…

    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 · D2023-05-25 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 observations, interviews, and record review, the facility failed to provide fluid management for 1 of 2 sampled residents reviewed for dialysis (Resident #92) and failed to provide snacks-to-go for 2 of 2 sampled residents for dialysis (Residents #92 and #115). The findings included: 1. Record review for Resident #115 revealed the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Systematic Lupus Erythematosus, and Dependance on Dialysis. Review of the Minimum Data Set (MDS) for Resident #115 dated 02/26/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Section G revealed for Bed mobility, Dressing, and Personal hygiene that all had a self-performance of extensive assistance with support of one person assist, eating had a self-performance of independent with support of setup help only. Review of the Physician's orders for Resident #115 revealed an order dated 11/19/22 for 'CHO Controlled Hi…

    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 · D2023-05-25 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 adaptive equipment for eating and drinking as ordered for 2 of 13 sampled residents reviewed for nutrition, Residents #126 and #132. The findings included: 1. During the observation of the lunch meal on 05/22/23 at 12:30 PM, it was noted that Resident #126 had 1 Proval Cup (Adaptive Drinking Cup) included on the meal tray. Further observation noted that there were 3 fluids (coffee, milk, and water) on the tray but none of the fluids were poured into Proval Cup. It was also noted there were 4 bottles of water and juices on the overbed table. The resident was noted to attempt to drink fluids from the regular drinking container but had issues grasping and swallowing. During a second observation conducted on 05/23/23 at 8:15 AM, it was noted that 4 beverages (water, juice, milk, coffee) were on the meal tray and only 1 Proval Cup provided on the tray. An interview conducted with the Certified Dietary Manager (CDM) on 05/23/23 at 10:00…

    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.

    Nutrition and Dietary 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

$16,152 in federal fines across 2 penalties.

  • $8,076 — penalty dated 2025-01-08
  • $8,076 — penalty dated 2025-01-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to 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 4 of 52.5+1.5 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 4 of 52.3+1.7 vs chain
Quality measures 5 of 54.2+0.8 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 2 of 5Yamato Nursing And Rehabilitation CenterBoca Raton, 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 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
BOYNTON 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
GLASS, JOHNIndividualW-2 MANAGING EMPLOYEEsince 04/01/2023
LANDA, BENJAMINIndividualCORPORATE OFFICERsince 04/01/2023

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.

$13.2M
Net patient revenuemost recent cost report
-17.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 5%Medicare 8%Other / private 86%

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

$365per resident / day
operating cost
$11,085per month
≈ monthly operating cost
$309per 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 105496. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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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