Braden River Rehabilitation Center LLC
2010 Manatee Ave E, Bradenton, FL 34208 · For profit - Limited Liability company · 208 certified beds · (941) 747-3706 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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.
| 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.0% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.8% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.8% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.5% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.7% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.5% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.0% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.8% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.23 | 2.13 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.31 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
45.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 288 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.5% 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 195 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.1%CMS range 40.0–49.8 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 8.4–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 78.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 86.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.1–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 208 beds and averages 159.7 residents a day — about 77% occupied, or roughly 48 beds typically open. It usually has some room. 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 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.38 hrs/resident/day on weekends vs 3.81 on weekdays — 11% thinner on weekends. RN hours go from 0.61 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Dcited before2025-06-04 · tag F0585 — failed to handle grievances — isolatedHonor 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 interviews and record review the facility failed to file a grievance for one resident (#1) out of three residents reviewed for grievances. Findings included: Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and discharged to another facility on 4/25/2025. A phone interview was conducted on 6/4/25 at 11:00 a.m. with Resident 1's Durable Power of Attorney (DPOA). Resident #1's DPOA said she was told Resident #1 was discharged to another facility and was transported there by a family member. Resident #1's DPOA said she went to the facility on 4/29/2025 and complained to the Director of Nursing (DON) about Resident #1 being discharged and transferred without her approval as well as not being notified of the transfer. The DPOA said she was very upset with the matter and felt the facility should have spoken and communicated with her. The DPOA said nobody from the facility had communicated back with her related to her complaint. Review of Resident #1's Durable Power…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-03 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility did not ensure a sanitary and homelike environment for four out of five units. Findings included: On 9/23/24 at 9:50 a.m., a tour of Unit 3 East was conducted. Observations of room [ROOM NUMBER] revealed paint and plaster on the right side of the mirror was missing with, an exposed nail head protruding from the wall. On 9/23/24 at 9:53 a.m., an observation of room [ROOM NUMBER] revealed an open drawer that appeared to have multiple holes in the wood laminate, towards the bottom of the drawer. Further observations of room [ROOM NUMBER] revealed missing wood laminate pieces on the closet door. An observation of the bathroom in room [ROOM NUMBER] revealed the right sink handle was missing a piece from the bottom. The drain in the sink appeared rusted and had a black and dark orange colored ring around the drain. On 9/23/2024 at 10:00 a.m., an observation of the bathroom in room [ROOM NUMBER] revealed a large opening in the wall, underneath the sink, which 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.
- Potential for harm · Ecited before2024-10-03 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and staff interviews, the facility failed to ensure cooked and prepared food was stored in a manner to prevent food contamination during four of four meal observations observed on 9/23/2024, 9/24/2024, 10/1/2024 and 10/2/2024. Findings included: During lunch and breakfast meal observations in the main dining room on 9/23/2024 at 11:59 a.m.; on 9/24/2024 at 8:20 a.m.; on 10/1/2024 at 8:00 a.m., 12:30 p.m.; and on 10/2/2024 at 8:00 a.m., 12:00 p.m., the dining room was observed with a Satellite steam table in the back of the room, near the kitchen entrance/exit door. The kitchen staff took cooked and prepared food items from the kitchen and placed them into hot service containers on this steam table. From there, a staff member plated the food items and handed them out to the receiving dining staff. Photographic evidence obtained. During all listed observed times, there were over thirty residents seated at tables in the main dining room and either awaiting or being served their meals. Two of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to file and follow-up on a grievance regarding Activities of Daily Living (ADL) care for one (#91) of five residents sampled. Finding includes: During an observation made on 09/23/2024 at 11: 47 a.m., and on 10/02/2024 at 1:00 p.m., Resident #91 was observed lying down in bed with her call light within reach. She was observed with no signs of distress. She stated she was very upset because she had not had a shower or her hair washed in two months. She stated she had reported this to everyone, but no one had assisted her. She stated she had told staff she preferred to take bed baths instead of showers because it hurt her when she got up. Review of an admission Record dated 10/03/2024 revealed Resident #91 was admitted to the facility with diagnoses to include but not limited to Heart Failure, Chronic Pain, Adult Failure to Thrive, Anxiety Disorder, Unspecified. Review of an annual Minimum Data Set (MDS) dated [DATE] revealed 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.
- Potential for harm · D2024-10-03 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for three (#93, #38, #60) of twenty-nine residents sampled. Findings included: 1. Review of Electronic Medical Record (EMR) for Resident #38 showed an admission to the facility with diagnoses including bipolar disorder, undifferentiated schizophrenia, post traumatic stress disorder, and major depressive disorder. Review of the resident's medication administration record for October 2024 revealed: - SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth at bedtime for GDR ATTEMPT related to SCHIZOPHRENIA, UNSPECIFIED (F20.9). - Wellbutrin XL Tablet Extended Release 24 Hour 300 MG (buPROPion HCl ER (XL)) Give 1 tablet by mouth in the morning for Depression related to MAJOR DEPRESSIVE DISORDER. Review of care plan dated 07/17/24 revealed: - A focus of PASRR level one Date Initiated: 10/10/2020 with a goal of PASRR will remain on his medical records…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 medical record review, the facility failed to ensure the revision and accuracy of care plan problem areas for two (#16, #91) of 55 sampled residents. Findings included: 1. On 9/23/2024 at 10:20 a.m., Resident #16 revealed he was at the facility for short term care and has plans to return home with his wife after completing therapy treatment/plan. Resident #16 confirmed he cannot get up out from bed on his own, and requires assistance from staff with dressing, personal hygiene, showering, and transfers. He reported that staff assist him out of bed to the wheelchair and staff take him where he needs to go as he cannot self propel himself in the wheelchair. Resident #16 expressed no desire to leave the facility prior to completing his therapy. Review of Resident #16's admission record he was his own decision maker and had no diagnoses to show he was an elopement risk. Review of the current Physician's Order Sheet for September 2024 and October 2024 revealed no orders related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and medical record review, the facility failed to provide grooming and personal hygiene assistance to one (#198) of four residents reviewed for activities of daily living (ADL's). Findings included: On 9/23/2024 at 10:20 a.m., 9/24/2024 at 8:00 a.m., 10/1/2024 at 9:30 a.m., and 10/2/2024 at 9:30 a.m., Resident #198 was observed with full facial hair to include the lower and upper neck. The facial hair was approximately three quarters to an inch long, and the resident's hair on his head appeared oily and uncombed. On 9/23/24 at 10: 20 a.m., Resident #198 revealed he had been in the facility for about a week and had no hair brush or comb. Resident #198 reported he could not shave and wash his hair on his own and needed staff assistance. On 10/1/2024 at 9:30 a.m., Resident #198 revealed he was having trouble with staff assisting him with shaving and getting him a hair cut since the time of admission. The resident said he was in the military in his past and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview,and record review, the facility failed to ensure a hazard free environment for one (#400) of six residents sampled. Findings included: On 09/23/24 at 11:46 a.m., fall mats were observed on the floor placed on both sides of bed two in room [ROOM NUMBER] with no resident in bed. Observed fall mats on the floor between bed one and bed two and between bed two and bed three, for a total of two fall mats located on each side of bed two. Resident #400 was sitting up in a wheelchair with fall mats on the floor next to her wheelchair. She stated they are a hazard she said she had tripped over them in the past, but they are still there. She stated they were her roommates, pointing to the empty bed. Photographic evidence obtained. On 10/01/24 at 2:11 p.m., fall mats were observed on the floor in room [ROOM NUMBER] on both sides of bed 2 with no resident in bed 2. Resident #400 was sitting up in a wheelchair next to a fall mat for bed 2. On 10/02/24 at 11:03 a.m., fall mats were observed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 one resident (#43), diagnosed with dementia, the treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being out of two residents sampled for dementia care. Findings included: On 9/23/24 at 12:39 p.m. Resident #43 was observed in her room in a wheelchair by the side of the bed. The resident had her head down on her knees. A lunch tray was observed on a bedside table untouched. The room was observed to be dark with no television or other stimulation present in the room. There was no roommate observed in the room. On 9/23/24 at 1:03 p.m. Resident #43 was observed still sitting in the room, crouched down with her head on her knees in a wheelchair. The lunch tray remained untouched. No staff members were observed attempting to assist with the meal. A review of the medical record showed Resident #43 was admitted to the facility with a primary diagnosis of dementia. Other diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. 29 medication administration opportunities were observed, and three errors were identified for two residents (#7 and #85) out of three residents observed. These errors constituted a 10.34% medication error rate. Findings Included: During medication administration on 10/2/24 at 8:39 a.m., Staff E, Licensed Practical Nurse (LPN) was observed preparing and administering the following medications to Resident #85. The medications included: amantadine 100 mg for Parkinson's gabapentin 100 mg for neuropathy fluphenazine HCl 10 mg for schizophrenia esomeprazole magnesium 20 mg for Gastroesophageal reflux disease (GERD) Zoloft 50 mg for depression Olanzapine 10 mg for anxiety aspirin 81 mg for preventative Loradamed 10 mg for allergies Cranberry 400 mg for urinary health Staff E, LPN administered Cranberry 450 mg, failed to administer the correct dose. Photographic Evidence Obtained. Fluticasone-Umeclidinium-Vilanterol- 100-62.5-25 inhalation aerosol for chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2024-07-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review and facility policy review, the facility failed to ensure an injury of an unknown source resulting in physical injury and subsequent death, were reported to the proper authorities within the prescribed timeframes for 1 (#1) of 3 residents reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on 06/13/24. Review of a progress note for Resident #1 dated 06/13/24 showed: Resident noted sitting up, leaning over in bed and was unresponsive. Hematoma and laceration noted to back of head. Wheelchair next to bed in locked position and blood noted on leg rest area of wheelchair. Resident appears to have had unwitnessed fall. MD [Medical Doctor] notified, and EMS [Emergency Medical Service] called to send resident to [name of Hospital] emergency room for evaluation and treatment. Resident's [Healthcare Surrogate] was notified of resident's status and transfer to hospital. Review of a progress note for Resident #1 dated 06/13/24 showed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observations, interviews and record review, the facility failed to ensure accurate documentation for dispensing and administration of controlled substances for two residents (Resident#15 and #16) of two residents sampled for pain medication administration. Findings included: 1) A review of Resident #16's Clinical Face Sheet revealed an admission date of 09/19/2023. The Medical Diagnoses list included: Multiple Sclerosis and chronic pain syndrome. A review of Resident #16's Medication Administration Record (MAR) for 10/2023, revealed a physician order as follows: Oxycodone HCI (hydrochloride) Oral Tablet 20 MG (milligrams) give 1 tablet by mouth every 4 hours as needed for non-acute pain 6-10, start date of 09/22/2023. A review of Resident #16's Grievance form, dated 10/30/2023, revealed the following: (Resident #16) stated that the two nurses did not fill his order and he was mad that his pain pills almost ran out. The form revealed the grievance had been investigated and the summary of the investigation was, They (sic) was no lapse in medication and (Resident #16) never…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review the facility failed to ensure the request for an outside medical procedure was honored for one residents (#44) out of two sampled residents in a timely manner. Findings included: On 07/25/22 at 9:23 a.m. Resident #44 said she told the nurse she wanted to see her gastroesophageal (GI) physician. Resident #44 stated she had to provide a stool sample to the facility first. Resident #44 stated, I don't understand their process. She denied anyone has followed up on the requested appointment. The resident said she told the nurse over a month ago, and does not know if an appointment was made. She stated, I don't know why I can't see the GI doctor. I only wanted to get a colostomy. Review of Resident #44's admission Record indicated she had resided at the facility for three years. Her primary diagnoses was anemia and Parkinson's disease. Review of a hospital Discharge summary, dated [DATE], showed: History of Present Illness. Seen In emergency department with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 observations, interviews and medical record review the facility failed to ensure reasonable accommodations were provided to maintain independence for assistance related to the use of the call light for one resident (#14) out of five residents reviewed for limited range of motion. Findings included: On 07/26/22 at 9:25 a.m. Resident #14 was observed from her doorway entrance sitting up in bed. She stated, I need some water. A table was positioned in front of her that contained her breakfast meal along with two spill proof cups. Both cups where empty and no water was available on the table. Resident #14 stated, yes when asked if she was able to use the call light. The call light was observed attached to the curtain divider. The call light was observed approximately one foot to her right and two feet behind the head of the bed. The resident looked back at the curtain, as she smiled stated, I can't reach that. Resident #14's right hand was noted with a contracture as she pointed back at the curtain. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure devices, braces, or splints for contracture prevention were provided as ordered for one resident (#333) out of six sampled residents. Findings included: Multiple observations were conducted of Resident #333. On 07/25/22 at 10:54 a.m. she was observed in her room seated in a wheelchair without any splints or braces on her arms or legs. On 07/25/22 at 12:54 p.m. the resident was observed in her room in a wheelchair with splints on both legs and a splint on her right elbow. On 07/26/22 at 3:36 p.m. the resident was observed in her room seated in a wheelchair without any splints on. Review of the medical record for Resident #333 was conducted. The admission Record revealed diagnoses that included Alzheimer's disease and hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting right dominant side. The Minimum Data Set (MDS) assessment, dated 07/16/22, revealed a Brief Interview for Mental Status (BIMS) score of 7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure care and services were in place for an indwelling catheter for one resident (#236) out of four residents with indwelling catheters. Findings included: On 7/25/22 at 8:00 a.m. Resident #236 was observed in his room seated in the bed. The resident was observed with an indwelling catheter hanging on the bed frame. On 7/25/22 at 11:00 a.m. a review of the medical record for Resident #236 revealed the resident was admitted to the facility on [DATE] with diagnoses, including but not limited to, benign prostatic hypertrophy, and obstructive and reflex uropathy. A review of the AHCA (Agency for Health Care Administration) Form 5000-3008 indicated the resident was transferred from an acute care hospital to the facility with an indwelling catheter. A review of the admission data set dated [DATE] revealed Resident #236 was admitted to the facility with an indwelling catheter in place. A review of the Order Summary Report on 7/25/22 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure physician orders were followed related to fluid restrictions for one resident (#129) out of nine sampled residents. Findings included: A review of the admission Record indicated Resident #129 was admitted into the facility on [DATE] with diagnoses that included end stage renal disease, calculus of kidney, and dependence on renal dialysis. Section C Cognitive Patterns of the admission Minimum Data Set (MDS), dated [DATE], showed Resident #129 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating cognitively intact. In Section O Special Treatments, Procedures and Programs, yes was checked indicating Resident #129 received dialysis while a resident. A review of the Order Summary Report with active physician orders as of 07/28/22 at 12:43 p.m. revealed the following: Dietary- Breakfast: 360 ml (milliliters) Lunch: 180 ml and Dinner 160 ml, order date 7/11/22, Nursing- Day: 120 ml, evening: 120 ml, night 60…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, medical record reviews, and policy review the facility failed to ensure 1. respiratory care and services was consistent with professional standards of practice for two residents (#99 and #111) out of two residents with tracheostomies, and 2. failed to ensure care and services were in place for oxygen therapy for one resident (#236) out of ten residents receiving oxygen therapy in the facility. Findings included: 1. On 07/25/22 at 10:27 a.m. Resident #99 was observed lying in bed and presented with a tracheostomy that was attached to a ventilation machine. The head of his bed was positioned at a 20-degree angle as his face revealed a moderate amount of perspiration. The bedside table contained a full box of inner cannulas. Staff A, Licensed Practical Nurse (LPN) was in the room and disconnected Resident #99's gastroesophageal tubing (G-Tube). Staff A stated, At this time is when I normally provide his trach care. Staff A, LPN opened a trach cleaning kit and while attempting to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-28 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to complete Dialysis Communication forms for one resident ( #129) out of the sampled five residents. Findings included: A review of the admission Record indicated Resident #129 was admitted into the facility on [DATE] with diagnoses that included to end stage renal disease and dependence on renal dialysis. Section C Cognitive Patterns of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #129 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. In Section O Special Treatments, Procedures and Programs, yes was checked indicating that Resident #129 received dialysis while a resident. A review of the Order Summary Report with active physician orders as of 07/28/22 revealed the following: Dialysis Chair Time: 6:50 AM, order date 7/5/22, Dialysis Days: One time a day every Monday, Wednesday, and Friday for ESRD (End Stage Renal Disease), order date 7/5/22. A 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.
- Potential for harm · D2022-07-28 · tag F0732 — isolatedPost nurse staffing information every day.
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 post current an accurate nurse staffing data at the beginning of each shift for two days (7/23/22 and 7/24/22) of three days. Findings included: During the initial facility tour on 7/25/22 at 7:07 a.m., an observation was made of the posted nurse staffing data at the reception desk. The posting showed a census of 137 and a date of July 22, 2022 (Photographic Evidence Obtained). An interview was conducted on 7/28/22 at 12:12 p.m. with the Staffing Coordinator. The Staffing Coordinator stated she updates the daily staffing posting. The Staffing Coordinator stated the posting is posted in the front at the reception area. The Staffing Coordinator stated the days that were missed were Saturday (7/23/22) and Sunday (7/24/22), and she did not work weekends. The Staffing Coordinator stated on weekends, the weekend supervisor updated the posting. The Staffing Coordinator stated the weekend supervisor is expected to ensure the posting is correct to include the date, census, and staffing numbers. A follow -up 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.
- Potential for harm · D2022-07-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure behavioral and side effect monitoring was conducted with the use of psychotropic medications for two residents (#233 and #84) of five residents sampled for unnecessary medications. Findings included: 1. On 7/25/22 at 9:50 a.m. Resident #233 was observed in his room lying in the bed. The resident was not able to answer questions related to his care. The resident appeared confused as to why he was in the facility and was asking what was going on. The resident had a wandering bracelet on his ankle. A review of the admission Record revealed Resident #233 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease, dementia, Alzheimer's Disease, restlessness, and agitation. A review of the Order Summary Report dated July 2022 revealed medication orders as follows: Deplin 15 capsule 15-90.314 milligrams give one capsule by mouth one time a day for depression, to start on 7/13/22. Namzaric…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-01-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to honor resident rights for seven (Residents #18, 33, 35, 38, 68, 84, and 94) of nine residents that smoked were denied the right to smoke and three (Residents #4, 19, and 69) of six residents were denied the right to have privacy during medication administration. Findings included 1. An interview of a group of alert and oriented residents on 1/28/21 at 10:00 a.m., revealed that the residents of the facility who smoke had not been able to smoke since March of last year when COVID-19 presented itself. The group reported that the facility banned smoking as everyone must stay in their rooms. Review of the smoking list provided by the Nursing Home Administrator (NHA) revealed that there were 9 residents highlighted as individuals who smoke. An interview with Resident #18 on 1/28/21 at 10:30 a.m., revealed that when she was admitted to the facility she smoked cigarettes. She reported that when COVID-19 started the facility stopped them 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.
- Potential for harm · D2021-01-29 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and medical record review, the facility failed to ensure care plans were developed and interventions implemented for four (#104, #177, #89, and #175) of 56 sampled residents related to 1. Ensuring fall floor mats were placed appropriately when the resident was in bed, 2. Development of a care plan related to dialysis treatment, and 3. Implementation of interventions related to weight loss. Findings included: 1. On 1/26/2021 at 10:45 a.m. and 1:30 p.m., Resident #104 was observed in her room and lying flat in bed with the call light placed within her reach. It was further observed in the room there was a large gray plastic fall mat placed upright against the bed by the door. Resident #104 was the only one who resided in the room. It was observed that the fall mat was not in place on the floor and there were no fall mats placed on either side of the bed both times observed while in bed. Resident #104 resided in the secured dementia unit. On 1/27/2021 at 1:40 p.m. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure an accident free environment for one (Resident #97) of eight residents sampled. The facility failed to ensure the area surrounding Resident #97's bed was clear of tripping hazards related to floor mats being placed to both sides of Resident #97's bed, and the floor mats were placed without objects stored on top of them. Findings included: Resident #97's admission Record revealed an initial admission date of 12/13/19, and an admission date of 07/13/20 with medical diagnoses of dementia with behavioral disturbance, cerebral infraction, traumatic subdural hemorrhage without loss of consciousness, muscle weakness, need for assistance with personal care, difficulty in walking, and cognitive communication deficit. His Minimum Date Set (MDS), dated 12/19/20, Section G: Functional Status revealed Resident #97 required extensive assistance with two-people for personal hygiene and toilet use. Resident #97 required limited assistance with two-people. A review of the Progress Notes, dated 12/27/20, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-01-29 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that each dialysis resident received dialysis services consistent with standards of practice for one (Resident #89) of three residents related to communication and follow up between the facility and the dialysis center. Findings included: Review of resident #89's record revealed that she was admitted to the facility on [DATE] with diagnosis that included End Stage Renal Disease, Dependence on Renal Dialysis, and, Metabolic Encephalopathy. The resident had a Brief Interview For Mental Status (BIMS) dated 12/31/20, with a score of 12 (Moderate Impairment). Review of the residents current physician orders revealed that she had a current order for dialysis on Tuesdays, Thursdays and Saturdays. Review of the resident's electronic records and the hard chart revealed that there was no documentation in the record to reflect any type of communication between the facility and the dialysis center. Interview on 1/29/21 at 9:06 a.m. with Staff F, LPN revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-01-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and record review, the facility failed to ensure medications were stored appropriately and supervised as given for one (Resident #17) of fifty-six sampled residents as evidence by nursing staff leaving cup with pills/tablets on the resident's over the bed table without ensuring that the resident took the medication. Findings included: On 1/26/2021 at 12:40 p.m., the room for resident #17 was observed. After knocking and announcing and upon entering the room, it was determined that the resident was out of the room and was seated in the dining room. This room and the dining room were on the secured unit which had residents who wandered and had need for constant supervision. Observation of the room revealed the over the bed table for resident #17 was positioned between her bed and the middle bed, and was observed with several opened snacks, several unopened drinks, a plastic hydration cup and a small clear mediation cup with two white in color round tablets. The cup of medications were observed within reach to anyone who came in the room. 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.
- Potential for harm · Dcited before2021-01-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, staff interview and facility record review, the facility failed to ensure kitchen equipment to include one of one walk in freezer maintained and free from heavy ice crystallization and ice build up. It was determined that large chunks of ice were forming in and around where food was stored. Findings included: On 1/26/2021 at 9:20 a.m. a brief kitchen tour was conducted with the Certified Dietary Manager (CDM). During tour the walk in freezer was observed with an internal temperature at around 13 degrees F. , which was below the required freezing temperature. Inside the freezer and up against the back wall, the motor housing and metal and foam insulated piping leading from the motor housing were observed with heavy ice crystallization and build up. The left corner of the motor housing and copper pipe was observed with a very large built up ice formation approximately two and a half feet long, two feet wide and approximately twelve inches thick at its thickest point. Further, there was ice build up and ice drops all over packaged food on the left side shelves to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SOVEREIGN HEALTHCARE HOLDINGS — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.7 | +0.3 vs chain |
| Health inspection | 3 of 5 | 3.2 | -0.2 vs chain |
| Staffing | 4 of 5 | 3.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 42 homes this chain runs (chain average 3.7★, per CMS)
Showing 40 of 42; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SOVEREIGN HEALTHCARE HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 01/01/2013 |
| CRONQUIST 2015 FAMILY TR | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2015 |
| JOHN J NOTERMANN BUSINESS TR | Organization | INDIRECT OWNERSHIP INTEREST | since 11/12/2017 |
| MANGINE, JOHN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/25/2012 |
| BERKADIA COMMERCIAL MORTGAGE LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 09/23/2014 |
| BLRE, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 01/01/2013 |
| HEALTH SERVICES PROPERTIES LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 01/01/2013 |
| CHERY, DAWN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 06/08/2017 |
| KAAR, SUSAN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 10/01/2003 |
| LANDY, FREDERICK | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 12/13/2022 |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2013 |
| CRONQUIST, ROYCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2018 |
| MARCIALES, WERTHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/08/2023 |
| MELTON, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/15/2009 |
| NOTERMANN, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| SEGER, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2025 |
| NOTERMANN, BRENDA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/05/2026 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 01/01/2025 |
| SOVEREIGN HEALTHCARE DISBURSEMENTS LLC | Organization | ADP OF THE SNF | since 01/01/2013 |
| KELLY, MICHELLE | Individual | ADP OF THE SNF | since 02/01/2018 |
CMS files one row per role, so the 33 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105045. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-03, 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.