Victoria Crossing Rehabilitation Center
701 Victoria St, Brandon, FL 33510 · For profit - Corporation · 120 certified beds · (813) 681-4220 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 number of inspection citations overall (15) — 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
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (67%) runs well above the national median (45%)
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) | 2 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 | 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 2026-04 to 2026-06, this home’s CMS overall rating held steady at 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 | 6.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.6% | 5.5% | 5.4% | worse |
| 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 | 3.2% | 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 | 1.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.7% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 6.4% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 99.7% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.6% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.4% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.88 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.58 | 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.
54.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.3% 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 239 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 0.81 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 44% 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 | 54.5%CMS range 44.6–63.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 7.7–15.5 | 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 | 47.3% | 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 | 49.8% | 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 | 45.2% | 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 | 96.7% | 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 | 99.3% | 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 | 97.9% | 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 | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.5%CMS range 4.5–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 120 beds and averages 114.5 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.480 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 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 3.19 hrs/resident/day on weekends vs 3.60 on weekdays — 11% thinner on weekends. RN hours go from 0.73 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 67% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2026-01-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure two (#25 and #19) of two residents reviewed for self administration of medications were assessed by the facility and a physician order was obtained to allow for the self-administration of medications related to the administration of oral and nebulized medications.Findings included: On 1/6/26 at 10:08 a.m. Resident #25 was observed lying in bed with an over-bed table within reach of the resident. A medication cup containing 10 oral tablets was sitting in the corner of the table within reach of the resident. The resident reported just getting the medication and would take them. Resident #25 reached over to the table, retrieved the cup, and swallowed all of the tablets at one time. During the observation, no staff member was in the room with the resident.Review of Resident #25s admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to acute and chronic 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.
- Potential for harm · D2026-01-08 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide Meal Menus to four (Resident #24, Resident #67, Resident #105 and Resident #110) out of four residents reviewed for choices.Findings Included: During an interview on 01/05/2026 at 9:27 a.m., Resident #24 stated they have not passed out menus in a while, so she has no idea what she is getting to eat until they bring the trays in. An observation of Resident #24's wall and overside table revealed no meal menu. During an interview on 01/05/2025 at 10:02 a.m., Resident #67 stated they don't pass out menus anymore, so I never know what they are bringing me to eat. They will bring my tray, and I can order something else, but I cannot order it ahead of time since I don't know what they are serving. An observation of Resident #67's room revealed no meal menu was posted. During an interview on 01/07/2026 at 10:00 a.m., Resident #110 stated I don't know what the meal will be before I get my meal tray so I can not pre-order an alternative meal. They stopped providing us with menus in our rooms. During an interview on 01/07/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to allow the resident to remain in the facility during a pending appeal for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness.Review of a care plan for Resident #133 initiated on 10/03/2025 revealed a focus; [Resident #133] wishes to return home with her [family member]. The goal showed the resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. Interventions included to encourage resident to discuss feelings and concerns impeding discharge. Establish a pre-discharge plan with the resident/resident representative and evaluate the process. SS (Social Services) will make…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to document the required discharge/transfer notifications and the reason for discharge for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #133's electronic medical record revealed revealed no documentation regarding required elements for discharge per policy.An interview was conducted on 01/08/2026 at 3:56 p.m. with the Social Services Director (SSD). The SSD stated having worked at this facility for only a week. The SSD stated not knowing Resident #133 or anything about an appeal for discharge. The SSD reviewed Resident #133's medical record and confirmed there was no documentation regarding the appeal. The SSD confirmed there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · 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 observation, interviews and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR)s for two (#3 and #105) were updated to include current diagnoses and screening questions were answered appropriately of two residents sampled for PASRR.Findings Included: During an interview on 01/05/2025 at 10:46 a.m., Resident #3 stated the people who speak spanish have it out for me. They are talking about me in Spanish. When I first got here, they (spanish speaking people) accused me of molesting my daughter. Resident #3 was not able to identify any certain person and just referred to the spanish speaking people. Review of Resident #3's admission Record showed Resident #3 was admitted to the facility on [DATE] with diagnoses of psychotic disorder with hallucinations due to known physiological condition (12/16/2025), bipolar disorder, current episode depressed, mild (04/17/2025), generalized anxiety disorder (11/05/2025), and unspecified dementia, unspecified severity, 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 · D2026-01-08 · 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
Based on interviews, observation, and record review, the facility failed to provide Activities of Daily Living (ADLs) related to fingernail trimming for one resident (#135) out of four residents sampled.Findings Included: During an observation and interview on 01/05/2026 at 10:30 a.m., Resident #135 was observed to have long untrimmed nails with black build-up underneath. Resident #135 stated I would like my nails trimmed. I don't like them being this long.During an interview and observation on 01/07/2026 at 9:04 a.m., Resident #135's was observed to have long untrimmed nails with black build up underneath. Resident #135 stated, I have asked them to trim my nails, but they have not done it yet.Review of Resident #135's admission record revealed an admission date of 01/02/2026. Resident #135 was admitted to the facility with diagnosis to include cerebral infarction, cerebral amyloid angiopathy, muscle weakness, unspecified lack of coordination, and need for assistance with personal care.Review of Resident #135's Care Plan dated 01/03/2026 revealed a focus - Resident #135 has an ADL…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review the facility failed to follow physician orders related to medication perimeters and wound care for two residents (#10 and #22) out of two residents sampled.Findings Included: Review of Resident #10's admission record revealed an admission date of 11/18/2025. Resident #10 was admitted to the facility with diagnosis to include hepatic failure, acute embolism and thrombosis of right femoral vein, portal hypertension, hypotension, and idiopathic hypotension, sedative, hypnotic or anxiolytic abuse. Review of Resident #10's physician orders dates active as of 01/08/2026 revealed:Midodrine Give 15 mg by mouth three times a day for Hypotension Hold if Systolic Blood Pressure (SBP) great than 130. Start Date: 12/18/2025 Review of Resident #10's Medication Administration Record (MAR) for November 2025 revealed the medication was given with a SBP greater than 130 on 11/01/2025, 11/24/2025, and 11/26/2025. Review of Resident #10's Medication Administration Record (MAR) for December 2025 revealed the medication was given with a SBP greater than…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to provide toileting needs for one (#97) of two residents sampled for bladder and bowel incontinence. Findings included: On 1/6/26 at 9:13 a.m. Resident #97 was observed lying in bed. The resident reported to being wet, had not been changed since 5:00 a.m., and normally does not get changed until staff dress around 11:00 a.m. An interview was conducted with Staff O, Central Supply/Certified Nursing Assistant (CNA) on 1/7/26 at 8:52 a.m. The staff member reported the process in morning was to receive report from 11 p.m.-7a.m. shift, rounds on residents to ensure they are clean, and if wet, changed them at that time. Staff O stated Resident #97 was a heavy wetter, checks residents for incontinence every 2-3 hours, checks heavy wetter's more often. On 1/7/26 at 9:08 a.m. Resident #97 was observed lying in bed eating breakfast. The smell of urine was noticeably in the resident room while conducting an observation of medication administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status for three (#1, #71, and #113) residents of eight residents reviewed for nutrition. Findings include:1.An observation on 1/5/2026 at 11:10 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/4/2026.An observation on 1/6/2026 at 9:46 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/5/2026.An observation on 1/8/2026 at 10:30 A.M. revealed Resident #1 had a foam water cup on his bedside table dated 1/7/2026.An interview was conducted on 01/06/2026 at 10:20 A.M. with Resident #1. He said his still hungry and asked for another breakfast tray. He had not received an additional tray. He said he does not need assistance eating his meals.A review of Resident #1's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to Type 2 diabetes mellitus, muscle weakness (generalized), and assistance with personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and three errors were identified for two (#138 and #7) of five residents observed. These errors constituted a 12.00% medication error rate.Findings included: 1.On 1/6/26 at 4:10 p.m., an observation of medication administration with Staff J, Licensed Practical Nurse (LPN), was conducted with Resident #138. The staff member dispensed the following medications:Ipratropium - Albuterol sulfate 0.5 milligram (mg)/3 mg/3 milliliter (mL) vial - prescribed to Resident #137insulin Lispro (Humalog) vial - 6 unitsacetaminophen extra strength 500 mg over-the counter (otc) tablets - 2 tabs ferrous sulfate 325 mg tab oral otcThe observation revealed Staff J removing a vial of Ipratropium - Albuterol from a box labeled for Resident #137. The staff member entered the resident's room with the vial and asked if the resident wanted…
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 5 citations
- Potential for harm · D2026-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen as evidenced by: a) food stored in the walk-in fridge and freezer were not labeled or stored properly b) garbage in the kitchen prep area was not contained safely or hygienically; c) food stored in the nourishment rooms were not labeled or stored properly; d) hand hygiene was not performed during a change of tasks.Findings Included:On 1/5/26 at at 9:11a.m., an initial tour of the kitchen was conducted with the Dietary Director (DD).On 1/5/26 at 9:20a.m., an observation of the facility's walk-in refrigerator revealed an opened, and unlabeled gallon of milk. The DD confirmed that the milk was not properly labled and stored.On 1/5/26 at 9:22a.m., an observation inside the facility's walk-in refrigerator revealed thawed pork loins located 2-3 inches above the floor of the walk-in on a plastic platform. The pork loin had no open date and no pull date from the freezer. The DD…
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 · E2024-09-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to ensure proper infection control practices were in place on one out of four units related to proper personal protective equipment (PPE) use, timeliness of contact precaution orders, and hang hygiene. Findings included: An observation was conducted on 9/5/24 at 9:46 a.m. of Staff E, Registered Nurse (RN) during medication administration. Upon exiting a resident room after administering mediation, Staff E did not perform hand hygiene. The nurse proceeded to the medication cart, touched the computer and other items on the cart. An observation was conducted on 9/5/24 at 10:03 a.m. of a visitor in the room of Resident #11. The room had a Contact Precaution sign on the door and the visitor had on no PPE. An observation was conducted on 9/5/24 at 10:21 a.m. of an unknown staff member in Resident #11's room with no PPE. An interview was conducted on 9/5/24 at 10:23 a.m. with a family member of Resident #11. The family member said the resident is…
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 · D2024-09-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's family/responsible party and the resident's physician of a change in condition for two (#1, #12) of 12 sampled residents. Findings included: 1. Review of the Medical Record for Resident #1 showed he was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's diagnoses included acute respiratory failure, acute pulmonary edema, intestinal pulmonary disease, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer's disease and dependence on renal dialysis. Review of a progress note for Resident #1 signed by Staff C, Registered Nurse (RN) dated [DATE] at 7:41 a.m., showed during morning rounds, the night shift nurse reported the patient spent the night calling family members and asking for help. This nurse went to the patient's room, and he was confused, but stable. Family member called 911, but patient refused to be transferred to the hospital. On [DATE] at 2:01 p.m., an interview was conducted with Resident #1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound assessments and wound care for 1 (Resident #12) of 1 sampled residents for wounds. Findings included: An observation and interview was conducted on 9/5/24 at 4:51 p.m. of Staff A, Registered Nurse (RN)/Unit Manager (UM) going to Resident #12's room and looking at the resident's bilateral lower extremities. The left lower extremity knee had a scab with small spots of blood. The posterior end of the right lower extremity stump was noted to be covered with a large area of necrotic eschar with small open areas of slough. The resident complained of pain, said she, told the nurses she needed wound care, and no one ever came. (Photographic evidence obtained with resident permission.) Following the observation, Staff A, RN/UM reviewed Resident #12's medical record. She confirmed the wound care team was not following the resident and there were no wound care orders in place. She said Resident #12 should be getting looked at 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 · D2024-09-05 · 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 interviews and record review, the facility failed to ensure Hemodialysis (HD) care was provided per physician orders for one (#1) of two dialysis residents reviewed. Findings included: Review of the medical record for Resident #1 showed he was admitted to the facility on [DATE] with diagnoses to include dependence on Renal Dialysis. Review of Active Physician orders as of 08/21/24 showed orders to: Assess dialysis site for signs and symptoms of infection every shift. Assess dialysis site and indicate yes/no. If yes, please indicate in progress note. Assess dressing site for bleeding upon return from dialysis and after dressing removal every shift. Call MD (Medical Doctor) if bleeding. Check venous access device every shift for bleeding and infection. If bleeding is noted apply adequate continuous pressure to site x 10 minutes and reassess. Repeat x 1 if necessary. Inform MD as needed. Review of a care plan for Resident #1 showed a focus initiated on 08/19/24 showing Resident #1 needed dialysis related…
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 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 32 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BRANDON HEALTH MEMBER LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/2022 |
| FLNHO CAPITAL GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 33% | since 04/01/2022 |
| ORNSTEIN, MARTON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 25% | since 04/01/2022 |
| LUCADANO, KIMBERLY | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2022 |
2 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.
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 106155. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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.