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Northbrook Center For Rehabilitation And Healing

575 Lamar Ave, Brooksville, FL 34601 · For profit - Limited Liability company · 120 certified beds · (352) 799-2226 Medicare & Medicaid certified

Call the home — (352) 799-2226 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
$13,501 in federal fines
Insights

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

Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,501 in federal fines (most recent 2025-03-27)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Pharmacy
80 Ponce de Leon Blvd · (352) 796-4975 · Call to confirm hours
Grocery
1230 S Broad St · (352) 799-2220 · Call to confirm hours
Park
800 John Gary Grubbs Blvd · (352) 540-3830 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.4%8.7%15.4%better
Long-stay residents who lose too much weight2.3%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.6%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.0%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.7%2.5%3.3%better
Long-stay residents whose ability to walk worsened7.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.1%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.4%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control8.3%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 table4.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.3%94.7%79.4%better
Short-stay residents rehospitalized after admission24.6%26.1%22.6%typical
Short-stay residents with an outpatient ER visit9.6%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.822.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.581.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

40.4% 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 110 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.4%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
50.7%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 50.7% 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 71 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF40.4%CMS range 32.8–50.351.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 7.9–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge47.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.7%CMS range 5.6–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.50
RN hours/ resident / day
0.95
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.34
RN hoursweekends
44.1%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.2 residents a day — about 93% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.33 hrs/resident/day on weekends vs 3.78 on weekdays — 12% thinner on weekends. RN hours go from 0.56 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

10
deficiencies at the latest standard inspection (2025-03-27)
7
at the previous standard inspection (2023-12-14)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2025-03-27 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide 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 interview and record review, the facility failed to ensure residents received restorative services to maintain their mobility for 1 of 3 residents reviewed for restorative services, Resident #16. Findings include: During an interview on 3/25/2025 at 9:20 AM, Resident #16 stated, I am not doing any physical therapy or walking program at this time. I want to start walking again. Review of Resident #16's physician order dated 12/16/2024 showed it read, Restorative Program: Ambulate using 2ww [2 wheeled walker], gait belt, close wc [wheelchair] follow, and close contact assistance up to 100 ft [feet], 3x [3 times] weekly . Order Status: Active. Review of Resident #16's Physical Therapy Discharge summary dated [DATE] showed it read, Discharge Recommendations and Status . Restorative Programs . Ambulation Program Established/Trained 100' CGA [Contact Guard Assist] using gait belt, close wc follow. During an interview on 3/27/2025 at 12:18 PM, the Director of Nursing confirmed Resident #16 had an order for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Review of Resident #81's admission record showed the resident was most recently admitted on [DATE], with the diagnosis of pneumonia with onset date of 1/23/2025. Review of Resident #81's physician order dated 1/23/2025 showed read, Levaquin Oral Tablet (Levofloxacin), Give 500 mg by mouth at bedtime for Pneumonia for 7 Days. Review of Resident #81's MDS dated [DATE] showed no infections were documented under Section I- Active Diagnoses. Active Diagnoses in the last 7 days. During an interview on 3/26/2025 at 1:35 PM, Staff K, MDS Registered Nurse, stated that Section I of MDS for Resident #81 was not correct and it should have listed Pneumonia. Review of the facility policy and procedure titled Summit Care Resident Assessment Instrument (RAI) MDS Compliance Policy with the last review date of 2/19/2025 showed it read, Purpose: This policy establishes procedures for completing the Minimum Date Set (MDS) 3.0 to ensure compliance with federal and state requirements, promote accurate resident assessments, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 residents received their medication as ordered by the physician for 1 of 10 residents reviewed for medication administration, Resident #402. Findings include: During an observation on 3/26/2025 at 9:38 AM, Staff C, Licensed Practical Nurse (LPN), measured 2 grams of Dicoflenac Sodium topical gel (Voltaren) onto the medication ruler. Staff C applied 2 grams of the medication to the medication ruler and applied one gram to the left knee of Resident #402 and then one gram was applied to the right knee. Review of Resident #402 physician order dated 3/14/2025 showed it read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical), Apply to knees topically two times a day for pain. During an interview on 3/26/2025 at 9:36 AM with Staff C, LPN, when asked if Diclofenac gel is 1 gram per knee or 2 grams per knee, Staff C stated, Will need to call the APRN [Advance Practice Registered Nurse] to clarify. During an interview on 3/27/2025 at 10:20 AM, the Director of Nursing (DON) stated, I spoke 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents reviewed for intravenous therapy, Resident #95. Findings include: During an observation on 3/24/2025 at 10:17 AM, Resident #95 was sitting at the edge of her bed. Resident #95 had a single lumen PICC (Peripherally Inserted Central Catheter) line on her right arm with a transparent dressing and a gauze underneath the dressing with no date. During an interview on 3/24/2025 at 10:17 AM, Resident #95 stated, The staff changed my dressing last Thursday [3/20/2025]. I am not sure why they did not date the dressing. Review of Resident #95's physician order dated 3/3/2025 showed it read, IV [Intravenous]: Central Line- PICC Line: Change transparent dressing every evening shift every Sat [Saturday] for preventative care. Review of Resident #95's Medication Administration Record (MAR) for March 2025 showed the last transparent dressing change was completed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide dietary services as ordered by physician for 3 of 8 residents reviewed for nutrition, Residents #31, #352 and #405. Findings include: 1) During an observation on 3/25/2025 at 12:55 PM, Resident #352 was eating in his room. The meal tray included cranberry juice, dessert, mixed vegetables containing broccoli, carrots, and cauliflower, and an inside out chicken potpie. Review of Resident #352's meal ticket for 3/25/2025 did not show fortified foods listed. During an observation on 3/26/2025 at 7:54 AM, Resident #352 was eating in the room. The meal tray included cold cereal mixed with white milk, scrambled eggs, toast with jelly and juice. Review of Resident #352's meal ticket for 3/26/2025 did not show fortified foods listed. Review of Resident #352's physician order dated 1/14/2025 showed it read, Low Concentrated Sweets diet, Regular Texture, Thin Consistency, for Fortified Foods. During an interview on 3/26/2025 at 12:18 PM, the Registered Dietitian [RD] stated, [Resident #352's name] has orders for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were assessed before and after dialysis treatments for 1 of 1 resident receiving dialysis services, Resident #30. Findings include: Review of Resident #30's Dialysis Center-Facility Communication Form dated 2/28/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/3/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/5/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's records showed no Dialysis Center-Facility Communication Form for dialysis visit on 3/10/2025. Review of Resident #30's physician order dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation upon entry to the facility on 3/24/2025 at 9:00 AM, the nurse staffing information posted at the front desk was dated 3/19/2025. During an interview on 3/24/2025 at 9:37 AM, the Administrator stated, Federal posting should be changed daily. The staffing coordinator will change it during the week and the weekend supervisor will be responsible for changing the posting. During an interview on 3/27/2025 at 8:45 AM, the Staffing Coordinator stated, I am responsible for placing the staffing information at the front desk during the week. The weekend supervisors change it on the weekends. The number was correct, but the date wasn't.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 halls. Findings include: 1) During an observation on 3/24/2025 at 10:51 AM, Resident #19 was lying in bed. There was a Ventolin HFA inhaler on top of the resident's nightstand. During an interview on 3/24/2025 at 10:51 AM, Resident #19 stated, I use the inhaler myself. The nurses do not help me with it. During an interview on 3/24/2025 at 8:07 AM, the Director of Nursing stated, There is no resident in the facility at this time that self-administers medication. The nurse will do a self-administration evaluation and it would be recorded in [electronic health record program's name]. Medication should not be left unattended. Even if resident has a self-administration evaluation and is considered safe to administer, the nurse will bring the medication and recollect it and take it back to the cart. During an interview on 3/27/2025 at 10:30 AM, the Director of Nursing stated,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for medication management, Residents #351 and #354, and 1 of 3 residents reviewed for gastric tubes, Resident #23. Findings include: 1) Review of Resident #354's physician order dated 3/6/2025 showed it read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML [unit per milliliter] (Insulin Glargine) Inject 40 units subcutaneously in the morning for Hyperglycemia. Review of Resident #354's Medication Administration Record (MAR) for March 2025 showed no entries documented at 6:00 AM on 3/11/2025 and 3/19/2025 for administration of Insulin Glargine. During an interview on 3/24/2025 at 10:11 AM, Resident #354 stated that the staff gave her all her medications. During an interview on 3/26/2025 at 7:10 AM, Staff G, Licensed Practical Nurse (LPN), stated, I got distracted and did not document it. I really do not know what happened. During an interview on 3/27/2025 at 11:24 AM, the Director of Nursing (DON) stated, I expect nurses 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and used proper personal protective equipment during medication administration for 2 of 11 residents reviewed for medication administration, Residents #32 and #56, and while providing care for 2 of 4 residents reviewed for isolation precautions, Residents #302 and #405, to prevent possible spread of infection and communicable diseases. Findings include: 1) During an observation on 3/25/2025 at 8:30 AM, Staff B, Licensed Practical Nurse (LPN), was standing in front of the medication cart. Staff B scratched the side of her head with her right hand. Without performing hand hygiene, Staff B continued to pour medication into a medication cup. Staff B poured the medication into a clear medication sleeve and crushed the medication. Staff B grabbed two capsules from the top of the medication cart, and without donning gloves, opened each capsule and poured the medication into a small bowl. Staff B pushed her medication cart to Resident #32's door, performed hand hygiene before…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2023-12-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure comfortable and safe temperature levels were maintained in 4 of 4 facility shower rooms, and failed to ensure a clean and homelike environment in 3 of 5 resident rooms. Finding include: 1. During an interview on 12/11/2023 at 10:06 AM, Resident #106 stated the facility shower rooms were cold and he passed on showers sometimes because the shower room was so cold. During an observation on 12/11/2023 at 10:23 AM, the ambient air temperature was 66.7 degrees Fahrenheit in the B Wing shower room directly across from the nurses' station. During an observation on 12/11/2023 at 10:25 AM, the ambient air temperature was 67.6 degrees Fahrenheit in the B Wing shower room located to the right side across from the nurses' station. During an observation of the A Wing shower room located to the left side across from the nurses' station on 12/11/2023 at 11:02 AM with the Administrator, the ambient air temperature was 66.2 degrees Fahrenheit. During an observation of the A Wing shower room located directly across 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-14 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents were referred to the appropriate state designated authority for a Level II evaluation and determination for 1 of 3 residents reviewed for Preadmission Screening and Resident Review (PASRR), Resident #68. Findings include: Review of Resident #68's admission record revealed the resident was diagnosed with bipolar disorder, schizophrenia, and anxiety disorder with onset date of 11/18/2023. Review of Resident #68's Level I PASRR dated 11/1/2023 reads, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #68's hospital progress note dated 10/31/2023 showed history of dementia, schizophrenia, and bipolar disorder. Review of Resident #68's psychiatry subsequent note dated 12/1/2023 showed the resident's chief psychiatric complaints included depression, anxiety, and schizoaffective disorder. During an interview on 12/13/2023 at 8:50 AM, the Social Services Director stated the facility did not have any documentation that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for notifying the physician of hypoglycemic episodes for 1 of 3 residents reviewed, Resident #82. Findings include: Review of Resident #82's physician order dated 9/11/2023 reads, Insulin Glargine Subcutaneous Solution Pen-Injector 100 unit/ml [milliliter]. Inject 30 unit two times daily related to type II diabetes with diabetic neuropathy. Review of Resident #82's nursing progress note dated 10/30/2023 showed insulin was held due to low BS (blood sugar). Review of Resident #82's nursing progress note dated 11/5/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/6/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/21/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/23/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/25/2023…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care services, Residents #52 and #49. Findings include: 1. During an observation on 12/11/2023 at 11:13 AM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 1/2 liters per minute (Photographic evidence obtained). During an observation 12/12/2023 at 8:58 AM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 1/2 liters per minute. During an observation 12/12/2023 at 1:48 PM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 1/2 liters per minute. Review of Resident #52's admission record revealed the resident was admitted on [DATE] with the diagnoses including pleural effusion, heart failure, chronic obstructive pulmonary disease. Review of Resident #52's physician order indicated administration of Oxygen at 3 liters per…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-14 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received adaptive equipment for eating for 1 of 4 residents reviewed, Resident #275. Findings include: During an interview on 12/11/2023 at 10:29 AM, Resident #275's wife stated Resident #275 spilled his food as he tried to eat as he was not provided with his curved utensils as ordered. During an observation on 12/11/2023 at 12:37 PM, Resident #275 was attempting to feed himself broccoli and cauliflower blended vegetables. Resident #275 had a scoop plate and regular utensils. As Resident #275 attempted to place the food in his mouth with the regular utensils, food spilled onto his shirt. Review of Resident #275's order summary showed an order for adaptive equipment with meals including a scoop plate and left-hand curved utensil. During an interview on 12/12/2023 at 11:45 AM, the Dietary Manager (DM) stated that adaptive devices should be on the tray for residents as the physician ordered. The DM confirmed Resident #275 did not receive his utensils as ordered. Review of Resident #275's care…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was properly stored and staff followed professional standards for food service safety. Findings include: A walk-through tour of the kitchen was conducted on 12/11/2023 at 9:15 AM with the Dietary Manager (DM). The walk-through of the walk-in cooler revealed a case of raw shell eggs stored over a case of opened raw bacon. A gallon milk container with approximately 8 cups of milk remaining in the container was stored in the cooler with an expiration date of 12/6/2023. There were 33 cups of an apple dessert stored in the cooler without a label or date. Four male dietary staff members with facial hair of a beard or mustache did not have a restraint or beard guard. During an interview on 12/11/23 at 9:35 AM, the DM identified the unlabeled cups as apple pies that were leftover. The DM stated that the products should be labeled according to the policy and all products should be covered and dated when stored. The DM confirmed that the container of milk had an expiration date of 12/6/2203 and should have…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-14 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 call light system was properly within reach for 3 of 5 residents reviewed for call light system, Residents #77, #374, and #49 (Photographic evidence obtained). Findings include: During an observation on 12/11/2023 at 9:45 AM, Resident #77's call light system was on the floor, not within reach of the resident. During an observation on 12/11/2023 at 10:00 AM, Resident #374's call light system was hanging on his headboard, not within reach of the resident. During an observation on 12/11/2023 at 10:42 AM, Resident #49's call light system was attached to the blanket at the foot of the bed, not within reach of the resident. During an interview on 12/11/2023 at 11:00 AM, Staff B, Licensed Practical Nurse (LPN), stated, The CNAs [certified nursing assistants] are supposed to make sure the call light is reachable for the resident before they leave the room. During an interview on 12/11/2023 at 11:04 AM, Staff C, CNA, stated, I don't usually work on this floor, and I will check on the residents every 2…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-06-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, and discarded in the areas of the kitchen coolers and freezers, failed to ensure food was properly served on the tray line, and failed to ensure the equipment were cleaned as per the policy guidelines. Findings include: A walk-through tour of the kitchen on 6/27/2022 at 9:16 AM with the Certified Dietary Manager (CDM) showed an opened large container of macaroni salad with no open date in the walk-in cooler. The tour also revealed a food container labeled as Lasagna and a pan of chicken noodle soup placed on the steam table at 9:13 AM that was designated as lunch by the CDM. During an interview on 6/27/2022 at 10:28 AM, the Certified Dietary Manager (CDM) confirmed that the observed products did not have a label and identified them as macaroni salad, potato salad, and cottage cheese. The CDM stated, The products should be labeled according to the policy. All products should be closed or covered when stored. The CDM confirmed that Lasagna and soup…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents, Resident #55, received the Skilled Nursing Advance Beneficiary of Non-coverage (CMS-10055) to inform the resident of potential liability for payment and related standard claim appeal rights. Findings include: Review of Resident #55's census data information revealed Resident #55's services in the facility was covered by Medicare Part A, effective 2/2/2022. Review of Resident #55's coverage notice records revealed a Notice of Medicare Non-Coverage form that documented Resident #55's skilled nursing services would end on 4/5/2022. Review of the Beneficiary Protection Notification Review form completed by the Minimum Data Set Coordinator revealed the facility initiated Resident #55's discharge from Medicare Part A Services with benefit days remaining. Review of Resident #55's coverage notice records failed to reveal any documentation that Resident #55 had been provided with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10055). During an interview on 6/29/2022 at 9:15 AM,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 personal privacy during enteral gastrostomy tube feeding for 2 of 2 residents receiving ostomy care, Resident #92 and Resident #410. Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021. During an observation on 6/27/2022 at 2:00 PM, Staff A, Registered Nurse (RN), approached Resident #92 to administer his enteral feeding. Staff A pulled the privacy curtain halfway and left the door wide open. Staff A proceeded to expose the abdomen to visualize the G-tube.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-30 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set assessment was accurate for 1 of 5 residents reviewed for unnecessary medications, Resident #48. Findings include: Review of Resident #48's quarterly Minimum Data Set, dated [DATE], revealed the resident received an anticoagulant medication for 7 days prior to the assessment. Review of Resident #48's medication administration record for the period from 4/1/2022 through 4/30/2022, did not show documentation that the resident had been administered an anticoagulant medication during April 2022. During an interview on 6/28/2022 at 12:53 PM, the Minimum Data Set Coordinator confirmed Resident #48 was not administered an anticoagulant medication during April 2022. She stated she must have clicked [anticoagulant] by accident.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to verify that the gastrostomy tube (G-tube) was functioning before beginning a feeding and before administering medications, which may include checking for gastric residual volume (GRV) according to professional standards of practice for 2 of 6 residents who received ostomy care, Resident #92 and #410. Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021 . Enteral Feed Order every shift Enteral: Check residual prior to initiating a feeding.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to inform residents, their representatives, and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. Findings include: Review of the facility records revealed Residents #98, #14, and #93 were COVID-19 positive on 6/2/2022, and Resident #47 was COVID-19 positive on 6/20/2022. Further review of the records did not reveal any notifications sent to the residents, resident representatives, and families. During an interview on 6/29/2022 at 2:00 PM, the Infection Control Nurse stated that notifications were not sent out when those residents were COVID-19 positive. Review of the policy and procedure titled COVID-19 Dedicated Unit: Responding to COVID-19 in the facility reviewed on January 19, 2022 reads, Policy: The facility will adhere to current CDC [Centers for Disease Control and Prevention] guidance and the direction of the Florida Department of Health and/or the Agency for Health Care Administration for infection prevention and control of COVID-19 . Procedure for COVID…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$13,501 in federal fines across 1 penalty.

  • $13,501 — penalty dated 2025-03-27

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

Part of a chain

This home belongs to SUMMIT CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.3-1.3 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 52.6+0.4 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)
1 of 5Hawthorne Center For Rehabilitation And Healing OfOcala, FL 1 of 5Valencia Hills Health And Rehabilitation CenterLakeland, FL 2 of 5Palatka Center For Rehabilitation And HealingPalatka, FL 2 of 5Scott Lake Health And Rehabilitation CenterLakeland, FL 2 of 5Springs At Boca Ciega BaySouth Pasadena, FL 2 of 5Springs At Lake Pointe WoodsSarasota, FL 3 of 5Lake Bennet Center For Rehabilitation & HealingOcoee, FL 3 of 5Seven Hills Health & Rehabilitation CenterTallahassee, FL 3 of 5Timberridge Nursing & Rehabilitation CenterOcala, FL 3 of 5Ybor City Center For Rehabilitation And HealingTampa, FL 4 of 5Hawthorne Center For Rehabilitation And Healing OfBrandon, FL 4 of 5Lakeside Center For Rehabilitation And HealingJacksonville, FL 4 of 5Sandy Ridge Center For Rehabilitation And HealingMilton, FL 4 of 5Santa Rosa Center For Rehabilitation And HealingMilton, FL 4 of 5Surrey Place Healthcare And RehabilitationBradenton, FL 4 of 5Tampa Lakes Health And Rehabilitation CenterLutz, FL 5 of 5Century Center For Rehabilitation And HealingCentury, FL 5 of 5Diamond Ridge Health And Rehabilitation CenterLecanto, FL 5 of 5Hawthorne Center For Rehab & Healing Of SarasotaSarasota, FL 5 of 5Madison Health And Rehabilitation CenterMadison, FL 5 of 5North Bank Center For Rehabilitation And HealingJacksonville, FL

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
SUMMIT CARE OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/09/2020
DREBIN, EZRIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 03/06/2020
SUMMIT CARE II INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2020
KLEIN, SOLOMONIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2020

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.

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.

$12.8M
Net patient revenuemost recent cost report
+5.2%
Operating marginrevenue minus expenses
$1.8M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 10%Other / private 18%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$312per resident / day
operating cost
$9,494per month
≈ monthly operating cost
$330per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105606. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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