Oak Hill Health & Rehabilitation
7371 Cortez Oaks Blvd, Brooksville, FL 34613 · For profit - Corporation · 109 certified beds · (765) 664-5400 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 0.3% | 0.9% | worse 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 | 2.0% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.5% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.5% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.4% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.2% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.8% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 88.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.3% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.5% | 9.1% | 12.0% | 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.
60.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 768 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 81.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 211 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 0.83 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 14% 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 | 60.9%CMS range 57.4–63.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 9.4–13.2 | 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 | 81.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 80.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.6% | 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 | 99.6% | 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 | 98.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 99.1% | 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 | 0.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.4% | 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 | 9.3%CMS range 6.9–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 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 109 beds and averages 104.0 residents a day — about 95% occupied, or roughly 5 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 4.44 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above 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 3.78 hrs/resident/day on weekends vs 4.70 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.81 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-02-18 · 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 interview and record review, the facility failed to ensure treatment and care was provided to all facility residents for physician prescribed medications for 2 of 4 residents, Resident #1 and #4, reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See…
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 before2026-02-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document unavailable medications and notification to physicians of missed doses of ordered medications for 2 (Resident #1 and Resident #4) of 4 residents reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 -…
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 · E2025-07-02 · tag F0645 — patternPASARR 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 interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR) were accurately completed for 7 of 7 residents, Residents #9, #15, #23, #28, #31, #44, #59, reviewed for mood and behavior.Findings include:1) Review of Resident #44 Preadmission Screening and Resident Review (PASRR) dated 7/27/2024 did not document serious mental illness or intellectual disability.Review of Resident #44's admission record resident was readmitted on [DATE] with diagnosis including but not limited to anxiety disorder, major depressive disorder and psychosis. Review of Resident #44's physician order dated 7/29/2024 read, Xanax Oral Tablet 0.25 mg [milligram] give 1 tablet by mouth at bedtime for anxiety.Review of resident #44's physician order dated 12/10/2024 read, Zoloft Oral Tablet 50 mg give 1 tablet by mouth at bedtime for depression. Review of Resident #44's psychiatry subsequent note dated 6/3/2025 read, Chief Complaint: Depression, anxiety, insomnia and Parkinson'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 before2025-07-02 · 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 observation, interview, and record review, the facility failed to ensure treatment and care was provided for intravenous (IV) dressing changes for 2 of 4 residents, Residents #195 and #444, reviewed for IV catheters and infusions, and failed to ensure medication management for 1 of 6 residents, Resident #55, reviewed for medications.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 had a double lumen PICC (peripherally inserted central catheter) line inserted in his left upper arm. The dressing covering the insertion site was dated 6/17/2025. Review of Resident #195's physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with a transparent dressing every shift every Tue [Tuesday] for IV therapy.During an interview on 7/1/2025 at 1:11PM Staff E, Licensed Practical Nurse stated, IV dressing changes should be done every week or as needed. I don't know what happened I thought I had changed the dressing.During an interview won 7/2/2025 at 9:45 AM the Director of Nursing (DON) stated, Central line dressing…
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 before2025-07-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended and failed to date and label intravenous (IV) medication infusion bags and tubing. Findings include: 1) During an observation on 6/29/2025 at 11:32 AM Resident #499 was lying in bed. Next to the bed was an intravenous (IV) pole. Hanging on the pole was a Zosyn IV infusion bag. The infusion bag and the tubing were not dated or timed. re was no date or time on the IV infusion bag or tubing. (photographic evidence obtained)2) During an observation on 6/30/2025 at 10:19 AM of Resident #27's room there was CeraVe eczema relief cream on top of the bedside table. (Photographic evidence obtained) 3) During an observation on 7/1/2025 at 8:22 AM Resident #195's IV medication was hanging from an IV pole. The infusion bag and the IV tubing was not labeled with the date and time. Observed on top of Resident #195 bedside table was a Germa Ubre Plus topical analgesic ointment (is a medicated ointment used to relieve minor aches and pains in muscle and joints). During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-02 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 foods and drinks were served at a safe and appetizing temperature.Findings include: During an interview on 6/29/25 at 10:03 AM Resident #493 stated, My food is always cold.During an interview on 6/29/25 at 10:20 AM Resident #495 stated, My food is sometimes cold. During an interview on 6/29/25 at 10:32 AM Resident #498 stated, The food is lukewarm.During an observation on 7/1/25 beginning at 7:00 AM, a test tray investigation on the 100 hallway was conducted related to resident complaints. At 7:19 AM the last tray/test tray was plated and placed on an enclosed meal delivery cart. At 7:20 AM the meal delivery cart exited the kitchen and headed towards the 100 hallway. At 7:35 AM the test tray/last tray was removed from the insulated meal delivery cart. The CDM (Certified Dietary Manager) tested the temperature of the scrambled eggs with a finding of 101 degrees Fahrenheit, the link sausages with a finding of 120 degrees Fahrenheit, and a glass of orange juice with a finding of 48 degrees Fahrenheit.…
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 before2025-07-02 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the kitchen walk-in cooler and walk-in freezer and in the second floor nourishment freezer. Findings include:During the initial observation of the kitchen on 6/30/25 beginning at 9:07 AM in the walk-in freezer, there was a clear plastic bag of tater tots sitting on a shelf. The bag was not labeled or dated. In the walk-in cooler, were two trays of uncovered slices of pie on a rolling cart.During an interview on 6/29/25 at 9:08 AM Staff G, Head [NAME] stated, It [plastic bag of tater tots] should be labeled and dated. The dessert [pie] should be covered. During the interview on 7/2/25 at 12:37PM the Dietary Manager states, Food should be labeled and dated and the desserts [pie] should have been covered.During observation on 6/29/25 at 9:40 AM of the nourishment refrigerator/freezer located on the second floor inside the life enrichment room, there was an ice bucket in the freezer with an ice scooper laying on the ice.During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 maintain complete and accurately documented medical records for 1 of 4 residents, Resident #195, reviewed for central catheters and 2 of 6 residents, Resident #5 and #13, reviewed for medication management.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 was sitting in wheelchair. Resident #195 was observed to have a peripherally inserted central catheter (PICC) line double lumen inserted in the left upper arm. The site was covered with a dressing that was dated 6/17/2025.Review of Resident #195’s physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with transparent dressing every shift every Tue [Tuesday] for IV [intravenous] therapy.Review of Resident #195’s Treatment Administration Record (TAR) for the month of June 2025, documented the PICC line dressing change was completed on 6/24/2025.During an interview on 7/1/2025 at 1:11 PM Staff E, Licensed Practical Nurse (LPN) stated, IV dressing changes should be done every week or as…
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 before2025-07-02 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 prevent the possible spread of infection when not following infection control standards to wear appropriate personal protective equipment for 3 of 5 residents, Resident #195, #444, and #499, reviewed for enhanced barrier precautions, and failed to store respiratory equipment when not in use for 1 of 2 residents, Resident #5, reviewed for respiratory services. Findings include: 1) During an observation on 7/1/2025 at 8:22 AM Staff C, Licensed Practical Nurse (LPN) entered Resident #195’s room. Outside on the door frame to Resident #195’s room there was an enhanced barrier sign posted. Staff C entered the room and performed hand hygiene. Staff C donned gloves but did not put on a gown. Resident #195’s IV (intravenous) pump was peeping. Staff C turned the pump off. Staff C walked outside of the room with the gloves on, returned to the medication cart, and grabbed a curos disinfecting cap [a single-use cap designed to disinfect and protect IV access points]. Staff C entered the room, removed her gloves, did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-28 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications were kept secured in the facility in 2 of 4 residents rooms observed, Resident #2 and Resident #4 (Photographic evidence obtained). Findings include: During an observation on 6/28/2024 at 9:30 AM, there were Systane eyedrops on Resident #2's bedside table within resident's reach, and Equate Baby Powder and Equate Arthricream Rub on the shelf inside the resident's room. During an interview on 6/28/2024 at 9:30 AM, Resident #2 stated, I use the eyedrops at least twice a day sometimes 4 times a day. I only use the baby powder and the cream if I need it. Review of Resident #2's physician orders revealed no orders for self-administration of medications. During an observation on 6/28/2024 at 9:55 AM, there was a bottle of Systane eyedrops on the bedside table by the bed within reach in Resident #4's room. During an interview on 6/28/2024 at 9:55 AM, Resident #4 stated, I use the eye drops whenever my eyes get blurry and I used them yesterday. Review of Resident #4's physician orders revealed no…
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 16 citations
- Potential for harm · D2024-03-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medication orders were obtained according to professional standard of quality for 1 of 6 residents reviewed for unnecessary medications, Resident #80. Findings include: Review of Resident #80's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included urinary tract infection, orthostatic hypotension, and heart failure. Review of Resident #80's physician order dated 3/3/2024 read, Midodrine HCL [hydrochloride] 5 mg [milligram] tablet (100 EA), Give 1 tablet by mouth every 8 hours as needed for hypothyroidism. During an interview on 3/14/2024 at 9:19 AM, Staff H, Licensed Practical Nurse (LPN), stated, The physician order written for Midodrine HCL tablet 5 mg is wrong. It is not given as needed for hypothyroidism. Midodrine is written for low blood pressure and with parameters. During an interview on 3/14/2024 at 11:19 AM, the Medical Doctor stated that the order for Midodrine HCL…
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 before2024-03-14 · 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 2. Review of Resident #18's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included chronic obstructive pulmonary disease, hypertensive heart disease, and chronic diastolic (congestive) heart failure. During an observation on 3/11/2024 at 1:11 PM, Resident #18 was receiving oxygen at 4 liters per minute via nasal cannula (NC). During an observation on 3/12/2024 at 9:42 AM, Resident #18 was receiving oxygen at 4 liters per minute via NC. During an interview on 3/13/2024 at 8:44 AM, Staff B, LPN, stated, There is no order for the oxygen. The oxygen should be set at 4 liters via Nasal Canula. During an interview on 3/13/2024 at 11:15 AM, the Director of Nursing stated, There are no orders for oxygen administration and the orders should have been written. Review of Resident #18's physician orders revealed no order written for oxygen administration. Review of Resident #18's care plan dated 2/29/2024 read, Focus: I have an alteration in my cardiac respiratory status…
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 · D2024-03-14 · 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 observation, interview, and record review, the facility failed to ensure residents were assessed by registered dietician and measures were put into place to maintain acceptable parameters of nutritional status to prevent weight loss for 1 of 4 residents reviewed for nutritional status, Resident #25. Findings include: Review of Resident #25's admission record showed that the resident was admitted on [DATE] with the diagnoses including fracture of T (thoracic) 9 through T10 vertebrae, fall on same level, repeated falls, urinary tract infection, paroxysmal atrial fibrillation (an irregular heartbeat), unspecified dementia, cognitive communication deficit, mixed receptive expressive language disorder, and essential primary hypertension. Review of Resident #25's weights and vitals summary showed the resident's weight as 230.8 pounds on 1/8/2024, 228.2 pounds on 1/22/2024, 224.6 pounds on 1/29/2024, 221.8 pounds on 2/7/2024, 217.6 pounds on 2/14/2024, 213 pounds on 3/7/2024, and 210.3 pounds on 3/13/2024.…
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 before2024-03-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care, Resident #19. Findings include: Review of Resident #19's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, seizures, essential primary hypertension, unspecified dementia, unspecified mood disorder, and anxiety disorder. Review of Resident #19's physician order dated 1/23/2024 read, Oxygen at 3 lpm [liters per minute] via nasal cannula continuous, every shift for COPD [Chronic Obstructive Pulmonary Disease]. During an observation on 3/11/2024 at 12:35 PM, Resident #19 was in bed, receiving oxygen from the concentrator via nasal cannula at 4 liters per minute. During an observation on 3/13/2024 at 7:46 AM, Resident #19 was in bed, receiving oxygen via nasal cannula at 4 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.
- Potential for harm · D2024-03-14 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were from unnecessary medications for 1 of 3 residents reviewed for urinary tract infections, Resident #209. Findings include: Review of Resident #209's admission record showed the resident was most recently admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, fall, essential primary hypertension, chronic obstructive pulmonary disease, acute kidney failure, diverticulosis, and cognitive communication deficit. Review of Resident #209's interact SBAR (Situation, Background, Assessment, Recommendation) dated 3/8/2024 at 4:45 PM read, Nursing observations, evaluation and recommendations are: Resident expressed feelings of hopelessness and sadness. Resident states she is having PTSD [post-traumatic stress disorder] from experiencing 09/11. MD [Medical Doctor] contact and psych [psychiatric] consult ordered, every 15 minute checks initiated, and UA to be collected. Resident daughter [Resident #209'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 before2024-03-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 6 residential halls, Hall 500. Findings include: During an observation on 3/11/2024 at 9:52 AM, Resident #101 was in her room. There were one container of eye drops and single doses of eye lubricant stored on Resident #101's bedside table. During an interview on 3/11/2024 at 9:52 AM, Resident #101 stated that the items stored on her bedside table were her over-the-counter eye medications. Review of Resident #101's physician orders revealed an order with the start date of 2/13/2024 for administration of one drop of Xalatan Ophthalmic Solution 0.005% in both eyes at bedtime for dry eyes. Review of Resident #101's care plan initiated on 2/14/2024 revealed no focus on self-administration of medications. During an interview on 3/13/2024 at 9:04 AM, Staff A, Licensed Practical Nurse (LPN), stated, The facility completes a self-administration of medication assessment of a resident and obtains an order from the physician before a resident is able to self-administer…
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 before2024-03-14 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 adhere to professional standards of infection Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible transmission of infections and communicable diseases during 3 of 7 observations of medication administration. Findings include: During an observation of medication administration on 3/13/2024 at 7:59 AM, Staff C, Licensed Practical Nurse (LPN), began preparing Resident #219's medications without performing hand hygiene. Staff C poured three medications into a medication cup. Then, Staff C removed one medication, which was not able to be crushed, with his bare hand and placed it in a different medication cup. Staff C crushed the medications and added the whole medication and mixed with applesauce. Staff C entered Resident #219's room and administered the medications. Staff C exited Resident #219's room and returned to the medication cart. At 8:07 AM, Staff C began preparing Resident #209'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 · D2023-08-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to complete and submit a federal report of alleged staff abuse for 1 of 3 residents, Resident #10, reviewed for reportable incidents. Findings include: Record review of Resident #10's investigation records revealed Resident #10 made an allegation on 5/24/2023 that Staff A, Certified Nursing Assistant, rolled her to her side and pushed on her nephrostomy tubes causing her to say ouch. Record review of additional facility investigation documentation, incident date 5/24/2023, showed the investigation was initiated as An event that is reported to law enforcement or it's personnel for investigation. Record review of facility investigation documentation related to the incident involving Resident #10 failed to reveal documentation that showed the facility had completed and submitted federal reports following the allegation. During and interview on 8/3/2023 at 11:03 AM, the Executive Director confirmed the facility had not completed and submitted federal reports following Resident #10's allegation of mistreatment by Staff A. Record…
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 · E2022-11-02 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure 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 ensure 2 of 2 residents who were fed by enteral means, Residents #181 and #183, received properly labeled enteral feeding bag with date, time, and initials of nurse. Findings include: 1. During an observation on 11/1/2022 at 8:15 AM, Resident #183 was frail, eyes closed with a pale complexion and tube fed with Jevity 1.5. The formula was hung in a clear Enteral Feeding Bag and pump was running at 60 milliliters (ml) per hour (ml/hr). The bag contained approximately 800 ml of formula. The formula appeared thick and lumpy, with cottage cheese like appearance and consistency. The label on the feeding bag was torn and the date, time or nurses' initials of when the formula was hung were not legible (Photographic evidence obtained). During an interview on 11/1/2022 at 8:19 AM, Staff K, Licensed Practical Nurse (LPN), stated, I rounded on my resident this AM and I did not find any concerns. The residents that are tube fed reported no discomfort.…
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 · E2022-11-02 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #5's medical records revealed the resident was admitted on [DATE] with the diagnoses including anxiety disorder, major depressive disorder, and dementia. Review of Resident #5's physician orders dated 8/13/2022 reads, Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for anxiety . Quetiapine Fumarate Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for behaviors . Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for anxiety. Review of Resident #5's physician orders dated 8/17/2022 reads, Memantine HCl Oral Tablet 10 MG (Memantine HCl) Give 1 mg by mouth every 12 hours for Agitation . Rivastigmine Tartrate Oral Capsule 1.5 MG (Rivastigmine Tartrate) Give 1 capsule by mouth every 12 hours for Agitation. Review of Resident #5's order summary report on 11/1/2022 at 11:00 AM revealed no physician orders for monitoring behaviors for resident. Review of Resident #5's Treatment Administration Record 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.
- Potential for harm · Ecited before2022-11-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the walk-in cooler and walk-in freezer. Findings include: During an initial tour of the facility's walk-in freezer conducted with the Kitchen Manager on 10/30/2022 beginning at 9:48 AM, the surveyor observed unlabeled and undated partial bags of breaded chicken tenders, French fries and mixed vegetables, opened and partially unwrapped box of corn on the cob, freezer storage bags with onion rings and sliced potatoes, an unwrapped single chicken breast portion on top of a box of individually wrapped frozen fish portions, an open plastic food storage bag with French fries, and an opened and partially unwrapped box of French toast slices in the walk-in freezer (Photographic evidence obtained). During an initial tour of the facility's walk-in cooler conducted with the Kitchen Manager on 10/30/2022 beginning at 10:12 AM, the surveyor observed an unsealed plastic storage bag containing two bottles of liquid, one of which was open and partially full,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-02 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received services for activities of daily living (ADL) needs specific to bathing and personal hygiene for 1 of 3 reviewed residents, Resident #64, in a total sample of 39 residents. Findings include: Review of Resident #64's medical records revealed the resident was admitted on [DATE] with the diagnoses including fractured neck of right femur, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), and history of falling. During an observation on 10/30/2022 at 1:32 PM, Resident #64 was in bed with greasy hair. During an interview on 10/30/2022 at 1:32 PM, when asked when the last time was the resident had a shower, Resident #64 stated, A week ago on a Wednesday. When asked if she ever refused a shower when offered, she stated, Oh no. During an interview on 10/31/2022 at 9:13 AM, Resident #64 stated, I did not get showered yesterday either. During an observation on 10/31/2022 at 2:22 PM, Resident #64 was up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · 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, record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents reviewed, Residents #32 and #182, in a total sample of 39 residents. Findings include: 1. Review of Resident #32's medical records revealed the resident was admitted to facility on 2/17/2022 with the diagnoses including hemiplegia and hemiparesis following cerebral infarct, multiple sclerosis, and gastritis. During an observation on 11/2/2022 at 11:03 AM, Resident #32 was sitting in her wheelchair with a peripheral intravenous (IV) catheter in right forearm. A 1000 milliliter bag of 0.9% Sodium Chloride was labeled as 11/1-2150 @ [Resident #32's room number] [Staff M's initials] Rate=75 ml/hr [milliliter/hour] continuous (Photographic evidence obtained). During an interview on 11/2/2022 at 11:03 AM, Resident #32 stated, The nurse started this for my bowels, constipation/diarrhea if had. I told them I drank lots of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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, Residents #54 and #1, in a total sample of 39 residents. Findings include: 1. During an observation on 10/30/2022 at 10:00 AM, Resident #54 was resting in bed, wearing a nasal cannula and the oxygen concentrator was set at 4 liters per minute (Photographic evidence obtained). Review of Resident #54's medical records revealed the resident was admitted to the facility on [DATE] with the diagnoses including pleural effusion, respiratory failure, personal history of COVID-19, pneumonia and pulmonary hypertension. Review of the physician order dated 10/11/2022 for Resident #54 reads, Oxygen at 2 lpm [liters per minute] via nasal cannula every shift. During an observation on 10/30/2022 at 11:00 AM, Resident #54 was sitting in wheelchair, wearing a nasal cannula and the oxygen concentrator was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the expiration date when applicable. Findings include: During an observation of the 200 Hall Medication Cart on 10/30/2022 at 11:10 AM with Staff A, Licensed Practical Nurse (LPN), there were two insulin pens with no opened date on pens: one Insulin Aspart with order date on label 10/22/22, and one Insulin Glargine with order date of 10/21/22 (Photographic evidence obtained). During an interview on 10/30/2022 at 11:10 AM, Staff A, LPN, stated, They are both used. The insulin pens should be labeled. I don't know who opened the insulin pens and did not date them. During an observation of the 500 Hall Medication Cart on 10/30/2022 at 11:25 AM with Staff B, LPN, there were one vial of Insulin Glargine with no opened date. (Photographic evidence obtained). During an interview on 10/30/2022 at 11:25 AM, Staff B, LPN, stated, The insulin vial should be dated when vial 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 · D2022-11-02 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the garbage and refuse were disposed of properly. Findings include: During an observation of dumpster area on 10/31/2022 at 2:15 PM with the Food Services Director, the surveyor observed one lid on each of the two dumpsters were open and refuse was around the dumpsters including used wrappers, a blue glove, and a N-95 mask (Photographic evidence obtained). During an interview on 10/31/2022 at 2:17 PM, the Certified Dietary Manager confirmed the dumpster lids were open and there was refuse on the ground around the dumpsters. During an interview on 11/1/2022 at 9:08 AM, the Administrator stated the facility did not have a policy regarding dumpster maintenance.
“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 TLC MANAGEMENT — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 19 homes this chain runs (chain average 3.8★, 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 | Since |
|---|---|---|---|
| OTT FAMILY TRUST | Organization | DIRECT OWNERSHIP INTEREST | since 06/17/2017 |
| OTT, DWIGHT | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | since 06/28/2017 |
| OTT, RYAN | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | since 06/28/2017 |
| OTT, GARY | Individual | CORPORATE OFFICER | since 06/28/2017 |
| TENDER LOVING CARE MANAGEMENT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| HOLDER, DESIREE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2024 |
| KOLLI, ANITHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2003 |
CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106145. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-02, 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 →
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