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Gulf Coast Village

1333 Santa Barbara Blvd, Cape Coral, FL 33991 · Non profit - Corporation · 85 certified beds · (239) 772-1333 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Special Focus Facility (federal watch list)Abuse/neglect citation on record (F0600) — cited May 20254 immediate-jeopardy citations$37,092 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it’s on the federal Special Focus watch list for a persistent pattern of problems
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • inspectors cited 4 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $37,092 in federal fines (most recent 2025-11-20)

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.

/5
CMS overall
Not rated — CMS suppresses ratings for Special Focus Facilities
Health inspectionSurveyor-assigned, ranked within your stateInspector-verifiedNot rated — CMS suppresses ratings for Special Focus Facilities
StaffingFrom payroll records (PBJ)Not rated — CMS suppresses ratings for Special Focus Facilities
Quality measuresSelf-reported by the facilityNot rated — CMS suppresses ratings for Special Focus Facilities

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1510 Santa Barbara Blvd · (239) 458-5775 · Call to confirm hours
Pharmacy
2409 Santa Barbara Blvd · (239) 458-8576 · Call to confirm hours
Grocery
Publix1.4 mi
2420 Santa Barbara Blvd · (239) 574-6395 · Call to confirm hours
Park
815 Nicholas Pkwy. · (239) 573-3128 · Typically dawn to dusk
Place of worship
431 Nicholas Pkwy E · (239) 573-1370

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 measuresNot rated — CMS suppresses ratings for Special Focus Facilities

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.

See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased33.3%8.7%15.4%worse
Long-stay residents who lose too much weight7.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder1.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.8%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.7%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.5%2.5%3.3%worse
Long-stay residents whose ability to walk worsened33.0%9.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication30.4%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.9%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control24.9%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 table5.5%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission34.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit14.4%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.462.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.211.151.80better

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.

57.8% 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 490 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.8%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
50.3%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.28hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 50.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 145 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF57.8%CMS range 53.5–62.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.8–13.210.7%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 discharge50.3%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 discharge42.8%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 discharge42.8%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 identified96.7%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 setting99.3%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 discharge77.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened2.1%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 hospitalization6.5%CMS range 4.4–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

1.20
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.98
Aide hours/ resident / day
4.93
Total nurse hours/ resident / day
0.89
RN hoursweekends
53.6%
Total nursing turnover
55.9%
RN turnover

How full it usually is: this home is certified for 85 beds and averages 88.8 residents a day — about 104% occupied, or roughly -4 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 4.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.98 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 4.58 hrs/resident/day on weekends vs 5.07 on weekdays — 10% thinner on weekends. RN hours go from 1.32 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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

2
deficiencies at the latest standard inspection (2026-05-07)
10
at the previous standard inspection (2025-11-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 15 most serious are shown; the remaining 6 are one tap away and print in full.

  • Immediate jeopardy · K2024-04-02 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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, facility's policies and procedures review and staff interviews, the facility failed to ensure staff followed established policies and procedures to honor the advance directives for full code status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, without a pulse or respiration. Clinical staff failed to ensure timely confirmation of code status and immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who had a full code status. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced dead by EMS. The failure to honor the residents' right to receive life saving measures, to include CPR, intubation, and defibrillation placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate Jeopardy (IJ). 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2024-04-02 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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, facility's policies and procedure reviews and staff interviews the facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in the absence of a Do Not Resuscitate (DNR) Order for 1 (Resident #1) of 4 residents reviewed who was found without a pulse or respirations. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, had no pulse, and no respirations. Clinical staff delayed calling Emergency Medical Services (EMS) and did not initiate CPR for 51 minutes while attempting to locate a non-existent DNR order. CPR is a crucial life-saving technique that aims to sustain blood circulation and oxygenation in individuals experiencing cardiac arrest. Resident #1 was pronounced dead by EMS. The facility's failure to implement their policies and procedures and immediately administer CPR to residents who requires such emergency care placed other residents with full code status at a likelihood of serious injury or death and resulted in the determination of Immediate…

    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
  • Immediate jeopardy · K2024-04-02 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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, facility's policies and procedures review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR) when residents with full code status experience cardiac or respiratory arrest. On [DATE] at 5:19 a.m., clinical staff found Resident #1 in cardiac and respiratory arrest. Three nursing staff on duty (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and the calling for Emergency Medical Services (EMS) for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced deceased by EMS. The facility failure to ensure nursing staff were trained and competent in facility's policies related to advance directives, including CPR created a likelihood for residents identified as a full code being denied lifesaving emergency treatment to include CPR, intubation 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2024-04-02 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 staff interview, the facility's Administration failed to utilize its resources effectively by failing to ensure staff was adequately trained and knowledgeable in policies and procedures to honor residents' rights to advance directives, including the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. On [DATE] at 5:19 a.m., Resident #1 was found without pulse or respiration. The clinical staff on duty did not initiate CPR until 6:10 a.m., 51 minutes after Resident #1 was found unresponsive. Resident #1's wishes to be a full code and receive CPR was not documented in the baseline care plan, despite the Social Services Department being aware of the resident's full code status on [DATE]. Resident #1 was pronounced dead by Emergency Medical Services. The facility's failure to manage resources to ensure staff are aware of and honor a resident's expressed advance directives created a likelihood for residents to be identified as a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure the safe transfer with a mechanical lift of 1 (Resident #14) of 3 residents by failing to ensure the sling was properly placed and secured, resulting in a bruise to the resident's left upper extremity. The findings included:Review of the facility's Policy and Procedure titled, Free of Accident Hazards/Supervision/Devices policy (last revised 10/2021) noted, All resident environments will remain free of accident hazards as is possible and each resident will receive adequate supervision and assistive devices to prevent accidents.The policy further noted Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . The facility must provide an environment that is free from accident hazards over which the facility has control.Review of the facility's Policy and Procedure titled, Mechanical Lifts (last revised 8/14/2023) noted all staff receive orientation and annual training for mechanical lifts. This training includes safety considerations…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to investigate a fall and implement individualized interventions to minimize the risk of further falls and fall related injuries for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility's policy and procedure titled, Fall Management Program with an effective date of 8/2018 and revision date of 10/24/2022 revealed, 1) All residents are assessed to identify risk for falls and individualized fall precautions will be developed on their care plan. 2) Preventative measures shall be taken to decrease the number of falls whenever possible. document fall as incident . following risk management/incident policy. The post Fall incident/Assessment form will be completed after each fall and any changes in interventions will be noted on the form, on the resident's care plan and Kardex (Provides instructions for care) and in the nurse's notes . A post fall huddle will be completed at the time of a resident fall . Use the huddle…

    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 · E2026-05-07 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, residents and staff interviews, the facility failed to ensure that the arbitration agreement signed by 3 (Residents #111, #115 and #107) of 3 residents reviewed provided the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that is convenient to both parties when there is a dispute. This has the potential to affect all residents residing in the facility.The findings included:Review of the Facility provided Arbitration Agreement, attachment J of contract revealed, Disputes . By signing this agreement Resident and Facility agree that the arbitration shall be administered by [name of lawyers association] in accordance with its Rules of Procedure . Location of Arbitration. The Arbitration will be conducted at a site selected by Facility which shall be either at Facility or somewhere within a reasonable distance of Facility that is convenient for both Facility and Resident . Time Limitation for Arbitration . In the event [name of lawyers association] is unable or unwilling to serve . Facility shall select 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and procedure, and staff interviews, the facility failed to develop and implement an individualized care plan to meet the needs of 1 (Resident #104) of 5 residents reviewed for care plan.The findings included:Review of the facility policy, Comprehensive Care Plans dated 4/11/2025 revealed, the facilities will develop and implement a comprehensive, person-centered care plan for each resident that reflects their unique needs, goals, and preferences, and ensures that all services are delivered in accordance with regulatory requirements and professional standards.Review of the clinical record for Resident #104 revealed an initial admission date of 4/16/2026. Diagnoses included but were not limited to, primary osteoarthritis left knee, aftercare following joint replacement surgery, unspecified psychophysiologic insomnia, unsteadiness on feet, muscle weakness (generalized), anemia in other chronic diseases, adjustment disorder with mixed anxiety and depressed…

    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 · Fcited before2025-11-20 · 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, review of facility policy and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.The findings included:Review of the facility policy Food Storage documented Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Food will be stored a minimum of 6 inches above the floor 18 inches from the ceiling and two inches from the wall with adequate space on all sides of the stored items to permit ventilation.Refrigerated food storage, All foods should be covered, labeled, and dated. Frozen foods- All freezer units will be kept clean and in good working condition at all times. All foods will be stored off of the floor.On 11/17/2025 at 7:30 a.m., during the Initial Kitchen Tour with the Certified Dietary Manager (CDM), the following observations…

    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 · E2025-11-20 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policy and procedure and staff interview the facility failed implement their policy and procedure and notify the office of the Long-Term Care Ombudsman of residents' discharges. The notification to the Ombudsman's office is to protect residents' rights to prevent unwarranted or unnecessary transfers or discharges and to prevent facilities from refusing to allow the residents return to the facility.The findings included:Review of the facility's Policy and Procedure Admission, Transfer, Discharge with a created date of 12/2019 documented, . Procedure. Provide notification to local ombudsman of all involuntary discharges, facility initiated discharges, including hospital transfers. Social Service or designee should provide the information to the ombudsman according to the format and frequency the specific ombudsman has requested (monthly, weekly notification via email/fax/scan/etc.Review of the facility's Admission/Discharge log from 7/8/25 through 11/20/25 revealed the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-20 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 record review, review of facility's Policy and Procedure, and staff interview the facility failed to ensure the clinical records were completely and accurately documented for 3 (Residents #115, #34 and #109) of 3 residents reviewed. The findings included:Review of the facility's Policy and Procedure titled, Change in Condition (CIC) Policy and Procedure revealed the purpose was to ensure timely identification, assessment, communication, documentation, and intervention when a resident experiences a change in physical, mental, or functional condition, in order to promote resident safety, meet regulatory requirements, and prevent avoidable transfers or adverse outcomes. A licensed nurse will assess the resident, notify the provider and family/responsible party as appropriate, initiate interventions, and document all actions . Change in Conditions Definitions: Any worsening, or sudden change in resident's: vital signs, cardiovascular status, respiratory status, pain level, skin integrity, mobility/functional ability signs of infection, bowel or bladder function or…

    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 · E2025-11-20 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of policy and procedure and staff interviews the facility failed to develop and implement systemic appropriate corrective actions related to identified quality of care deficiencies related to falls and failed to identify and address unresolved quality deficiency related to food safety and sanitation in the kitchen.The findings included:Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) dated 4/22/25 revealed the objective of QAPI was to, Ensure care delivery systems function consistently, accurately, and incorporate current and evidence-based practice standards where available.Prevent deviation from care processes to the extent possible;Identify issues and concerns with facility systems, as well as identify opportunities for improvement; andDevelop and implement plans to correct and/or improve identified areas.Program Systemic Analysis and Systemic Action:(a) The facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-20 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy and staff interview, the facility failed to maintain an effective pest control program to ensure a sanitary environment free from pests for residents. The findings included: Review of the facility's policy Pest Control documented The facility maintains an affective pest control program to remain free of pests and rodents. On-going measures are taken to prevent, contain, and eradicate common household pests.On 11/17/25 at 12:00 p.m., observation of the lunch meal in the memory care unit revealed multiple small flying insects in the dining area. Family members were observed swatting at the flying insects.On 11/17/25 at 12:30 p.m., observation of the lunch meal in the Bistro dining area revealed multiple small flying insects.Review of the facility control company summary of service reports revealed:On 10/17/25, 10/22/25, 10/29/25, 11/5/25 and 11/12/25 in the memory care unit the log documented Be sure to keep garbage can clean. Drain trap is dry allowing pest entry. Please add water to the drain to block pest entry. Recommend fly light.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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility's Policy and Procedure, resident representative and staff interview the facility failed to notify the resident's representative of a change in condition requiring treatment with a new medication for 1 (Resident # 115) of 3 residents reviewed for change in condition.The findings included:Review of the facility's undated facility's Policy and Procedure titled, Change in Condition (CIC) Policy and Procedure revealed the purpose was to ensure timely identification, assessment, communication, documentation, and intervention when a resident experiences a change in physical, mental, or functional condition, in order to promote resident safety, meet regulatory requirements, and prevent avoidable transfers or adverse outcomes. Change in Conditions Definitions: Any worsening, or sudden change in resident's: vital signs, cardiovascular status, respiratory status, pain level, skin integrity, mobility/functional ability signs of infection, bowel or bladder function or…

    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 · D2025-11-20 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #66 and #92) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability.The findings included:Clinical record review revealed Resident #66 was admitted to the facility on [DATE]. The Medicare Part A Skilled Services episode start date was 5/2/25.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC), and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (Form CMS-10055) issued to Resident #66 contained conflicting information.The Notice of Medicare Non-Coverage form (Form CMS 10123-NOMNC) noted that the effective date coverage of the current skilled services would end on 6/7/25.Resident #66 signed the form on 6/5/25.The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form noted, Medicare does not pay for everything, even…

    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
Show the remaining 6 citations
  • Potential for harm · D2025-11-20 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide activities that meets the interests and accommodate the needs of 1 (Resident #7) of 3 residents reviewed for involvement in activities.The findings included:Review of the facility policy Activities Programs, effective 3/2005 (revised 8/2/23) revealed, Varied activities will be planned and routinely scheduled. Activities will focus on the following:1. To stimulate socialization and encourage fellowship.2. To help maintain muscle tone and coordination.3. To encourage and provide opportunities for mental functioning.4. To provide sensory stimulation.5. To reduce isolation, build self-esteem, and strengthen capabilities and identity.6. To provide entertainment.7. To strengthen existing spiritual tenets, and to provide an opportunity to express individual beliefs.Review of the clinical record for Resident #7 revealed an admission date of 6/14/24. Diagnoses included…

    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 · D2025-11-20 · 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 observations and interviews, the facility failed to properly store medications in a safe manner. Throughout the survey, medications were observed unattended at bedside, unsupervised on medication carts and medication carts left unlocked leaving these medications to be easily accessible to residents.The findings include:Review of facility Storage and Expiration Dating of Medications and Biologicals (last revised 6/30/3035) states the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The policy further states facility should ensure all controlled substances are stored in a manner that maintains their integrity and security. The policy also notes the facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration.On 11/17/2025 at 8:16 a.m. 2 medication cups containing pills were observed on Resident #66'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · 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 physician's orders received via text for 1 (Resident #92) of 3 residents reviewed for change in condition were immediately documented, signed, dated, and implemented, creating the potential for a negative outcome. The findings included: On 4/28/25 at 12:32 p.m., in a telephone interview Resident #92's son said he visited his father on 12/23/24. He said his father had not been feeling right, had been cold and shaky. The son said he explained to the nurse that his father had problems in the past with potassium levels and asked if they could get the doctor to check his potassium levels. Record Review of Resident #92's chart revealed no progress notes were documented on 12/23/24, no documentation of notification to the physician was found for 12/23/24, no orders were found to be entered on 12/23/24 and no lab work was taken on 12/23/24. Further review of Resident #92's chart revealed a change of condition note dated 12/24/24 at 4:34 a.m., indicating the resident was exhibiting Altered mental status and Diarrhea. A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-05-01 · 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 observations, facility policy, and staff interviews, the facility failed to maintain sanitary conditions during food service, including a visibly soiled ice machine, inadequate sanitizer levels in the three-compartment sink, and kitchen staff without proper hair restraints, posing a risk of food contamination and potential foodborne illness. The findings included: On 4/28/2025 at 9:30 a.m., during the initial kitchen tour with the Certified Dietary Manager (CDM), the ice scooper was observed lying unholstered on the ice machine. Photographic evidence obtained. On 4/29/2025 at 11:35 a.m., during a follow up observation of the kitchen, the ice machine scooper was again observed lying unholstered on the edge of a table next to the ice machine. Photographic evidence obtained. On 4/30/2025 at 11:15 a.m., black biofilm buildup and crust-like debris were observed on the interior and exterior of the ice machine. Photographic evidence obtained. The CDM verified the observation. In an interview the CDM said the kitchen's policy was to clean and sanitize the ice machine monthly.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility's policies and procedures, resident and staff interviews the facility failed to protect the residents' right to be free from verbal and mental abuse resulting in feeling of humiliation for 1 (Resident #35) of 3 residents reviewed. The findings included: Review of the facility's policy and procedure titled, Freedom from Abuse, Neglect and Misappropriation revealed, Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The facility policy also stated, Emotional or psychological abuse is the verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering which includes demeaning statements, harassment, threats, insults, humiliation and intimidation. Review of facility a posttest for the education for Freedom from Abuse, Neglect and Exploitation dated 1/20/2025 noted, A caregiver reportedly uses derogatory and humiliating language when talking to, and about a patient on the unit. What type of abuse is this behavior?. Record review…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and records review, the facility failed to provide the necessary service to maintain grooming for 1 (Resident 12) of 3 sampled residents dependent on staff for Activities of Daily Living. The findings included: Review of the facility's Activities of Daily Living Policy updated 4/29/25 noted, A resident who is unable to carry out ADLs will be provided the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. The policy also noted, The resident's or representative's decision to refuse care and treatments will be documented in the resident's medical record. Record review for Resident #12 revealed an admission date of 9/4/20. Diagnoses included unspecified dementia. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 4/13/25 revealed Resident #12's cognition was severely impaired with a Brief Interview for Mental Status score of 03. Resident #12 required partial/moderate assistance for personal hygiene. 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

“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

$37,092 in federal fines across 3 penalties.

  • $19,920 — penalty dated 2025-11-20
  • $8,586 — penalty dated 2024-04-02
  • $8,586 — penalty dated 2024-04-02

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.

Who owns this facility

Owner / managerTypeRoleShareSince
VOLUNTEERS OF AMERICAOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 08/01/2004
VOLUNTEERS OF AMERICA NATIONAL SERVICESOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/01/2026
BLOOM, SHAWNIndividualCORPORATE DIRECTORsince 07/01/2017
ERICKSON, KARENIndividualCORPORATE DIRECTORsince 07/01/2022
HACKETT, KARENIndividualCORPORATE DIRECTORsince 07/01/2023
JACKSON, CARMENIndividualCORPORATE DIRECTORsince 07/01/2024
KITTLESON, MELISSAIndividualCORPORATE DIRECTORsince 07/01/2024
MANEVAL, JOHNIndividualCORPORATE DIRECTORsince 07/01/2024
MULLEN, BETHIndividualCORPORATE DIRECTORsince 07/01/2023
PERKINS, DERRICKIndividualCORPORATE DIRECTORsince 07/01/2019
PETERSON, JEANNEIndividualCORPORATE DIRECTORsince 07/01/2017
SHERIDAN, PATRICKIndividualCORPORATE DIRECTORsince 07/01/2023
STRIBLING, MORRISIndividualCORPORATE DIRECTORsince 07/01/2024
STRINGFELLOW, JANETIndividualCORPORATE DIRECTORsince 07/01/2024
TEJADA, WALTERIndividualCORPORATE DIRECTORsince 07/01/2024
VIGEE, VORISIndividualCORPORATE DIRECTORsince 07/01/2022
BATA, JEFFIndividualCORPORATE OFFICERsince 10/24/2025
KELLER, RYANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
KING, MICHAELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/05/2020
NISIVOCCIA, DAVIDIndividualCORPORATE OFFICERsince 12/01/2023
NUTZ, FAITHIndividualCORPORATE OFFICERsince 09/01/2018
SOCZYNSKI, PAULIndividualCORPORATE OFFICERsince 07/01/2024
BUDZYNSKI, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2012
DIVIETRO, ANGELIQUEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/12/2025
MAHADEVAN, ANANDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2020
RICHARD, SARAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/17/2025
SALTMARSH CPAS, INC.OrganizationADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 39 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$33.3M
Net patient revenuemost recent cost report
-41.7%
Operating marginrevenue minus expenses
$3.1M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 14%Medicare 11%Other / private 75%

This home reported $3.1M 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

$633per resident / day
operating cost
$19,258per month
≈ monthly operating cost
$447per 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 105672. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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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