Rehab & Healthcare Center Of Cape Coral
2629 Del Prado Blvd, Cape Coral, FL 33904 · Non profit - Other · 118 certified beds · (239) 574-4434 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $32,188 in federal fines (most recent 2025-02-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 14.7% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| 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 | 3.7% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 10.0% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.0% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.6% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 5.6% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.6% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.26 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.81 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
49.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 260 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.0% 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 105 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 0.66 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% 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 | 49.0%CMS range 41.8–55.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.3%CMS range 9.9–16.1 | 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 | 61.0% | 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 | 56.2% | 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 | 54.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.5% | 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 | 100.0% | 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 | 100.0% | 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 | 0.6% | 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 | 2.9% | 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 | 10.3%CMS range 7.3–13.6 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 118 beds and averages 114.0 residents a day — about 97% 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.33 on weekdays — 8% thinner on weekends. RN hours go from 0.85 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Ecited before2025-05-13 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, residents and staff interviews, the facility failed to ensure reasonable accommodation of needs by failure to ensure the call light was within reach to request assistance as needed for 9 (Residents #900, #1000, #1001, #20, #12, #89, #10, #1002, and #1004 ) of 18 sampled residents The findings included: On 5/12/25 at 8:45 a.m., during an initial tour of the facility the following observations were made: 1. Resident #900's room. The call light was hooked to a metal bracket that contained a box of gloves, on the wall behind the head of the bed. In an interview, Resident #900 said he did not know where the call light was. Photographic evidence obtained. 2. Resident #1000's room. Resident #1000 was observed sleeping in bed. The call light was hooked to a metal bracket that contained a box of gloves. Photographic evidence obtained. 3. Resident #1001's room. Resident #1001 was observed in bed. The call light was on the floor near the head of the bed. 4. Resident #20's room. Resident #20 was observed in bed and did not respond to interview questions. The call light 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 · E2025-05-13 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to provide the necessary care and services to maintain personal hygiene for 3 (Resident #999, #89, and #27) of 5 sampled residents. The findings included: The facility policy Abuse Prevention Program documented The facility has designated and implemented processes, which strive to reduce the risk of . neglect . The policy defined neglect as, Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The facility Policy Documentation for CNA'S (Certified Nursing Assistants) instructed CNA's to Document what you did for the resident (assisting with ADL's). 1. Review of the clinical record revealed Resident #999 had an admission date of 4/17/25. Diagnoses included cerebral vascular accident with left hemiparesis (weakness of one side of the body) and chronic kidney disease stage 4. Review of the Discharge Minimum Data Set (MDS) (standardized assessment tool that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-13 · tag F0825 — patternProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the clinical record and staff interviews, the facility failed to provide specialized rehabilitative services as directed by the plan of care for 1(Resident #999) of 3 residents for rehabilitative services. The findings included: Review of the clinical record revealed Resident #999 had an admission date of 4/17/25. Diagnoses included cerebral vascular accident with left hemiparesis (weakness of one side of the body). On 5/12/25 at 1:35 p.m., in a telephone interview a family member said Resident #999 did not receive therapy during his stay at the facility. Review of the plan of care initiated 4/23/25 revealed Resident #999 had an activities of daily living self-care performance deficit. The goals for the resident included Occupational Therapy (OT) as ordered, goals are established per the OT plan of care. PT (Physical Therapy) is ordered and goals are established per the PT plan of care. Will improve level of self-performance by next review period. Review of the Physical Therapy (PT) evaluation dated 4/18/25 revealed, Resident to be seen 6 x's a week (six times a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and record reviews, the facility failed to provide a safe, sanitary, and homelike environment as evidenced by dry wall damage in resident's rooms. Failure to identify and complete needed repairs could cause safety and sanitary hazards to residents on Unit 1, which had damage in 8 of 31 rooms. The findings included: On 2/9/25 during the initial tour of Unit 1's resident rooms: observation revealed the drywall and chair-rails behind resident's beds in rooms 6, 9, 14, 18, 21, 35, 37 and 39 were damaged and chair-rails were on the floor. Holes were observed in the dry walls next to the bathroom door in rooms 6, 9, 14, 21, and 39. On 2/9/25 at 10:23 a.m., in an interview with Resident #55, he said the chair rail molding behind bed A and B had been damaged and broken for the past several months. He said he told the staff about the drywall damage in the room, but nothing had been done to repair the drywall damage and the missing chair rails behind the beds in months. The review of the Maintenance Director's Job Description stated they were…
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 before2025-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, review of job description, clinical record review, staff and resident interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 5 (Resident #24, #69, #72, #83 and #271) of 6 residents reviewed for activities of daily living (ADL's). The findings included: The facility Job Description, Position: CNA's documented The CNA is responsible for assisting with direct residents/patients care. Ensures that each resident's personal care needs are being met in accordance with the resident's/patient' wishes.Bathes residents (recognizing that some residents may physically resist bathing). Gives oral hygiene. Shaves patients. Provides nail and hair care. 1. Review of the clinical record revealed Resident #24 had a readmission date of 10/30/24 with diagnoses including dementia, psychosis, and anxiety. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date 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 · E2025-02-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 record review, and staff interviews, the facility failed to have documentation nursing staff addressed a reported change of condition for 2 (Residents #46 and #66) of 3 residents reviewed for changes that may indicate a change in health status and need to revise the plan of care. The findings included: Review of the facility's policy and procedure titled, Notification of Resident/Patient Change in Condition effective October 2021 revealed, Notify the Physician . if there is a significant change in condition, regardless of the time of day . Review of the facility's Stop and Watch Early Warning Tool noted, If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. The symptoms to report included but were not limited to: Overall needs more help, ate less, tired, weak, confused, or drowsy, help with walking, transferring, toileting more than usual. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-12 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, clinical record review and staff interviews the facility failed to ensure a medication error rate less than 5 percent. 29 opportunities, 5 residents and four different nurses were observed. Four medication errors were identified resulting in a medication error rate of 13.79%. The findings included: On 2/9/25 at 9:15 a.m., Registered Nurse (RN) Staff R was observed administering 11 different medications to Resident #470, including: Lidocaine Patch 5% (topical anesthetic), one patch to the resident's left shoulder and one patch to the resident's left knee. Loratadine (antihistamine) 10 milligrams (mg), one tablet by mouth. Venlafaxine 75 mg (antidepressant), one tablet by mouth. Reconciliation of the medication administration observation with the physician's orders revealed the current physician's orders included: Lidocaine external patch 4%, apply to left shoulder/left leg topically one time a day for chronic pain. Venlafaxine HCL (Hydrochloride) 75 mg, give one tablet by mouth one time a day related to Major Depressive Disorder, administer with 37.5 mg total to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility policy review the facility failed to provide appropriate infection control practices during wound care for 2 (Residents #53 and #107) of 3 residents reviewed for Infection control/Enhanced Barrier Precautions. The findings included: Review of the clinical record revealed Resident #53 was admitted to the facility on [DATE]. Her medical history included Senile Degeneration, Dementia, Weight Loss, and pressure wounds. She had Physician orders for daily wound care. She also had Physician orders for Enhanced Barrier Precautions. There was PPE (Personal Protective Equipment) and a sign on her room door along with a sign over her bed that said EBP (Enhanced Barrier Precautions); Gown and gloves required. The Policy and Procedure provided by the facility for Barrier Precautions with an effective date of April 2024 stated Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission or multi-drug-resistant organisms that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accommodate smoking needs and preferences for 1 (Resident #470) of 2 reviewed for smoking, who required a specialized chair for transport to the smoking area, which was not available, that prevented the resident from smoking. This failure caused unnecessary anxiety to the resident, who was a long-term smoker, who required assistance from the facility staff and specialized equipment to get to the designated smoking area. The findings included: Review of the facility policy for Resident Rights Effective November 2024 noted the facility strives to assure that each resident has a dignified existence and self-determination (Self-determination is a set of concepts and values that people with disabilities should have the freedom and support to decide how they live and participate in the community) Review of the facility policy for Smoking/Tobacco Use Effective October 2021, the facility permits smoking and use of tobacco products in accordance…
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 · D2025-02-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, and resident and staff interviews, the facility failed to develop a care plan that described the resident's medical, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences for 1 (Resident #83) of 28 care plans reviewed. The failure to complete an accurate and individualized care plan has the potential to impact the resident's quality of life and quality of care. The findings included: Review of the clinical record revealed Resident #83 was a [AGE] year-old male with a readmission date of 11/8/24. Diagnoses for the resident included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral vascular infarction, anxiety, major depressive disorder, and muscle wasting. The record indicated Resident #83 was on hospice services beginning 1/9/25. A significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2025-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff and resident interviews, and review of facility policy and procedure, the facility failed to identify and provide the appropriate services and interventions for the management of contractures and limitations in range of motion (ROM) for 1(resident #83) of 3 residents reviewed for limitations in ROM. The failure to provide the necessary services and interventions has the potential to cause pain and worsening of the contracture and loss of ROM. The findings included: The facility policy Restorative Nursing Programs and Guidelines (revised 10/17) documented The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical functioning. Contracture management and prevention.includes the provision of active and or passive ROM exercises/movements to maintain or improve joint flexibility as well as strength. Review of the clinical record revealed Resident #83 was a [AGE] year-old male with a readmission date 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 before2025-02-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to provide appropriate care and services to prevent urinary tract infection for 1 (Resident #107) of 2 residents reviewed with indwelling urinary catheter. The findings included: Clinical record review revealed Resident #107 was admitted to the facility on [DATE] and had a re-admission date of 1/23/25. The admission Minimum Data Set (MDS) assessment with a target date of 1/23/25 noted the resident was rarely/never understood. Diagnoses included cerebral infarction, cerebral edema (swelling), compression of the brain, obstructive uropathy (flow of urine is blocked in the urinary tract). Resident #107 had an indwelling urinary catheter (catheter inserted into the bladder to drain urine). The care plan initiated on 12/2/24 noted Resident #107 used a urinary catheter with risk for infection and/or complications related to retention. The goal was for early identification and treatment of UTI (urinary tract infection). The interventions…
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 · D2025-02-12 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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
Based on observation, review of facility policy and procedure, record review and staff interview the facility failed to follow physician's orders for an abdominal binder over a feeding tube for 1 (Resident #26) of 1 resident reviewed, to prevent pulling and accidental removal of the tube. The findings included: The facility policy Medication Administration General Guidelines documented The individual who administers the medication, records the administration on the resident's MAR immediately following the medication being given. If a scheduled medication is withheld, refused, the space provided on the front of the MAR/TAR (treatment administration record) for that dosage administration is initialed and circled. An explanatory note is entered. Review of the clinical record revealed Resident #26 had a readmission date of 1/28/25 with diagnoses including dysphagia, need for assistance with personal care, delusional disorders, and obesity. The record indicated the resident was Spanish speaking only. A nursing progress note with a date of 1/30/25 documented SOC (standards of care)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-12 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 short peripheral catheter (a thin, flexible tube is inserted into a vein, usually in the back of the hand, the lower part of the arm) cover dressing was changed every 7 days to prevent local and systemic infection related to the intravenous (IV) catheter for 2 residents (271 and 23) of 3 reviewed for IV catheters. The findings included: Review of the policy for Vascular Access Devices and Infusion Therapy Procedures Dressing Change for Vascular Access Devices dated 10/2024, the purpose is to prevent local and systemic infection related to the IV catheter. A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide microbial barrier, and to provide vascular access device securement. Short peripheral catheter dressings are changed every 7 days or when the integrity of the dressing is compromised. On 2/9/25 at 10:16 a.m., Resident #271 was observed in bed with intravenous (IV) antibiotic infusing through an IV line inserted in the resident's right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-08 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, staff and resident interviews the facility failed to ensure a safe, clean, comfortable and sanitary environment for residents and failed to make necessary repairs inside of the facility for 2 (North and South) of 2 units observed. The findings included: The facility policy Equipment- Cleaning/Disinfecting effective 10/21 documented, The facility will take action to prevent resident care equipment and supplies from becoming sources of infection. A facility specific cleaning schedule will be developed for the routine cleaning of noncritical equipment. The facility policy and procedure Ice Machine documented, The ice machine, scoop and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once per day. On 5/6/24 at 12:03 p.m., during an initial tour of the facility, the following was observed: 1. room [ROOM NUMBER]:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-08 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, review of the clinical record, and staff and resident interviews, the facility failed to provide the necessary care and services to maintain hygiene for 3 (Resident #24, #750 and #999) of 3 residents reviewed for activities of daily care (ADLs). The findings included: 1. On 5/6/24 at 10:26 in a telephone interview, Resident #24's representative said the resident was not receiving her scheduled showers. Review of the clinical record revealed Resident #24 had an admission date of 2/9/22 with diagnoses including depression, chronic obstructive pulmonary disease and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 2/15/24 documented Resident #24 required partial to moderate assistance with bathing. The MDS noted Resident #24's cognitive skills for daily decision making were moderately impaired. Review of the Certified Nursing Assistant (CNA) documentation for March 2024 showed Resident #24 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 · E2024-05-08 · tag F0925 — failed to control pests — patternMake 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, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests for residents residing in the skilled nursing facility. The findings included: On 5/6/24 at 12:30 p.m., during an initial tour of the facility one large live brown insect was observed on its back with legs moving in a resident's room next to an oxygen contractor. Photographic evidence obtained. On 5/6/24 at 12:10 p.m., Resident #900 said he had bugs in his room all the time and reported it to the nurse. He said, they are in here crawling on the walls at times, and the time of the day does not matter. On 5/6/24 at 12:15 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said the facility has bugs, the big ones. We put it in a log when we see them and they spray. It works for a while, but they come back. On 5/6/24 at 12:25 p.m., in an interview Resident #850 said, There are roaches in here all the time, they crawl on the walls. The nurses step on them, they are good at that, they crunch them. On 5/6/24 at 12:37…
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 · D2024-05-08 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility records, review of facility policies and procedure and resident and staff interviews the facility failed to ensure appropriate corrective action to resolve the expressed concerns with broken furniture and call light for 1(Resident #24) of 3 residents reviewed for grievances. The findings included: The facility policy Grievance/Concerns Management effective 2/21, documented Residents/representative has the right to present concern on behalf of themselves, and/or others to the staff and or administrator of the facility, to government officials, or to any other person. The concern may be filed verbally or in writing, and the reporter may request to remain anonymous. On 5/6/24 at 10:26 a.m., in an interview Resident #24's representative said the resident's closet drawer was broken and the call light had frayed and exposed wires for several months. The representative said he had notified the facility Administrator of the concerns and work orders for maintenance were filed but the repairs were not completed. He said he voiced the grievances to the Administrator…
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 · E2023-02-22 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove outdated medications from the refrigerator and failed to ensure proper storage of medications to prevent unauthorized access for 1 (Unit 2) of 2 units observed. The findings included: The Facility policy titled: Medication Storage, Section 4.1, dated 9/18, was provided. The policy stated the medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedure #3 indicated in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Procedure #14 indicated outdated, contaminated, discontinued, or deteriorated medications, and those in containers that are cracked, soiled 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.
- Potential for harm · Dcited before2023-02-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to provide a call light to accommodate the needs, of 1 (Resident #108) of 5 residents reviewed for call light needs. The findings included: Review of the clinical record revealed Resident #108 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs). The admission Minimum Data Set (MDS) assessment with an assessment reference date of 12/22/22 noted the resident required extensive physical assistance of two persons for all activities of daily living, including bed mobility and transfer. On 2/19/23 at 10:16 a.m., Resident #108 was observed in bed. A flat pad call light (specialized call light for residents with limited dexterity activated by slight pressure) was on the floor, not accessible to the resident. Resident #108 said, I can't use it anyway. On 2/20/23 at 9:02 a.m., Resident #108 was observed in bed. A flat pad call light was on a pillow by the resident's right shoulder.…
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 before2023-02-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview the facility failed maintain an indwelling catheter (tube inserted into the bladder to drain urine) in a safe and sanitary manner for 1(Resident #69) of 1 resident sampled with an indwelling catheter. This had the potential to cause urinary tract infection and complications. The findings included: Review of the clinical record revealed Resident #69 had an admission date of 9/19/22 with diagnoses including dementia, epilepsy and hemiplegia affecting the left side, urinary tract infections and neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problem). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 12/21/22 documented Resident #69 required extensive assistance with transfers and bed mobility. The MDS noted Resident #69's cognition was intact. The care plan initiated on 9/19/22 documented the Resident uses a urinary catheter with risk for infection and or complication. The care plan goal…
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 · D2023-02-22 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of facility policy, and staff interviews, the facility failed to ensure 1(Resident #69) of 1 resident reviewed for accidents was assessed for alternative interventions prior to the use of bed rails. The facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. In addition, the facility failed to have ongoing routine maintenance of the bed rails to ensure they remained safe for resident's use. The findings included: The facility policy Side Rail-Assistive Device (effective 10/21) documented, Side rails will not be used unless or until all other alternative devices have been exhausted. If a side rail is used the facility must ensure correct installation, use and maintenance of rail. Side rails may be a restraint or entrapment risk. Side rails will not be used as a restraint. The facility strives to ensure the safety of residents by following manufacturer's instructions and through preventive maintenance of side rails. Facility will maintain a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-22 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the Consultant Pharmacist's Medication Regimen Review report, and staff interview, the facility failed to have documentation of monthly medication review for 2 (Resident #93, and #27) of 5 residents sampled for unnecessary medication review. The findings included: Review of the facility policy Medication Monitoring Section 8.1 Medication Regimen Review (MRR) and Reporting dated 09/18 Procedures: The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly . The findings are communicated to the Director of Nursing (DON) or designee and the medical director. The findings are documented and filed with other consultant pharmacist recommendations in the resident's chart. Resident specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician. A record of the consultant pharmacist's recommendations is made available .within 48 hours of completion. The nursing care center follows-up on the recommendations to verify that appropriate action has been taken. Recommendations…
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 · E2021-07-15 · tag F0563 — failed to protect the right to visitors — patternHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of the facility's policies and procedures, staff, resident, and family member interview, the facility failed to ensure residents' right to receive visitors of his or her choosing at the time of his or her choosing. The findings included: Review of the Centers for Medicare and Medicaid Services memorandum dated 3/10/21 for new guidance for visitation in nursing homes during the COVID-19 Public Health Emergency (PHE), including the impact of COVID-19 vaccination read, Responsible indoor visitation should be allowed at all times and for all residents, regardless of vaccination status of the resident. Review of facility policy for visitation, effective April 2021, stated, The facilities will not restrict visitation without a reasonable clinical or safety cause. Review of the facility letter signed by facility administrator dated 6/3/21, sent to residents and families as communication regarding the facility's visitation policy read, . As a reminder, the facility is currently open for general visitation during the following hours: Monday, Tuesday, Thursday,…
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 · E2021-07-15 · tag F0661 — patternEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 have documentation of a discharge summary including recapitulation and post discharge plan of care to ensure a safe transition home for 3 (Resident #413, #164, and #165) of 3 sampled discharged residents. The findings included: 1. On 7/14/21 review of the clinical record revealed Resident #413 was admitted to the facility on [DATE] with diagnoses including muscle wasting, gastrointestinal hemorrhage, history of fall with injury to the face, dementia, and anemia. Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 5/30/21, revealed the resident required limited physical assistance of 1 person for transfer and ambulation. Resident #413 received Physical and Occupational Therapy from 5/29/21 through 6/14/21. The Physical Therapy Discharge summary dated [DATE], noted Resident #413's goals were not met. The explanation was Pt [patient] and family's decision to go home and have home health care. The physician'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 · E2021-07-15 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a meaningful, resident centered activity program for 3 (Resident #88, #92 and #5) of 3 residents with cognitive impairment. The lack of individualized activity program has the potential to not maintain a physical and psychological quality of life. The findings included: Review of the facility policy 12.1.1 titled, Activities Program, dated November 2013 which said, . Scheduled activities shall be planned to include recreational, social and educational opportunities, offering no less than 12 hours weekly of activities, 6 days each week. The activities policy provided by the facility did not list specific activities for residents with cognitive decline. 1. Review of the admission Activity Assessment dated 6/29/21, showed Resident #88 required physical assistance to and from activities. The assessment noted Resident #88 would prefer or benefit from sitting outside, listening to music, watching movies and enjoyed sports and fishing. The admission Minimum Data Set (MDS) assessment with a target date 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.
- No harm found · B2023-02-22 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to post the required current daily staffing data in a prominent place readily accessible to residents and visitors. The findings included: On 2/19/2023 at 11:21 a.m., the facility daily staffing was posted and reflected a current census of 114 for 2/19/2023. On 2/20/2023 at 7:29 a.m., the facility daily staffing posted and remained dated as 2/19/23 but the census was changed to 111. On 2/20/23 at 3:38 p.m., the facility daily staffing was not updated and remained dated as of 2/19/23. On 2/22/23 at 12:25 p.m., the facility daily staffing was not updated and remained dated 2/19/23 with a census of 111. On 2/22/23 at 12:30 p.m., the administrator stated the staffing coordinator was responsible for posting and updating the staffing numbers. He said The process needed to be posted and updated daily for all visitors or residents to view at the receptionist desk. The administrator stated the staffing should reflect today's date and verified the staff information posted was from 2/19/23.
“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
$32,188 in federal fines across 3 penalties.
- $4,147 — penalty dated 2025-02-12
- $4,979 — penalty dated 2025-02-12
- $23,062 — penalty dated 2025-02-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 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 | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 2 of 5 | 3.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 16 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FLORIDA INSTITUTE FOR LONG TERM CARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 04/07/2025 |
| JAFFE, HOWARD | Individual | CORPORATE OFFICER | — | since 07/01/2003 |
| KATZ-HALL, KATHY | Individual | CORPORATE OFFICER | — | since 07/01/2003 |
| MULLARKEY, JAMES | Individual | CORPORATE OFFICER | — | since 07/01/2003 |
| RICHMOND, PENNY | Individual | CORPORATE OFFICER | — | since 07/01/2003 |
| AEGIR HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2003 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/28/2011 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/13/2010 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/06/2012 |
| JONES, MARTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/02/2012 |
| WATSON, SASHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/22/2022 |
| OMEGA HEALTHCARE INVESTORS, INC | Organization | ADP OF THE SNF | — | since 07/01/2003 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 20 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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 $159K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105342. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-12, 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 →
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