Aviata at Sand Key
1980 Sunset Point Rd, Clearwater, FL 33765 · For profit - Limited Liability company · 120 certified beds · (727) 443-1588 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 Oct 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $163,898 in federal fines (most recent 2023-10-31)
- 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)
- nursing-staff turnover (62%) runs well above the national median (45%)
- about 27% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 9.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.9% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 9.9% | 4.6% | 6.5% | worse |
| 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 | 2.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.6% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.2% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.7% | 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 | 2.0% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.16 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.86 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 49.1% 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 57 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.0–16.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 49.1% | 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 | 43.9% | 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 | 38.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.5% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.8% | 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 | 6.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.5%CMS range 5.2–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 107.8 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.98 hrs/resident/day on weekends vs 3.35 on weekdays — 11% thinner on weekends. RN hours go from 0.60 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Immediate jeopardy · J2023-10-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to protect the resident's right to be free from neglect for one Resident (#1) of three residents reviewed for change in condition. On [DATE] during a 12 hour shift when Resident #1 exhibited shortness of breath and not feeling well, was unable to perform her normal daily activities, unusual behaviors and was begging to go to the hospital the nurses on duty neglected to respond with in a way that could have helped the resident. There were no PRN (as needed) medications provided to the resident except pain medication, no documented assessments or vital signs (VS), no call to the resident's provider, and no call to the resident's family. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) started. EMS (Emergency Medical Services) transported the resident to a hospital where she was admitted to intensive care and died 2 days…
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.
- Immediate jeopardy · J2023-10-31 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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 record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure nursing staff were competent to recognize and respond to a change in condition for one resident (#1) out of three residents reviewed for change in condition. On [DATE] Resident #1 complained of shortness of breath and not feeling well, was unable to perform her normal daily activities, exhibited unusual behaviors and was begging to go to the hospital. The aide assigned to the resident notified the nurses on duty of the resident's condition and complaints multiple times during a 12-hour shift. There were no documented assessments, vital signs (VS) or notifications to a physician or family member. There were no PRN (as needed) medications provided to the resident except pain medication. One hour into the following shift the resident was found unresponsive by an aide and CPR (Cardiopulmonary Resuscitation) was begun by facility staff. EMS (Emergency Medical Services) transported 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 · E2024-09-05 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to respond to un-timely call bell light grievances voiced by Resident Council for three of three sampled months, June, July and August of 2024. Findings included: A review of Resident Council Monthly meeting notes, dated 06/27/2024, documented, Old Business, Issues from last meeting: Call lights have not been answered in a timely manner. The form continued, How are these issues being resolved?: Staff will rotate shifts to audit call light response times-Administrator and ADON (Assistant Director of Nursing) will do night shifts check-ins call lights. The form continued, New business: Blank A review of Resident Council Monthly meeting notes, dated 07/23/2024, documented, Old Business, Issues from last meeting: Residents have complained that their call lights are not being answered in a timely manner. The form continued, How are these issues being resolved?: Staff will do audits. The form continued, New business: Call lights are still bad . A review of Resident Council Monthly Meeting notes, dated 08/27/2024, documented Old…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-05 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 and interview, the facility failed to ensure a safe and sanitary environment for residents as evidenced by discoloration on ceiling tiles in one of two resident day rooms; discoloration on ceiling tile in room [ROOM NUMBER] with evidence of water by the air conditioning wall unit; ceiling damage from rain in room [ROOM NUMBER]; discoloration on ceiling air vents above one of two nursing stations; and a fallen tree limb in one of one resident courtyard. Findings included: During the tour of the facility conducted on 09/05/2024 initiated at 9:30 a.m., the following physical plant observations were conducted. Photographic evidence obtained. At 9:30 a.m., an observation on the 300 hall, the resident day room, revealed three of the ceiling panels next to the fan had brownish, black, pinkish discoloration present. The discoloration was approximately 10 inches by 10 inches in size each, with one of the marks having grayish growth like material on top of the pinkish black. At 9:40 a.m., an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-02-01 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services to residents on four (100, 200, 300 and 400) of four halls observed Findings Include: 1. On 1/29/2024 at 7:00 AM an observation occurred of Staff O, Registered Nurse (RN) stating to another employee, I refuse to take over two medications carts that are across the building, that is too much. On 1/29/2024 at 7:30 AM an observation of Staff O, RN was in the Nurse Manager office stating, only taking the cart accepted on the 300 hallway and to accept the cart for 100 hallway is too much for one nurse. On 1/29/2024 at 7:45 AM an observation of Staff O, RN speaking to Staff C, RN. Staff O, RN explained that Staff O, RN would not be taking over the care of the residents on the 100 cart. An interview was conducted with Staff C, RN on 1/29/2024 at 10:45 AM. Staff C, RN stated I am the only nurse on this unit, the other nurse scheduled did not show up. I am currently responsible for 47 residents. An interview was conducted with the Staffing Coordinator…
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 before2024-02-01 · 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, policy review and interview, the facility failed to provide a clean, clutter free, comfortable, and homelike environment in three (100 Hall, 200 Hall, 400 Hall) of four halls, and in one (#47) of one resident rooms. Findings included: 1. On 2/1/2024 the following observations were made: -In the clean utility rooms (North and South) multiple pieces of trash on the floor, flowerpot, walls without baseboards, baseboards with gunk, dirty floor tiles, air vents with hanging dust particles and dust on adjacent ceiling. (Photographic Evidence Obtained) -In the North and South shower rooms, the external toilet surface was dirty. The shower chair was noted with feces on the seat stored next to clean patient items. (Photographic Evidence Obtained). Staff M, Certified Nursing Assistant, who was present during the observation agreed there was feces on the shower chair seat and said, I will clean it now. During the survey between 1/29/24 to 2/1/24 the following was observed in multiple resident rooms: -peeling paint, scuffed and dirty walls, buckling baseboards, holes in…
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 · E2024-02-01 · 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 observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and ten errors were identified for three (#86, #29, and #63) of six residents observed. These errors constituted a 28.57% medication error rate. Findings included: On 1/30/24 at 4:18 p.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #86. The staff member dispensed the following medications: - Lubiprostone 8 microgram (mcg) capsule - medroyprogesterone acetate 2.5 milligram (mg) - 2 tablets - Metformin Extended Release 850 mg tablet The staff member confirmed dispensing 2 tablets of medroyprogesterone and with a plastic spoon removed one of the tablets, taking it to the medication room where it was destroyed. Staff A stated I wouldn't normally. Review of Resident #86's Medication Administration Record (MAR) revealed the following medication was scheduled to be administered at the time of the observation: -…
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 before2024-02-01 · 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 observations, record reviews, and interviews, the facility failed to store medications appropriately and safely as evidenced by improper temperature in one (north) of two medication room refrigerators, failed to ensure medications were stored when administering medications on one (100) out of four hallways, and failed to ensure medications were not left at the resident's bedside unattended in five (104a, 302, 303b, 304b, and 308b) of five resident rooms. Findings included: 1. On 1/31/24 at 7:56 a.m., an observation was conducted with Staff S, Licensed Practical Nurse (LPN) of medication administration. The staff member dispensed medications which were refused by the resident. Staff S walked to the medication room on the north unit to destroy the medications and the observation of the med room revealed the refrigerator door was open. The thermometer hanging inside the refrigerator read 68 degrees Fahrenheit. The staff member stated it was warm, and she had not noticed the door being open but did confirm…
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 · E2024-02-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure one (north) of two nourishment refrigerator/freezer was maintained to prevent the potential for foodborne illness and to ensure that food items were dated and labeled. Findings Included: On 01/31/ 2024 at 9:00 AM an observation was made in North and South Nourishment Rooms with the dietary manager and Nursing Home Administrator. The North nourishment room was observed dirty with food items stored in the refrigerator and freezer not dated or labeled. On 01/31/2024 at 9: 20 AM an interview was conducted with the Certified Dietary Manager. He said the nourishment room refrigerator and freezer were maintained by the dietary staff daily. The refrigerators and freezers in the nourishment rooms should be kept clean. If food items are stored in the nourishment rooms staff must ensure those items are labeled and dated before they store food in the refrigerator or freezers. Staff are not allowed to store their own food in the refrigerator because it's only for the residents. If food is stored in the refrigerator of freezers…
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 · E2024-02-01 · tag F0848 — patternProvide 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 and interview, the facility failed to ensure the arbitration agreements presented to two residents of of three residents reviewed provided for the selection of a venue convenient to both parties and selection a neutral arbitrator agreed upon by both parties. Findings included: Review of the admission Agreement with a revised date of 8/19, page 13 and 14. Page 13, showed a heading of OPTIONAL ARBITRATION AGREEMENT. the fifth paragraph on page 13 shows: The parties agree that only one (1) arbitrator is required to resolve any Dispute(s) and the arbitrator shall be selected from a panel to be provided by the Facility. The panel shall consist of at least three (3) individuals who are qualified by the state to serve as an arbitrator, who have experience and knowledge of the health care industry or have served as mediators in health care malpractice claims, and who can certify they are neutral and impartial. If the parties agree to a single arbiter, the arbitrator's compensation and administrative fees related to the arbitration shall initially be paid by Facility.…
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 · E2024-02-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure infection control practices were followed related to 1.) cleanliness and prevention of biogrowth on two (north and south) ice machines; 2.) use of Personal Protective Equipment (PPE) as required by door signage for two (#342, #20) of two residents; 3.) hand hygiene on three of four halls (100, 200 and 400) halls; and 4.) cleanliness of resident equipment/supplies in resident rooms for residents #47 and #66 Findings included: On 1/13/24 at 8:20 a.m. during observation of the North and South Clean utility rooms. The Ice machines (bins) had what appeared to be yellow mineral deposits and grayish black bio growth. (Photographic Evidence Obtained). On 1/31/24 at 8:45 a.m. the Nursing Home Administrator (NHA) was accompanied to observe the ice machines. The NHA said she was not sure if the housekeeping or maintenance staff was responsible for cleaning the ice machines. The NHA took photographs of the ice machine. Copies of the ice…
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 · E2024-02-01 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure the resident's medical record included documentation indicating the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; and the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal for five (#12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not include influenza and pneumococcal immunization education and vaccine consents. A review of the immunization and miscellaneous sections of the resident's Electronic Health Record (EHR) where vaccine administration and related education are documented was conducted. Residents #12, #77, #15, #55 and #20 EHR was silent for documentation indicating the resident or the resident's representative was provided education regarding the benefits and potential side effects of influenza 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.
Show the remaining 21 citations
- Potential for harm · E2024-02-01 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure screening and eligibility to offer the COVID -19 vaccine and vaccine education regarding the benefits and potential side effects was documented according with national recommendations for five (# 12, #77, #15, #55 and #20) out of five resident immunization records reviewed. Findings Included: A review of the facility's admission forms, provided to all new admissions did not reveal COVID-19 immunization education, refusal or consents related to vaccines. On 1/30/24 at 2:25 p.m. during an interview the Director of Nursing (DON), said vaccine administration is documented in the Medication Administration Record (MAR). When vaccine education is provided the Vaccine Information Sheet (VIS) is scanned to the resident's Electronic Health Record (EHR). Documentation can also be found in the immunization section of the EHR. A request was made for the facility's immunization policies. On 1/31/24 at 10:15 a.m. an interview was conducted with the DON said this is what I found. Documentation of screening, and eligibility 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 · D2024-02-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure two residents (#20 and #78) out of two residents the at will right to access persons and services outside the facility. Findings included: On 1/30/23 at 02:50 p.m. Resident #20 was observed in his wheelchair in the lobby. On return to his room during an interview he said he enjoys going to [retail store] (close to the facility) to get snacks. Resident #20 said the Social Services Director (SSD) told him, Unsupervised leave of absence (LOA) was rescinded because the facility was told I [Resident #20] was observed behind a retail store smoking and drinking alcohol. Resident #20 said facility staff refused to identify who made the accusation. Review of admission records for Resident #20's admission record revealed [last] admission date 11/2/22 with diagnoses including diabetes, renal disease, right below the knee amputation. Review of Resident #20's order listing report revealed the following: -May go LOA per Nurse Practitioner (NP)…
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 · D2024-02-01 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure one (#81) out of four residents utilizing a Geri-chair was assessed for its use, a physician order had been obtained for its use, and it did not restrict the residents movement. Findings included: On 1/29/24 at 6:48 a.m. Resident #81 was observed lying in a Geri-chair, asleep and dressed appropriately in the doorway of the resident's room. On 1/29/24 at approximately 2:19 p.m., Resident #81 was observed lying in a Geri-chair next to the nursing station and the 400 hall medication cart. The chair back was laid back and resident was observed attempting to sit upright. On 1/30/24 at 2:18 p.m. Resident #81 was observed sitting upright in a high-back wheelchair in the North unit Dining Room alone, while facing out toward the hallway. On 1/31/24 at 8:50 a.m., Resident #81 was observed sitting in a highback wheelchair with the back layed back to approximately 30 degrees near the nursing station. Staff A, Licensed Practical Nurse/Unit…
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 · D2024-02-01 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four (#74, #81, #14, and #45) of thirty-eight initially sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and/or later identified. Findings included: 1. Review of Resident #74's admission Record revealed the resident was admitted on [DATE]. The record showed diagnoses present on admission included primary insomnia and generalized anxiety. The record revealed secondary diagnoses with an onset date of 4/12/23 of unspecified post-traumatic stress disorder (PTSD), uncomplicated cocaine, and opioid abuse, a diagnosis of moderate recurrent major depressive disorder with an onset date of 4/26/23, and a diagnosis of dysthymic disorder with an onset date of 9/21/23. Review of Resident #74's Level 1 PASRR, completed at an acute care facility on 11/2/22, showed the resident had diagnoses of substance abuse, anxiety disorder, and depressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · 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 observations, interview, and record review, the facility failed to develop and implement a care plan related to a urinary catheter for one resident (# 62) out of three residents sampled. Findings included: On 01//30//24 at 9:00 AM., Resident was observed laying in bed with his call light within reach. On 02/01/2024 at 10:00 AM., Resident was observed laying in bed with his call light within reach. Resident was observed with a urine catheter, with sluggish sediment inside the tubing. Review of a Resident Information Record dated 02/01/2024 showed Resident # 62 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Sepsis, Unspecified Organism, Urinary Tact Infection Site Not Specified, Retention of Urine, Difficulty Walking Major Depressive Disorder. Review of a Minimum Data Set (MDS) dated [DATE] showed Resident # 62 had a Brief Interview Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Further review of the MDS showed…
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 · D2024-02-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure splints were applied and oxygen flow rate was accurate and completed per physicians' orders for one (Resident #47) of one sampled resident. Findings included: Multiple observations were conducted of Resident #47, from 1/29/2024 at 6:50 AM to 2/1/2024 at 10:00 AM. Resident #47 was observed in his bed, with the head of his bed slightly raised without any splints, braces, abduction pillow, or palm guards. Resident #47 was observed during this time frame with a washcloth rolled up in the palm of his right hand. Resident #47's right and left hands were closed, fingers bent and touching the palms. The oxygen concentrator flow rate was set to 4.5 liters/minute (L/M). (Photographic Evidence Obtained). Review of the medical record for Resident #47 was conducted. The admission Record revealed diagnoses that included persistent vegetative state, Traumatic Brain Injury with loss of consciousness of unspecified duration, person injured in a motor-vehicle accident, tracheostomy, gastrostomy, and other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to document a fall, assess the resident, and notify the physician of an injury for one (#74) out of four residents sampled for accidents. Findings included: During an initial observation and interview with Resident #74 on 1/29/24 at 9:34 a.m., the resident reported falling last night (1/28/24). The resident stated the Certified Nursing Assistant (CNA) and the nurse were aware of the fall. Resident #74 revealed a right forearm abrasion approximately 6 inches long that was reported as occurring during the fall the night before. Review of Resident #74's progress notes did not show the resident had a fall on the night of 1/28 or prior to the interview conducted on 1/29/24. During an interview with the Director of Nursing (DON) on 1/29/24, she stated she was unaware Resident #74 had fallen. Review of a late entry progress note, effective 1/29/24 at 1:27 p.m., showed Resident #74 had reported to the DON of a fall in the resident room while…
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 · D2024-02-01 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to recognize, document, and educate staff regarding triggers for two (#74 and #14) out of two residents sampled for Post-Traumatic Stress Disorder (PTSD). Findings included: 1. On 1/29/24 at 9:34 a.m., Resident #74 was observed lying in bed with no lights, and the door and blinds closed. The resident reported falling during the night and the aide had been rude to her. The resident showed writer an approximate 6 inch abrasion to the right forearm. The resident said she does see psychiatry and has had suicidal ideations in the past. Review of Resident #74's admission Record showed the resident was admitted on [DATE] and the diagnoses of unspecified Post-Traumatic Stress Disorder (PTSD) was added on 4/12/23. Review of Resident #74's Level II Preadmission Screening and Resident Review, dated 11/4/22, showed the resident had a medical history included suicide attempt and opioid abuse with intoxication. The screening revealed the resident had…
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 · D2024-02-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 interviews, the facility failed to provide and obtain medication per physician orders for one resident (Resident #35) of the sampled six residents. Findings included: On 01/30/24 at 9:30 a.m., Resident #35 was observed lying in bed. She was alert and responded appropriately to questions. Resident #35 stated she felt a little sick in her stomach. A review of the admission Record for Resident #35 showed she was originally admitted to the facility on [DATE] with diagnoses to include pancytopenia, myelodysplastic syndrome, and anemia. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating cognitively impaired. A review of the Order Summary Report with an order date range of 12/01/23-02/29/24 revealed the following orders: -01/17/24- Send resident to emergency room for blood transfusion for hemoglobin and hematocrit 6.5; -12/26/23- Send resident 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 · Ecited before2021-12-10 · 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 and interviews, the facility failed to ensure air conditioning (A/C) units were maintained in a sanitary manner on one (Hall 100) of four halls observed. Findings included: During a facility tour on 12/07/21 between 10:13 a.m. and 12:38 p.m., the air conditioning (A/C) units and filters were observed with dirt, debris, and bio-growth in the 100 hall in resident rooms 101, 102, 105, 106, 107, 108, 109, 111 and 112. The filters were noted fully clogged with visible dark ashy-looking material, bio-growth, a white fuzzy appearance of growth on the unit's surfaces, and covered with dirt, dust, and debris. Photographic evidence was obtained. On 12/08/21 at 11:15 a.m., a second facility tour was conducted in hall 100. The A/C units were observed in the same condition as the observation made on 12/07/21, with concerns related to dirt, dust, debris, and bio-growth in rooms 101, 104, 105, 106, 107, 108,109, 111 and 112. On 12/09/21 at 9:49 a.m., a third facility tour was conducted in hall 100. The A/C units were observed in the same condition as the observations made on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two (Resident #19 and #33) of two sampled residents were free from potential accident hazards related to unsafe smoking in undesignated smoking areas. Findings included: On 12/08/21 at 8:40 a.m., the Nursing Home Administrator (NHA) reported the facility had two residents who smoked. Both residents smoked independently and were allowed to sign out for a leave of absence (LOA) to smoke on the facility grounds. She reported they had a designated smoking area underneath the covered patio area. On 12/08/21 at 8:15 a.m., Resident #19 was observed wheeling her wheelchair out of the main entrance of the facility with an unlit cigarette in her mouth. She wheeled out to the sidewalk near a trash can underneath the tree in the front of the main entrance (photographic evidence obtained). Resident #19 pulled a lighter from her pocket, lit the cigarette, and began smoking. The resident was observed dumping the ashes on the ground. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-10 · 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 observations, interviews, and medical record review, the facility failed to ensure a care plan intervention was implemented for one (Resident #9) of thirty-four residents in the sample group. Findings Included: An initial observation was conducted on 12/07/2021 at 9:47 a.m. of Resident #9 lying in bed, not wearing the physician-ordered splint to her right hand. A later observation was made on 12/08/2021 at 12:47 p.m. During the observation, Resident #9's hand splint was not applied to her right hand for a contracture. An observation was made later in the day on 12/08/2021 at 3:35 p.m. During the observation, an interview was conducted with Resident #9's mother who was at bedside. Resident #9's mother revealed the resident wore a right-hand splint for her right-hand contracture. The resident's mother also confirmed that Resident #9 did not have the splint on at the time. She walked over to the resident's dresser top drawer and opened it up. An observation was made of a blue hand splint in the drawer;…
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 · D2020-09-18 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of the resident, interview with facility staff, and review of the medical record and facility policy the facility did not ensure that one resident (Resident #25) of 30 sampled residents, received a Level II PASRR evaluation prior to admission to the facility, as required since the resident had been identified on the Pre-admission Screening and Resident Review (PASRR) as not being eligible for admission to a nursing home because of serious mental illness. Findings included: Resident #25 had multiple admissions to the facility based on a review of the electronic medical record and the Minimum Data Set (MDS) Assessments. The resident was initially admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive, Schizophrenia, and Metabolic Encephalopathy. A transfer to the hospital, documented in the MDS assessments, was dated 8/13/2020 with a return to the facility on [DATE]. The resident was again transferred to the hospital on [DATE] and returned on 08/31/2020. 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 · Dcited before2020-09-18 · 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, record review, and interview the facility failed to implement and develop a resident centered care plan for three (#20, #22, #80) of thirty sampled residents related to continuous oxygen use for Resident #20, activities of daily living (ADL) for Resident #22, and the use of Thrombo-Embolic Deterrent (TED) hoses for Resident #80. Findings included: 1. On 9/15/20 at 10:15 a.m., Resident #20 was observed in her room watching television, and wearing an O2 (oxygen) Nasal Cannula (NC) connected to an oxygen concentrator. The oxygen concentrator was set to 2.5 Liters (L). An observation was conducted on 9/16/20 at 11:40 a.m. of Resident #20 self-propelling in a wheelchair to her room, wearing a Nasal Cannula facemask. The oxygen tubing was connected to an oxygen tank located behind the wheelchair. The dial on the oxygen tank was set to 1.5 (L). On 9/17/20 at 12:09 p.m., Resident #20 was observed in her room watching television and was receiving 2.5 liters of oxygen via NC. The resident stated, I…
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 · D2020-09-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and interview, the facility failed to ensure storage of respiratory equipment, of a facemask, in accordance with professional standards of practice for three residents (#4, #20 and #44) of 17 residents receiving respiratory treatments for four of four days observed. Findings included: 1. On 9/15/20 at 10:05 a.m., an observation was conducted of Resident #4's room; the resident was in the bathroom and it was observed that the respiratory (nebulizer) facemask was hanging on the side of the bedside nightstand, and not properly stored in the plastic treatment bag. (Photographic Evidence Obtained.) During observation and interview of Resident #4's on 9/16/20 at 9:00 a.m., the respiratory (nebulizer) facemask was observed to be hanging on the side of the bedside table. The resident was observed to be looking at the facemask and was asked if she had previously had a nebulizer treatment that morning. Resident #4 revealed that it was her fault that the facemask was not stored…
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 · D2020-09-18 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of the resident, review of the resident's medical record, and interview with facility staff, the facility did not ensure that one resident (#25) of 30 sampled residents, received mental health services appropriate for his assessed needs. Findings included: Resident #25 had multiple admissions to the facility based on a review of the electronic medical record and the Minimum Data Set (MDS) Assessments. The resident was initially admitted to the facility on [DATE] with diagnoses that included Adult Failure to Thrive, Schizophrenia, and Metabolic Encephalopathy. A transfer to the hospital, documented in the MDS assessments, was dated 8/13/2020 with a return to the facility on [DATE]. The resident was transferred to the hospital on [DATE] and returned on 08/31/2020. The resident was transferred to the hospital on [DATE] and returned on 09/11/2020. The resident was transferred to the hospital on [DATE] and returned on 09/16/2020. When the resident returned to the facility on [DATE], admission…
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 · D2020-09-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a drug regimen review was conducted and communicated to report and correct irregularities for 3 out of 5 (Resident #30, Resident # 22, Resident # 17) residents sampled for unnecessary medications regarding lack of recommendations related to missing data on the Medication Administration Record (MAR), lack of monitoring of medications used to control resident behavior and failure to ensure that the consultant pharmacist recommendations were reviewed and acted on. Findings include: 1. Review of Resident #30's current physician orders and his MAR for the months of July 2020, August 2020 and September 2020 revealed that the resident had order for medications that included the following: -Accu check twice per day REPORT GLUCOSE BELOW 60 AND ABOVE 400, with a start date of 12/27/18. -Baclofen 10 mg three times a day for Muscle Spasms, with a start date of 6/4/20. -Dextromethorphan-Qulnldine Capsules 20-10 mg two times a day for PBA, with a start 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 · D2020-09-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to assure 2 out of 5 (#30, #44) sampled residents were free from unnecessary medications related to Gradual Dose Reductions (GDR), lack of monitoring medications used to control behavior. Findings included: 1. Review of the Resident #30's medical record revealed his diagnoses included Schizoeffective disorder dated 9/27/18, and Major Depression dated 10/1/16. Review of the resident's current physician orders revealed that he had the current medications to address behaviors: -Depakote sprinkles cap DR 125 mg 2 caps bid (twice daily) for major depressive -Quetiapine Fumarate 25 mg qd (daily) for schizophrenia -Duloxetine HCI cap DR particles 30 mg bid for depression An interview on 09/17/20 at 11:40 AM with the Director of Nurses (DON) revealed that he was not sure if he could locate Gradual Dose Reduction (GDR) information and said that the consultant pharmacist reviews and recommendations were non-existent. Interview on 9/17/20 at 1:35 PM with Staff B…
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 before2020-09-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review the facility failed to appropriately secure medications in three of four medication carts. Findings included: A review of the facility's Policy & Procedures Page 01-02, dated 12/1/07 and revised 10/31/16, titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, read as follows: Applicability: Policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. 3. General Storage Procedures: 3.3 Facility should ensure that 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. 10. Facility should ensure that all medications and biologicals for each resident are stored in containers in which they were originally received. On 09/17/20 at 12:40 p.m., an observation of medication cart #2, located on the South Hall included seven (7) loose tablets, and seven (7) loose half and quarter pieces of loose tablets. (Photographic…
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 · D2020-09-18 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, review of maintenance requests and proposals for work, an interview with the Director of Dietary, the Director of Maintenance and the Administrator, the facility failed to maintain equipment and the facility premises in safe operating condition as evidence by the facility: 1. failed to ensure that four ceiling tiles surrounding air vents in two of four resident halls were clean and free of dark stains and black spots; 2. failed to replace floor tiles and a loose wall board in the kitchen; and 3. failed to replace a freezer door that was identified as not fitting the door frame due to a build-up of ice. Findings included: 1. On 09/16/2020 at 8:49 a.m., three ceiling tiles surrounding outflow air vents on the 400 hall were noted to be stained with a brown color and the metal flanges on the ceiling vents were noted to be soiled with a black spotty substance. The three ceiling tiles (Photographic Evidence Obtained, photo # 5, 6, 7), were adjacent to rooms #402, #406, and #408. The fourth ceiling tile was observed outside of the storage room on the 300 hall. In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-09-18 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to ensure that the environment was maintained in a safe manner in three of eight resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) located on one of four resident halls (200 hall) related to a wrapped call light string and holes in the walls. Findings included: Observations during the initial tour of the facility on 9/15/20 at 10:30 a.m. revealed the following: -room [ROOM NUMBER]- A hole was noted in the wall, located near the bathroom door, where an electrical outlet should be. -room [ROOM NUMBER]- A large gaping hole was noted in the wall behind the bed located closest to the window. -room [ROOM NUMBER]- The call light string was noted to be wrapped around the grab bar located in the bathroom. (Photographic Evidence Obtained) Observations on 9/17/20 at 2:30 p.m. of the resident rooms 203, 204, 206 with the Director of Maintenance present confirmed that there was a large hole behind the resident's bed in room [ROOM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$163,898 in federal fines across 1 penalty.
- $163,898 — penalty dated 2023-10-31
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 AVIATA HEALTH GROUP — 50 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 | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 49 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 49; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SUNSET ROAD PARENT LLC | Organization | DIRECT OWNERSHIP INTEREST | since 11/15/2023 |
| ASP FL LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/15/2023 |
| FREUND, NOCHUM | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/15/2023 |
| CHUDYK, HOLLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/06/2025 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| HERSKOWITZ, ELIEZER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| HERSKOWITZ, YAAKOV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| TRAVITSKY, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/22/2025 |
| ASPIRE HEALTHCARE LLC | Organization | ADP OF THE SNF | since 11/15/2023 |
| SRIVASTAVA, SUNIT | Individual | ADP OF THE SNF | since 07/01/2024 |
| TARIQ, MARIUM | Individual | ADP OF THE SNF | since 07/01/2024 |
CMS files one row per role, so the 16 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105373. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-01, 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.