Highland Pines Rehabilitation Center

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

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.

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.

35.1% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 58.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 63 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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.

Staffing

How full it usually is: this home is certified for 115 beds and averages 107.4 residents a day — about 93% occupied, or roughly 8 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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.04 hrs/resident/day on weekends vs 3.17 on weekdays — 4% thinner on weekends. RN hours go from 0.32 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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.

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.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · K2025-04-17 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect the residents' right to be free from neglect for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) out of eleven residents sampled related to seizure medication management and follow-up laboratory orders for seizure medication therapeutic levels. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-04-17 · tag F0710 — pattern
  Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
  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 interviews and record reviews, the facility failed to provide competent physician services for the treatment and monitoring of seizure diagnoses for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven sampled residents. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1'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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-04-17 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure nursing staff were competent in caring for residents with seizure diagnoses to include laboratory monitoring process, following through with orders, processing consultations, and communications with physicians for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-04-17 · tag F0773 — pattern
  Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
  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 interviews and record reviews, the facility failed to ensure laboratory orders were entered in the electronic medical record and electronic laboratory (lab) portal, labs were completed as ordered, and abnormal results were reported to providers in a timely manner for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-04-17 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure they effectively monitored adverse events to systematically identify, report, track, and analyze the data to prevent potential or serious harm to residents for ineffective management of health care services, and treatment for seizure medication management for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure physician orders were followed in a timely manner, related to wound care treatment for one resident (#19) out of three residents sampled. On 10/20/2025 Resident #10 sustained an injury to his right pinky finger. On 10/20/2025 orders were given by the provider for wound care treatment and medications to fight infection. The facility staff failed to enter the orders until 10/22/2025. Resident #10 continued to experience pain and go without medications for the infection for two days. Resident #10 was transferred to a higher level of care and had to have his right pinky finger amputated. Findings Included:During an interview on 02/25/2026 at 10:41 AM, Staff A Licensed Practical Nurse (LPN), stated she went to give Resident #10 medication on 10/20/2025 and noticed the resident had an injury to the right pinky finger. Staff A stated she asked Resident #10 what happened to the finger and was told the finger was caught in his wheelchair spokes. Staff A…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-03-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, and care plan in order to eliminate or reduce the risk of accidents and injuries for one (Resident #44) of five residents sampled for accidents. Resident #44 was admitted to the facility in September of 2020 with a diagnosis of repeated falls. Resident #44 sustained five falls since admission between 10/8/20 and 2/27/21 with no documented evidence of analysis of hazards and risks to prevent further accidents. Resident #44 was placed on 15 minute checks on 1/20/21 with no documentation of safety checks maintained. On 3/10/2021 scans revealed Resident #44 had bilateral fractures in the hip area thought to be associated with the fall on 2/27/21. Observations and interviews with staff during the survey revealed staff continued to be unaware of Resident #44's hip fractures and interventions to prevent further injuries from occurring. Findings…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide 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, interviews, and record review, the facility failed to ensure urinary catheter care and services were provided in accordance with professional standards of practice for two residents (#16, #7) out of three residents sampled for catheter care.Findings Include:1. On 03/04/2026 At 9:27 AM Resident #16's urinary catheter bag was observed detached from the bed and resting directly on the floor. Urine appeared slightly cloudy.On 03/04/2026 At 12:32 PM the urinary catheter bag was observed on the floor. On 03/04/2026 At 1:35 PM the urinary catheter bag was observed on the floor.Record review of the March 2026 (Treatment Administration Record) TAR indicated Resident #16 received urinary catheter care as ordered on the day shift of 03/04/2026.Review of Resident #16's admission Record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (Stage 4) and obstructive uropathy.The Care Plan for Resident #16, initiated 10/24/2025, directed staff 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not ensure pain management was provided as ordered for two residents (#11 and #13) out of two residents sampled. Findings included:1) An interview on 2/24/2026 at 12:25 P.M with Resident #11 was conducted. Resident #11 said she does not receive her medication as scheduled. Resident #11 said when she does not receive her pain medication as scheduled, she has pain for the rest of the day.A review of Resident #11's admission Record showed she was admitted to the facility on [DATE] with diagnoses including contusion of right knee, muscle weakness, and need for assistance with personal care.A review of Resident #11's Minimum Data Set (MDS), Section C, dated 12/11/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of Resident #11's MDS Section J, dated 12/11/2025 revealed the resident was experiencing pain with an average pain intensity of 07 over the last five days. The numeric pain rating scale 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-29 · tag F0645 — widespread
  PASARR 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 record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were updated for five (#9, #22, #7, #39 and #23) of six residents sampled. Findings included: Resident #9 was originally admitted to the facility on [DATE] with a primary diagnosis of dementia onset date 10/01/22. Other diagnoses included Schizophrenia, Major depressive disorder with an onset date of 10/10/19. Review of a level I PASRR for Resident #9 dated 10/09/19 revealed page 2 of the PASRR was missing and the qualifying diagnoses were not checked. The level I PASRR showed the primary diagnosis of Dementia was not checked. This diagnosis was initiated after the PASRR was completed. Review of a PASRR level II determination summary report dated 09/13/19 showed this determination was submitted prior to the diagnosis of Dementia becoming primary. The report…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner in three (300, 200, 100) of three halls observed, during 4 of 4 days of survey. Findings included: On 08/26/24 at 10:25 a.m., upon entering the secured unit in hall 300, a strong urine odor was noted. On 08/26/24 at 10:26 a.m., an immediate interview was conducted with Staff AA, Certified Nursing Assistant (CNA). She confirmed the smell. She stated this was not the first time. She stated she did not know why the unit had a foul odor. On 08/26/24 at 11:02 a.m., an interview was conducted with Staff L, Regional Housekeeping Manager. He said, Yes, it smells in here. It could be because of soiled depends or a foul wound. He stated some of the residents urinated on the floors which could be the source of the foul smell. On 08/26/24 at 10:49 a.m., room [ROOM NUMBER] was observed with stains and scratches on the walls, stained floors, and dirt and grime along the…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-29 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure 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, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. 32 medication administration opportunities were observed, and six errors were identified for two residents (#110 and #107) of six residents observed. These errors constituted a 18.75% medication error rate. Findings Included: On 8/28/24 at 10:08 a.m., a medication administration observation was conducted with Staff U, Registered Nurse (RN) for Resident #110. Staff U, RN administered insulin subcutaneously and Cyanocobalamin (Vitamin B 12) intramuscularly. Resident #110's electronic medication administration record (eMAR) was highlighted in red. Staff U, RN, confirmed the medications were late. Review of Resident #110's August 2024 MAR showed insulin administration was due at 0800 with meal and Cyanocobalamin was scheduled to be given at 9:00 a.m. On 8/28/24 at 10:13 a.m., a medication administration observation was conducted with Staff U, RN for Resident #107. Staff U, RN prepared and administered Amlodipine 10 milligrams (mg) for high blood pressure,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-29 · tag F0880 — failed to prevent and control infections — pattern
  Provide 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 and interviews, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff members donned appropriate personal protective equipment (PPE) before entering the rooms of residents with transmission based precaution signage on the door for four (#2, #86, #104, #38) of four residents and two (#102 and #217) of four rooms sampled in the secure unit. Findings included: 1. On 08/26/24 at 10:15 a.m., a tour of the secure unit was conducted which revealed three residents (#86, #104, #38) had contact isolation signage posted on the door to their rooms. The signs showed everyone must: Put on gloves and gown before room entry, discard gloves and gown before room exit. An interview was conducted with Staff Z, Certified Nursing Assistant (CNA) on 08/26/24 at 10:35 a.m. She stated there was no one on isolation in the unit. An interview was conducted with Staff AA, CNA on 08/26/24 at 10:37 a.m. She stated there was no one on isolation in the unit and 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-29 · tag F0881 — failed to use antibiotics responsibly — pattern
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed. Findings included: Review of the facility's infection prevention documentation did not reveal any documentation related to an ongoing surveillance of resident infections and antibiotic orders for the months of July and August of 2024. During an interview on 8/26/2024 at 3:30 p.m., the Nursing Home Administrator (NHA) stated the Infection Control Preventionist (IPC) was the Staff R, Registered Nurse (RN) Unit Manager (UM). During an interview on 8/27/2024 at 10:30 a.m., Staff R, RN stated she was not responsible for Infection Control. Staff R, RN stated she was hired as the UM. During an interview on 8/27/2024 at 1:40 p.m., the NHA confirmed there was confusion as to who was the ICP but Staff R, RN UM was the designated IPC. During an interview on 8/29/2024 at 10:57 a.m., the Director of Nursing (DON) and the IPC who was also the Unit Manager stated they were both new to the building and not currently working on any surveillance 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-29 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 observations, interviews and record review, the facility failed to ensure the resident's living environment promoted, maintained and enhanced dignity and respect for three (#56, #265, #264) of four residents sampled. Findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses to include dementia, and developmental disorders of scholastic skills. Review of an annual MDS (Minimum Data Set) dated 05/31/24, section C showed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe impairment. On 08/26/24 10:54 a.m. and 12:32 p.m., Resident #56 was observed in his room laying on his bed. His roommate was performing sexual acts on himself exposed to Resident #56. The privacy curtain was partially drawn. Review of a care plan dated 06/09/21 showed a cognition focus. Resident has impaired cognitive function/dementia or impaired thought processes related to developmental disability. Interventions included to promote dignity, talk with resident and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably 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 observations interviews, and record review, the facility failed to ensure call lights were within reach in eight resident rooms (207A/B, 206B, 210A/B, 214B, 305, 307, 312 and 314) in two (200 and 300) of four halls. Findings included: During multiple facility tours of halls 200 and 300, call lights were observed on the floors as follows: On 08/26/24 at 10:52 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/26/24 at 10:57 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/26/24 at 11:06 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/28/24 at 12:08 p.m., and on 08/29/24 at 9:36 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/28/24 at 9:32 a.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA). She stated she made sure the call lights are within reach during her rounds. She said, If I see them on the floor or under the bed, I pick them up. On 08/29/24 at 10:03 a.m., an interview…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-29 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident had privacy in his room for one (#9) of two residents sampled. Findings included: Resident #9 was readmitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included Schizophrenia, major depressive disorder and age-related cognitive decline. Review of a quarterly MDS (Minimum Data Set) dated 07/16/24, section C showed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 00 that indicated severe cognitive impairment. During facility tours of the secured unit on 08/26/24 at 10:54 a.m., and 12:32 p.m., Resident #9 was observed in his room, laying on his bed performing sexual acts on himself. The resident's privacy curtain was not enclosed. The resident was in Bed A, which was closer to the door, leaving him exposed to other residents, visitors, and employees. This resident was also fully exposed to his roommate. On 08/27/24 at 3:42 p.m., Resident #9 was observed wandering 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$196,670 in federal fines across 2 penalties.

• $182,782 — penalty dated 2025-04-17
• $13,888 — penalty dated 2023-11-08

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 →

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

CMS files one row per role, so the 21 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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 87% 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 $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