No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Indigo Manor

595 N Williamson Blvd, Daytona Beach, FL 32114 · For profit - Limited Liability company · 173 certified beds · (386) 257-4400 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2023Resident-funds citation (F0569)1 immediate-jeopardy citation$22,530 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2023
  • it has a citation for mishandling residents’ money or property (F0569)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,530 in federal fines (most recent 2025-03-13)
  • 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 (61%) runs well above the national median (45%)

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.

2/5
CMS overall
2 of 5
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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1821 Business Park Blvd
Pharmacy
700 Fentress Blvd · (386) 274-1993 · Call to confirm hours
Grocery
2388 Mason Ave · (386) 944-3700 · Call to confirm hours
Park
Bent Tree Park Daytona Beach Florida · Typically dawn to dusk
Place of worship
594 N Williamson Blvd · (386) 274-7074

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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.2%8.7%15.4%better
Long-stay residents who lose too much weight6.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.2%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.5%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.9%2.5%3.3%better
Long-stay residents whose ability to walk worsened7.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.5%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.5%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control20.2%10.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table6.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine85.7%94.7%79.4%typical
Short-stay residents rehospitalized after admission22.5%26.1%22.6%typical
Short-stay residents with an outpatient ER visit4.8%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.142.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.581.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

49.6% 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 117 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.6%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
42.7%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 42.7% 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 89 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.6%CMS range 40.4–57.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.7–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge42.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge38.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 3.1–9.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.72
RN hours/ resident / day
0.70
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.63
RN hoursweekends
60.6%
Total nursing turnover
48.1%
RN turnover

How full it usually is: this home is certified for 173 beds and averages 124.6 residents a day — about 72% occupied, or roughly 48 beds typically open. It usually has some room. 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 3.08 hrs/resident/day on weekends vs 3.37 on weekdays — 9% thinner on weekends. RN hours go from 0.76 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above 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

5
deficiencies at the latest standard inspection (2025-03-13)
14
at the previous standard inspection (2023-04-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2023-04-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of resident records and facility policies, and interviews with staff, the facility failed to ensure residents were free from neglect, by failing to provide supervision and interventions to maintain safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's neglect to provide appropriate services and interventions to prevent elopement after identifying the resident as at risk, permitted Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-02-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to maintain sanitary conditions in the cooking area, with significant accumulation of grease buildup, food debris and residue, and heavy soilage on both floor surfaces and equipment. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:A tour of the kitchen was conducted on 2/17/26 at 10:15 am. During the tour the following unsanitary conditions were observed: food residue on equipment and cookware, grease buildup, accumulated debris, and grime on the kitchen floor in and around the cooking area. (Photographic evidence obtained)A follow-up tour of the kitchen was conducted on 2/17/26 at 3:27 pm. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #3) of five residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 7 residents. The finding include:On 02/17/26 at 10:49 AM, Resident #3 was observed sitting in a wheelchair adjacent to the south unit nurse's station. Several of the resident's fingernails of both hands were observed as jagged and extended approximately 1/2 inch beyond the nail bed. When the resident was asked about his nails, he stated he did not like his nails so long but could not remember if he asked the facility staff to trim his fingernails. (Photographic evidence obtained)A review of Resident #3's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, type II diabetes mellitus without complications, pseudobulbar affect, chronic kidney disease, stage 2 (mild), 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-17 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make 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, interviews, record review, and facility policy review, the facility failed to ensure one (Resident #7) of five sampled residents' room were maintained in a safe, functional, sanitary, and comfortable environment by leaving disposable razors unattended on the resident's bedside table. The findings include:On 02/17/26 at 11:13 AM, two unused disposable razors were observed on Resident #7's bedside table. When asked about the razors, the resident reported that a certified nursing assistant (CNA) brought the razors into his room and abruptly left before providing shaving assistance. He couldn't remember the name of the CNA or whether the incident occurred during the daytime or nighttime shift.A review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, muscle weakness, type II diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, unspecified, chronic systolic (congestive) heart…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on kitchen food service observations, staff interviews, record review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to log proper temperatures for the dish machine and chemical sanitization for the 3-compartment sink, and clean food buildup stuck on the back handle and under the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 03/10/25 at 11:07 AM. During the tour, a review of the dish machine temperature logs for January, February, and March 2025, revealed a wash temperature of 140 degrees Fahrenheit (F) and a rinse temperature of 145 degrees F, consistently. Further, a review of the 3-compartment sink, Pot/Pan temperature logs for January…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to provide toenail care for one (Resident #33) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 41 residents. Resident #33's toenails extended approximately one half inch beyond the nailbed and were jagged. The findings include: An observation made on 03/10/25 at 1:43 PM, revealed that Resident #33's toenails extended approximately one half inch beyond the nail bed and were jagged on both feet. (Photographic evidence obtained) An interview was attempted with the resident, but he did not respond. On 03/11/25 at 10:44 AM, Resident #33's toenails were observed and were in the same condition as the previous day's ovservation. They extended approximately one half inch beyond the nail bed and were jagged on both feet. (Photographic evidence obtained) An interview was again attempted with the resident, but he did not respond. During an interview with Certified Nursing Assistant (CNA) B on 03/13/25 at 11:37 AM, she reported that she had been employed by the facility since…

    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 before2025-03-13 · 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 observations, interviews, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision to prevent accidents for one (Resident #7) of three residents reviewed for accidents, from a total survey sample of 41 residents. Resident #7 was discovered keeping smoking materials on self. The findings include: On 03/10/25 at 9:55 AM, an observation was made of Resident #7 holding a cigarette lighter while seated in his wheelchair on the elevator going to the first floor. On 03/13/25 at 10:29 AM, Resident #7 was observed in his room and was interviewed. He reported that he was a smoker and smoked during the 8:00 AM, 10:00 AM, 1:00 PM and 3:00 PM smoking breaks. He further reported that he kept his cigarette lighter in the dresser next to his bed. He became agitated and yelled that the facility could just take his lighter and take it all away. During an interview with the Assistant Director 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and policy and procedure review, the facility failed to ensure ensure that one (Resident #137) of 39 residents receiving respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #137 was not receiving oxygen at the ordered flow rate. The findings include: On 03/10/25 at 1:51 PM, Resident #137 was observed lying in bed receiving oxygen via nasal cannula (NC). The oxygen concentrator located next to the head of her bed had a flow rate setting of 3.25-3.50 Liters per minute (L/min). (Photographic evidence obtained) On 03/13/25 at 12:50 PM, while checking the resident's oxygen flow rate, Licensed Practical Nurse (LPN) K verified that Resident #137's oxygen flow rate setting was currently set at 4 L/min, but the oxygen order was for a flow rate of 2 L/min. She stated nurses provided ongoing monitoring of the resident's oxygen therapy. Nursing was responsible for ensuring that the resident was receiving 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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, staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that its medication error rate was not 5% or greater. Two medication errors out of 25 opportunities for error, resulted in an error rate of 8 % and involved Residents #45 and #113. The findings include: On 03/12/25 at 12:44 PM, Registered Nurse (RN) L was observed preparing Oxycodone-Acetaminophen 10/325 mg (milligrams), 1 tablet by mouth every 6 hours routinely for Resident #45 in room [ROOM NUMBER]-2. RN L was then accompanied into room [ROOM NUMBER]-1 where Resident #77 was lying in bed. RN L greeted the resident and explained that she was going to administer pain medication the resident had requested. The nurse asked Resident #77 what her pain level was and at that point, was asked to hold the medication and step outside of the resident's room. RN L was asked if she had chosen the right patient, medication, dose, time, and frequency. RN L was accompanied back to 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-03 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make 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

    Based on observations, interviews, and facility policy review, the facility failed to maintain the kitchen in a safe and sanitary manner due to a ceiling area having a plastic sheet covering an opening that was dripping liquid where food is prepared, and by failing to maintain missing ceiling tiles in the dish room. The findings include: During a visit to the kitchen on 10/02/23 at 12:06 pm, the ceiling was observed with three plastic bags covering an opening. One of the areas was covered by a bag near the tray line taped with black and red duck tap. A brown liquid was observed dropping water on the floor. Water was also observed on the floor at the tray line where the carts were parked. In the dish room there were missing tiles in the ceiling. (Photographic evidence obtained) During an interview with the certified dietary manager (CDM) on 10/02/23 at 12:15 pm, she confirmed there was liquid dripping close to the tray line and there were missing tile pieces in the dish room. When asked what the status was to repair these areas, she stated the maintenance manager would have more…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-03 · tag F0569 — pattern
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to convey within 30 days upon discharge the resident's funds, and a final accounting of those funds for 2 (Residents #2 and #7) of 4 residents reviewed for personal funds; and failed to notify the resident or the resident's representative when the amount in the residents account reached $200 less than the eligibility limit for 1 (Resident #6) of 4 residents reviewed, from a total sample of 8 residents. The findings include: 1. A closed record review for Resident #2 revealed that she was admitted on [DATE] and discharged on 1/21/23. A review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE] revealed that Resident #2 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Resident had a planned discharge to hospice and her daughter was listed as the power of attorney (POA). During a phone interview with Resident #2's POA on 10/2/23 at. 1:30…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Fcited before2023-04-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure the ice machine located in the kitchen and one of three microwaves located on the 1st floor at the nursing station was clean. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 4/12/23 at 10:50 a.m. The ice machine located next to the three-compartment sink was observed with a pink, slimy substance that was in close proximity to the ice in the internal shoot of the ice machine. (Photographic evidence obtained) During the tour, the microwave in Nourishment Room One of three located at the nursing station on the 1st floor was observed with a buildup resembling fungal growth.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments for three (Residents #31, #260, and #133) in a total sample of 52 residents. The findings include: On 4/10/23 at 12:45 p.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table in plain sight. She stated, Oh, they forgot and left it there this morning. I'll remind them when they come back. I only take it once a day. (Photographic evidence obtained) On 4/11/23 at 8:40 a.m., a bottle of Flonase nasal spray was observed on Resident #31's bedside table. (Photographic evidence obtained) On 4/12/23 at 8:28 a.m., Licensed Practical Nurse (LPN) B was observed administering medications to Resident #260. She started to administer a Trelegy Ellipta Aerosol Powder breath-activated inhaler, but the resident stopped her and said she already took that inhaler this morning. The resident pointed to a box on her bedside table which revealed several medications in plain sight. These medications…

    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 · E2023-04-13 · 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

    Based on observations, staff interviews, and facility policy and procedure review, the facility failed to ensure process surveillance, the review of practices by staff directly related to resident care, specifically hand hygiene, for two residents (#31 and #260) from a total sample of 52 residents. The findings include: On 4/12/23 at 8:17 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #31. Gloves were not donned during this preparation. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. Gloves were not donned during this medication administration. The nurse returned to the medication cart at 8:27 a.m., and without performing hand hygiene, she proceeded to prepare medications for Resident #260. Gloves were not donned during this preparation or during medication administration. LPN B did not perform hand hygiene prior to preparing the medications, or before or after administering the medications. She returned to her medication cart at 8:35 a.m. and proceeded to prepare…

    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 · D2023-04-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility records and interviews with staff, the facility failed to provide advanced notice to two (Residents #36 and #63) of three Medicare beneficiaries reviewed when Medicare skilled services were terminating, from a total of 52 residents in the sample. The findings include: 1. A record review found that Resident #36 was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, diabetes mellitus, Parkinson's disease, malnutrition, and depression. Further review of the record found that Resident #36 was issued a Notice of Medicare Non-Coverage (NOMNC) informing her that skilled nursing services (occupational therapy/physical therapy/speech therapy (OT/PT/ST) would end on 3/9/23. The notice indicated that Resident #36's Medicare provider and/or health plan had determined Medicare would likely not pay for current skilled services after the effective date. The resident may have to pay for services received after that date. Resident #36 signed the form on 3/9/23, 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 · D2023-04-13 · 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

    Based on observations, staff interviews, and facility document and policy review, the facility failed to protect the residents' right to personal privacy and confidentiality of his or her personal/medical records for three (Residents # 26, 31, and 28) out of a total sample of 52 residents. The findings include: On 4/11/23 at 9:04 a.m., an observation was made on the 2600 hallway. Licensed Practical Nurse (LPN) B, assigned to the medication cart on this hallway, was not observed anywhere in the vicinity. Her medication cart was halfway down the residential hallway. The laptop computer on the cart was open, unlocked, and displaying Resident #26's personal health information. (Photographic evidence obtained) LPN B returned to the cart at 9:07 a.m. and began preparing medications. On 4/12/23 at 8:20 a.m. during a medication administration observation with LPN B, she left her medication cart to deliver medications to Resident #31. The medication cart laptop screen was left open with Resident #31's personal medication information visible. When LPN B returned to her medication cart five…

    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 · D2023-04-13 · tag F0644 — isolated
    Coordinate 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 a review of resident records, facility policies, and interviews with staff, the facility failed to coordinate with the state pre-admission screening and resident review (PASARR) program under Medicaid to determine whether a Level II screening was indicated after one (Resident #25) of two residents reviewed for PASARR, from a total of 52 residents in the sample, received a post-admission diagnosis of serious mental illness (SMI). The findings include: A record review for Resident #25 found she was admitted to the facility on [DATE]. She had a Level 1 PASARR screening, dated 1/24/22, that indicated she had no SMI or intellectual disability (ID) and did not require a Level II screening (an evaluation that determines the appropriate setting and recommends specialized services needed for individuals with SMI or ID). (Photographic evidence obtained) Further review revealed that Resident #25's cumulative diagnoses list reflected that on 7/19/22, a diagnosis of schizoaffective disorder, bipolar type (a mental…

    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 · Dcited before2023-04-13 · 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 observations, a review of resident records and facility policies, and interviews with staff, the facility failed to provide supervision and implement interventions to maintain resident safety, prevent elopement (leaving the premises without supervision or permission) and minimize the risk of injury or death for one (Resident #92) of three residents reviewed for elopement risk, from a total of 52 residents in the sample. The facility's failure to provide appropriate supervision and implement identified and/or available interventions, allowed Resident #92 to exit the facility and wander to a busy intersection without staff supervision, placing him at risk for serious bodily harm or death. On 2/27/23, Resident #92 was admitted to the facility's first floor. The same day, at 2:15 p.m., he was assessed as an elopement risk and a Wanderguard (alarm bracelet) was to have been applied. On 2/28/23 at 6:29 a.m., the resident was noted as wandering the unit checking exit doors. An order and placement of a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observations, interviews, and record reviews, the facility failed to ensure that one (Resident #70) of 26 residents receiving respiratory treatment, from a total of 52 residents in the sample, was provided respiratory care consistent with professional standards of practice and the resident's comprehensive care plan. The facility was administering oxygen at a greater flow rate than was ordered. The findings include: On 4/10/23 at 12:17 p.m., Resident #70 was observed in his room sitting in a wheelchair and receiving oxygen (O2) via nasal cannula from an O2 concentrator. The oxygen flow rate was set at three liters per minute (L/min). (Photographic evidence obtained) On 4/11/23 at 10:12 a.m., Resident #70 was observed lying in his bed. He was receiving O2 via nasal cannula at a flow rate of three L/min. (Photographic evidence obtained) When the resident was asked what his oxygen flow rate should be, he replied, I don't know. On 4/12/23 at 11:56 a.m., Resident #70 was observed in his room resting in bed.…

    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 · D2023-04-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, medical record review, and a review of the facility's dialysis agreement, the facility failed to ensure shared communication between the nursing home and the dialysis center for one (Resident #269) of two residents receiving hemodialysis services, from a total of 52 residents in the sample. The findings include: A medical record review for Resident #269 revealed no communication with the dialysis clinic she attended. A review of the resident's current physician's orders revealed an order dated 3/31/23 for [Dialysis Center Name] Dialysis: M/W/F (Mondays, Wednesdays, and Fridays). On 4/13/23 (Thursday) at 9:30 a.m., Resident #269 was observed in her room, awake. She stated she went to dialysis yesterday. She was asked if she brought a communication book or binder with her to and from her dialysis appointments. She stated, I bring a magazine to read. She was asked if facility staff give her a binder for dialysis staff to chart her weights and vital signs and any medications given at dialysis as a communication tool for the dialysis…

    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 · D2023-04-13 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on staff and resident interviews, and medical record review, the facility failed to provide routine medications to one (Resident #269) in a total sample of 52 residents. The findings include: On 4/10/23 at 3:20 p.m., a medical record review for Resident #269 revealed the resident had not been receiving Cinacalcet (Medication used to treat hyperparathyroidism (overactive parathyroid gland) in the dialysis patient according to www.ncib.nlm.nih.gov, accessed on 4/14/23 at 2:00 p.m.) 90 mg (milligrams), one tablet by mouth daily for chronic kidney disease CKD (ordered on 4/1/23). A progress note written on 4/10/23, revealed, [Provider name] at the dialysis center is saying they don't provide this medication, Cinacalcet. [Provider name] said the pharmacy is supposed to fill it, that the resident is not part of the bundle. Writer called pharmacy again from the facility phone at 1907 (7:07 p.m.) on 4/10/23. Pharmacy sending a 5-day supply of the medication. The medication will be on the next run. MD (physician's) office and family aware that the resident has missed doses of the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident records and interviews with staff, the facility failed to ensure psychotropic medications were only utilized with appropriate monitoring for one (Resident #63) of five residents reviewed for unnecessary medications, from a total of 52 residents in the sample. The findings include: A record review for Resident #63 found she was admitted on [DATE]. A review of the quarterly minimum data set (MDS) assessment, with an assessment reference date of 3/10/23, revealed that Resident #63 had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact and independent with daily decision making. She required limited assistance with activities of daily living. Active diagnoses included heart failure, malnutrition, depression, schizophrenia, insomnia and aftercare following hip joint prosthesis. Resident #63 received antipsychotics and antidepressants on seven of seven days during the MDS look-back period. Antipsychotics were received…

    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 · Dcited before2023-04-13 · tag F0759 — failed to keep medication error rate low — isolated
    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 observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure its medication error rate was less than 5%, based on three errors over 27 opportunities for two (Residents #31 and #260) of five residents observed during medication administration, and resulting in an error rate of 11.11%. The findings include: On 4/12/23 at 8:17 a.m., Licensed Practical Nurse (LPN) B was observed preparing medication for Resident #31. After administering the resident's pills, she held her Budesonide Formoterol Fumarate Inhalation Aerosol 160-4.5 micrograms per actuation (mcg/act) and puffed it twice into her mouth. The nurse did not offer the resident water, nor did she instruct the resident to rinse her mouth and spit after administering the inhaler. On 4/12/23 at 8:28 a.m., LPN B was observed preparing medications for Resident #260. Reading an order which read Aspirin 81mg (milligrams) oral chewable, give two tablets by mouth daily, LPN B poured two tablets from the enteric-coated aspirin 81 mg bottle. The expiration date on the bottle 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, and medical record review, the facility failed to maintain resident medical records that were accurately documented for one (Resident #269) in a total sample of 52 residents. The findings include: On 4/10/23 a medical record review for Resident #269 revealed the resident had not been receiving Cinacalcet 90 mg, one tablet by mouth daily (ordered 4/1/23). Further review of the record revealed a progress note written by Licensed Practical Nurse (LPN) D on 4/10/23, which read, [Dialysis center employee] at the dialysis center is saying they don't provide this medication, Cinacalcet. [Dialysis center employee] said the pharmacy is supposed to fill it; that the resident is not part of the bundle. Writer called pharmacy again from the facility phone at 1907 (7:07 p.m.) on 4/10/23. The pharmacy is sending a 5-day supply of the medication. The medication will be on the next run. MD (physician's) office and family aware that the resident has missed doses of the medication. A review of the electronic medication administration record (eMAR)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-07-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the observations, interview, record review and facility policy and procedure review, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure that staff implemented the facility policy and procedures for monitoring refrigerator and freezer temperatures. The findings include: On 7/6/21 at 10:25 AM, an initial kitchen tour was conducted. Upon inspection of the refrigerator and freezer temperatures, the monthly temperature logs were requested from the Kitchen Manager. She produced seven documents, each dated July 2021 at the top, and each had a refrigerator description as follows: 1. Reach In Cooler 2. Cold Cart Cooler 3. Juice Cooler 4. Sm. [NAME] Freezer 5. Ice Cream Freezer 6. Walk In Freezer 7. Walk In Cooler A review of the seven temperature logs revealed there were no temperatures filled in for the month of July. A review of the same titled logs dated June 2021 revealed the following dates with no or missing temperatures for AM and PM. June 1 June 2 June 5 (PM temp not filled in) June 7 (AM temp not filled…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-09 · 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 observation, interviews and record review, the facility failed to ensure that residents with an indwelling catheter were assessed for removal of the catheter as soon as possible for one (Resident #52) of seven residents with Foley catheters, out of a total sample of 38 residents. Failure to assess residents for indwelling catheter removal predisposes residents to catheter acquired urinary tract infections (CAUTI). The findings include: During the initial tour on 7/6/21 at 12:52 PM, Resident #52 was observed lying in the bed. The Foley catheter tubing was draining clear yellow liquid with an infusion pump at bedside. On 7/6/21 at 12:55 PM, Resident #52 stated that she had just completed the antibiotic therapy for urinary tract infection (UTI). She added that the facility does not change her catheter per physician orders and certified nursing assistants do not empty the bag often. Record review indicated that Resident #52 was admitted to the facility on [DATE]. Diagnoses included COVID 19, type 2…

    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 · D2021-07-09 · 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 resident observations, interviews, and record review, the facility failed to ensure pain management was provided to residents requiring such services, consistent with professional standards of practice by failing to appropriately assess pain and provide interventions for pain relief for one (Resident #102) of one sampled resident reviewed for pain management, out of a total sample of 38 residents. The findings include: On 7/7/21 at 10:50 AM, Resident #102 was observed lying on his bed. When he was asked how he was, he said, I am hurting all over. On 7/8/21 at 10:14 AM, Resident #102 was asked if he was in pain, he stated, Yes. Record review indicated that Resident #102 was admitted to the facility on [DATE]. Diagnoses included disorder of urea, right side hemiplegia, angina pectoris, schizophrenia, mood disorder, and cerebral infraction. Physician orders with start date of 3/6/20 revealed an order for pain rating scale every shift. There were no orders for pain medications. Review of Resident #102'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of manufacturers information for use, the facility failed to appropriately store the Glucose Control Solutions (GCS) on three of five medication carts observed. The findings include: On 7/8/21 at 09:00 AM during an observation of medication administration for the 2400 and 2600 halls, two vials of GCS revealed an open date of 1/23/21 written on the vial. Manufacturer's expiration date was 11/3/2021 for both vials. On 7/8/2021 at 12:30 PM during an observation of the medication cart for 2West, two vials of GCS were opened but did not have a date written on the vial indicating the date it was opened. Manufacturer's expiration date of 11/3/21. On 7/8/2021 at 12:40 PM during an observation of the medication cart for 2East, two vials of GCS were opened but did not have a date written on the vial indicating the date it was opened. Manufacturer's expiration date of 11/3/21. On 7/8/21 at 09:05 AM, Employee A, Registered Nurse (RN) who was assigned to the medication carts for the 2400 and 2600 halls was asked how long controls can be open before…

    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

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$22,530 in federal fines across 3 penalties.

  • $6,380 — penalty dated 2025-03-13
  • $6,380 — penalty dated 2025-03-13
  • $9,770 — penalty dated 2025-03-13

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 BEDROCK HEALTHCARE — 9 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 →

RatingThis homeChain avg
Overall 2 of 51.4+0.6 vs chain
Health inspection 1 of 51.3-0.3 vs chain
Staffing 2 of 52.1-0.1 vs chain
Quality measures 5 of 52.7+2.3 vs chain
The other 8 homes this chain runs (chain average 1.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BEDROCK AT DAYTONA HOLDING, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/13/2021
MC CAPITAL 2 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
MC CAPTIAL TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
SC CAPITAL 2 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
SC CAPITAL TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
TC CAPITAL 2Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
TC CAPITAL TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/13/2021
CHOPP, MARTINIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 10/16/2021
CHOPP, PNINAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 10/16/2021
CHOPP, SOLOMONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 10/15/2021
OPAL HEALTHCARE FL LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/16/2021
EDDIN, HUSAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/16/2021
NICHOLS, KENNETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023

CMS files one row per role, so the 23 rows in the source record cover these 13 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.

$18.2M
Net patient revenuemost recent cost report
-8.1%
Operating marginrevenue minus expenses
$880K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 8%Other / private 57%

This home reported $880K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$302per resident / day
operating cost
$9,186per month
≈ monthly operating cost
$279per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105570. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, 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.

What to do next