Abbey Delray South
1717 Homewood Blvd, Delray Beach, FL 33445 · Non profit - Corporation · 90 certified beds · (561) 454-5200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,963 in federal fines (most recent 2023-12-15)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.3% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 6.3% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.0% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 2.9% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.3% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.5% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 15.0% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.3% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.2% | 9.1% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
71.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 843 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.4% 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 421 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 0.85 therapist hours per resident per day in 2026Q1 — more than 95% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 71.3%CMS range 67.5–74.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 9.4–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 55.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 43.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.6% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 4.8–8.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 71.5 residents a day — about 79% occupied, or roughly 18 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 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.36 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.77 hrs/resident/day on weekends vs 4.31 on weekdays — 13% thinner on weekends. RN hours go from 1.47 to 1.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Fcited before2025-02-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of the facility's policy titled, Foods Brought by Family/Visitors with a revised date of March 2022 included in part the following: Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from the facility-prepared food .Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. Record review for Resident #648 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit and Parkinsonism. The Minimum Data Set for Resident #648 dated 02/04/25 documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. On 02/17/25 at 11:00 AM, an observation was made of Resident #648 sitting in the wheelchair next to the bed, on the overbed table in front of the resident was an opened container of cut up mango with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-20 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to maintain an effective system to obtain and use of feedback and input from (Minimum Data Set (MDS) Department and ensure an effective QAPI/PIP (Quality Assurance Performance Improvement/Performance Improvement Plan) to ensure MDS assessments were completed timely with the potential to affect 70 out of 70 residents. The findings included: . Review of the facility's policy titled, Quality Assurance and Performance Improvement Program Plan with a revised and reviewed date of 08/31/22 indicated in part the following: Each facility's Administrator will be accountable for leadership and will provide coordination of the overall health center QAPI program. Together with members of the QAPI Committee, the Administrator will be responsible for planning, designing, implementing, and coordinating care and services and selecting QAPI activities to meet the needs of residents. Guidelines for Performance Improvement Projects: The facility will have a plan for conducting PIPs to improve care and services. This will be accomplished by:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow the care plan's interventions to prevent falls for 2 of 2 resident reviewed for accidents (Resident #69 and Resident #64). The findings included: 1.) A review of the facility's policy titled, Comprehensive Care Plan, revised on 09/06/2022, revealed the following: The resident care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and will be developed and implemented for each resident. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met, c. When the resident has been readmitted to the facility from a hospital stay. A review of the facility's policy titled, Fall Prevention and Management Program revised on 09/23/2019 showed the following: Post-fall: there are two key elements of the post-fall response and management: Initial post fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide assistance during dining for 1 of 2 residents reviewed for nutrition (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses of Dementia, Osteoporosis, and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #12 has a Brief Interview of Mental Status (BIMS) score of 13, which is cognitively intact. Section GG of this MDS showed that for eating, Resident #12 was coded for supervision or touching assistance only. A review of the Physicians' orders revealed an order for assistance with feeding with every meal-careful oral assisted feeding by hand every shift dated 2/11/25. In an interview conducted on 02/17/25 at 11:15 AM with Resident #12, she stated that she eats as much as she can and has lost some weight, but she is not sure how much. She is given Ensure Supplements and has tried to drink them when they are provided. In an observation conducted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to acquire a Physician order for a urinary catheter and failed to initiate a urinary catheter Care Plan for 1 of 2 sampled residents, Resident # 502; and failed to keep the urinary catheter anchored for 1 of the 2 residents, Resident #69. The findings included: A review of a facility policy titled, Indwelling Catheter Use and Removal dated 01/06/25, revealed under the Compliance Guidelines that if an indwelling catheter is in use, the community will provide appropriate care for the catheter in accordance with current professional standards of practice, will identify and document clinical indications for use of the catheter, and will keep the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral dislodgement of the catheter. 1) A record review for Resident #502 revealed the resident was admitted on [DATE] with diagnoses including Malignant Neoplasm of Cervix, Acute Cystitis, and Urinary Tract Infection. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 meet the nutritional needs and provided the correct nutritional supplement for 1 of 2 residents reviewed for nutrition (Resident #47). The findings included: A record review revealed that Resident #47 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction and Dementia. The quarterly 10/29/24 Minimum Data Set (MDS) showed that Resident #47 had a Brief Interview of Mental Status (BIMS) score of 02, which is cognitively impaired. In an interview conducted on 02/17/25 at 1:00 PM, Resident 47's family stated that Resident #47 had lost some weight and that he used to be around 180 pounds. He receives Ensure supplements twice a day and drinks them all. In this interview, a bottle of Ensure original was noted on the side table near Resident #47. In an observation conducted on 02/18/25 at 9:07 AM, Resident #47 was eating his breakfast. Staff were in the room setting up the breakfast meal for Resident #47. At 9:13 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to have an order for oxygen for 1 of 1 sampled residents, Resident #501. The findings included: A record review of a facility policy titled,Oxygen Administration with a revision date of 10/2010, revealed to verify that there is a physician's order for oxygen administration. A record review for Resident #501 revealed the resident was admitted on [DATE] with diagnoses that included Displaced Intertrochanteric Fracture of Right Femur, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Systolic Congestive Heart Failure. A review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it was blank for the Brief Interview for Mental Status (BIMS) score. A review of Section I revealed a yes response to Asthma. A review of Section O was blank for oxygen therapy. A review of Physician Orders for Resident #501 revealed there was no order for oxygen indication, administration, care and management. A record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 observations, interviews, and record review, the facility failed to ensure that psychotropic medication PRN (as needed) orders were limited to 14 days for 1 of 5 residents reviewed for Unnecessary Medication (Resident #17). The findings included: A review of the policy titled, Medication Utilization and Prescribing-Clinical Protocol, revised in April 2018, showed the following: As part of the overall review, the Physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN. The Physician will provide and or document rationale when the indication, dose, duration, or frequency of a prescribed medication is more significant than commonly accepted practice. The Consultant Pharmacist can help by reviewing facility medication usage patterns and trends and by intensifying medication reviews of individuals taking medications that present clinically significant risks. Resident #17 was admitted to the facility on [DATE] with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) A record review revealed Resident #501 was admitted on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Right Femur, Type 2 Diabetes Mellitus, and Anxiety Disorder. A record review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it is in progress. Section C for Brief Interview for Mental Status score was blank. Section I revealed, yes responses to anxiety and depression. A record review of Physician Orders dated 02/16/25 revealed Escitalopram Oxalate (Anti-depressant) 10 MG (milligram), to give by mouth one time a day for depression. An additional review of Physician Orders for Resident #501 revealed to monitor for signs and symptoms of depression and to include the following numerical codes : 0-None, 1-Isolation, 2-Sadness, 3-Withdrawn, 4-Lack of interest, 5-Crying, 6-Other, see nurses note, every day and night shift, and document the corresponding number(s) reflecting any sign and symptom of depression. A further review of the Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure medications were secured at the bedside for 1 of 22 sampled residents (Resident #645). The findings included: Review of the facility's policy titled, Medication Labeling and Storage with a revised date of February 2023 included in part the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's policy titled, Self-Administration of Medications with a revised date of February 2021 included in part the following: As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · Dcited before2025-02-20 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 provide water consistent with resident needs for 1 of 3 residents on thickened liquids (Resident #645). The findings included: Review of the facility's policy titled, Menus and Therapeutic Diets with a revised date of 04/14/20 that included in part the following: Nectar, honey and pudding thickened liquids are offered as ordered by the physician. Record review for Resident #645 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Acute Myocardial Infarction, Personal History of Malignant Neoplasm of Tongue. Review of Resident #645's record revealed no documentation of a Brief Interview of Mental Status having been completed. Review of the Physician's orders for Resident #645 revealed an order dated 02/13/25 for NAS (No Added Salt) diet Mechanical Soft texture, Nectar Thick Liquids consistency, and was discontinued on 02/18/25. Review of the Physician's orders for Resident #645…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain an effective Infection Prevention and Control Program, for 3 sampled residents, as evidenced by staff failed to wear Personal Protective Equipment (PPE) while providing direct care for residents on Enhanced Barrier Precaution (EBP) for Resident #545 and Resident #38; and failed to have an order and care plan for EBP for Resident #501. The findings included: The Center for Disease Control and Prevention (CDC) Enhanced Barrier Precautions included the following: Everyone must clean their hands, when entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following: High-contact care resident care activities - dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care with any skin opening requiring a dressing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, record review and interview, the facility failed to ensure that it followed through in processing a physician's order, in a timely manner for 1 of 5 sampled residents reviewed, Resident #1. The findings included: Review of the facility policy and procedure, titled, Medication Administration provided by the Director of Nursing (DON) revised 12/01/21 documented in the Procedure Statement: The administration of medications will be performed only in accordance with written and signed orders from the client's physician. All orders, as appropriate, shall include: Complete name of client, complete name of medication, strength of the medication, dosage to be given, frequency of administration, route of administration .Controlled Substances .The Comprehensive Drug Abuse Prevention Control Act .requires that the nurse understand her responsibility in the administration, handling, and record keeping of controlled substances .A controlled substance may be given only with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records review, the facility failed to treat in a dignified manner 1 of 3 sampled residents (Resident #110). The findings included: On 10/09/23 at 11:13 AM, Resident #110 said that she recently was admitted to the facility after undergoing hip surgery. Upon her admission to the facility, she had requested a commode, because the toilet seat in her room was too low, for her to use. Resident #110 said although different staff members promised to bring the commode, they did supply it. She reiterated that since the toilet bowl in her bathroom was too low and she could not use it, she ended up urinating on her sanitary briefs. She said that wearing a brief was not the primary problem, the main issue was that they did not provide the requested commode. That situation left her with no choice but to urinate on herself. Resident #110 ensued and stated that she had reported the issue to Employee (H) daily, last week or since her admission to the facility. Last Wednesday, 10/4/2023, Resident #110 said she spoke to Employee (H)'s Assistant, Employee (I), and Employee (I)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0572 — isolatedGive residents a notice of rights, rules, services and charges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records review, it was determined that Residents' rights were not discussed and 3 of 3 sampled Residents (Residents # 4, 14, & 19) were not reminded of their rights during Resident Council meetings. The findings included: On 10/12/23 at 11:10 AM an interview was conducted with the Resident Council President, Resident #43. She said that she was not sure whether she was the President. If they say that I am the President, then I must be. She could not recall whether they met monthly. The Activity Director, Employee (M) reported on 10/12/23 at 11:23 AM, that he has been working at this facility since January 2023. He said that he assists in setting up the Resident Council meeting every month and help facilitate the meeting. He reported that they did not discuss Residents' rights during the meeting. Review of the Resident Council minutes documented no Residents rights items discussed. The Minutes of the meetings documented that the Management team informed the resident council about the renovation that was happening in the building, from January 2023 to September…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 records review and interviews, the facility failed to file a federal report for an allegation of injury of unknown origin immediately to the State Agency for 1 of 1 sampled resident (Resident #108). The findings included: Review of an incident report dated 6/26/2023 revealed that on 06/08/2023, on the 6:00 AM to 2:00 PM shift, Resident #108 sustained an injury which origin the facility could not explicitly determine. The record revealed that Resident #108 was diagnosed with: Unspecified Dementia; Unspecified Anxiety Disorder; Other recurrent Depressive Disorder; Poly Osteoarthritis; Glaucoma and Edema, among others. Review of the Minimum Data Set (MDS) documented that Resident #108 obtained a score of 3 out of 15 which is indicative of significant cognitive deficit. Further records review showed that Resident #108 was impulsive and used the bathroom for her toileting needs without using her call lights and waiting for assistance. Consequently, on 6/08/2023 while using the bathroom, Resident #108…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately document a resident's discharge status for 1 of 3 residents reviewed for discharges (Resident #56). Findings included: Record review noted that Resident #56 was not hospitalized as per discharge assessment, but was discharged home. Resident #56 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and limited 1 person assist for activities of daily. A review of Resident #56's progress notes revealed a Discharge summary dated [DATE] at 12:55 PM that documented the resident was discharged home with home health. A review of Resident #56's discharge assessment dated [DATE] documented the resident was discharged to hospital. An interview was conducted on 10/12/23 at 1:20 PM, with the MDS coordinator. The coordinator stated Resident #56 was discharged to home on 7/28/23, not transferred to the hospital, and the discharge assessment was coded wrong.
- Potential for harm · D2023-10-12 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide appropriate activities for 1 of 1 resident reviewed for activities (Resident #209). The findings included: Resident #209 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive impairment, and required extensive one-person assist with activities of daily living. Resident #209 was care planned for using an iphone, reading newspaper and listening to big band music, watching the news and other shows on Univision (Spanish speaking network). On 10/09/23 and 10/10/23 throughout the survey from 8:00 AM-4:00 PM, the resident was observed in her room laying in bed watching an English program on TV. Surveyor attempted to speak with the resident, and the resident responded that she does not speak English, only Spanish. On 10/11/23 at 11:00 AM, Resident #209 was observed in her room with a private duty aide that also spoke only Spanish, and they were both watching TV on the English TV…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to obtain a physician's order for care of nasal steri-stips for 1 of 1 sampled residents observed, Resident #157. The findings included: Review of the facility policy and procedure titled Wound Care provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor and intervene for a resident identified with significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #35); and failed to identify significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #53). The findings included: 1. Resident #35 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive one-person assist with activities of daily living. The assessment further documented Resident #35 had weight loss, and was not on a prescribed weight loss regimen. A review of Resident #35's care plan revealed a care plan, revised 07/10/23, for nutritional problem or potential nutritional problem related to cognitive functions, history of weight loss, and needs assistance with meals. An intervention included to observe for/record/report to physician signs and symptoms of malnutrition such as significant weight loss: 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) Follow the physician's order for Oxygen Therapy Administration for 1 of 6 sampled residents observed for Oxygen, Resident #158; and 2) Failed to obtain a physician's order for administration of Oxygen for 1 of 6 sampled residents observed for Oxygen, Resident #109. The findings included: Review of the facility policy and procedure on 10/11/23 at 1:23 PM titled Oxygen Administration provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: The purpose of this procedure is to provide guidelines for safe Oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for Oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .Assessment: Before administering Oxygen, and while the resident is receiving Oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it 1) secured prescription insulin medication following a Glucometer Observation for 1 of 1 sampled residents observed during a Medication Administration Observation, Resident #213. And, 2) failed to secure an order for self-medication of a prescription inhaler medication for 1 of 1 residents observed with an inhaler, Resident#158. The findings included: Review of the facility policy and procedure on 10/11/23 at 2:15 PM titled Medication Labeling and Storage provided by the Director of Nursing (DON) revised February 2023 documented in the Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage 4. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to involve a resident in discharge planning for 1 of 3 residents sampled for discharge (Resident #53). The findings included: A review of the facility's policy Discharge Summary and Plan, dated 11/28/17, documented: When the Health Center anticipates a resident's discharge to a private residence or another nursing care Health Center, a discharge summary and a post-discharge plan will be developed which will assist the resident in adjusting to his or her new living environment. The post-discharge plan will be developed by the care planning/interdisciplinary team (IDT) with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and service; c. A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 address missing personal clothing in a timely manner, for 2 of 2 sampled residents (Residents #514 and #515). Findings include: Facility policy titled Release of Resident's Belongings dated 11/28/2017, included under Procedures, the personal belongings of a resident who is temporarily transferred from the health center will be inventoried and stored by the health center until the resident has returned. 1.) Resident #514 was initially admitted to the facility on [DATE], but then transferred to the hospital on [DATE], and readmitted on [DATE] to a different room. The inventory sheet from 05/20/2022 was not provided for review, the inventory sheet from 05/25/22 did not have any clothes listed. During an interview on 06/06/22 at 11:00 AM with Resident #514, he was observed wearing a hospital gown, and he stated he had no clothes. He stated he had clothes when he was initially admitted but when he returned to the facility, he asked for his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents will remain free from falls for 3 of 3 sampled residents reviewed for falls (Residents #19, 52, 18). The findings included: Review of the facility's policy titled Falls Prevention and Management Program, revised 09/23/19 revealed the following: Fall Risk Evaluation frequency: just prior to or on admission to the community; following a fall; following any changes of status; quarterly or as required by regulations. Initial Post-Fall Evaluation: assess the resident for any obvious injuries and to then conduct an initial investigation to collect facts about the fall related incident. Information needed: date/time of fall; resident's description of fall; timely notification of provider and family; vital signs; current medications; resident assessment; environmental factors; care plan interventions. Documentation and Follow Up: determine the need for ongoing monitoring; complete an incident report; complete internal 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.
- Potential for harm · Dcited before2022-06-09 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 provide the correct fluid amount as per the Physician's order for 1 of 1 resident reviewed for Fluid Restriction (Resident #414). The findings included: A record review showed that Resident #414 was admitted on [DATE] with type 2 diabetes and muscle weakness diagnoses. Further review of the physicians' orders showed an order for Fluid Restriction of 1500 milliliters (ml) per day; Nursing: 150 ml day and evening, 0 ml nights, Dietary: 720 ml breakfast; 240 ml lunch and dinner, which was dated 05/28/22. The facility's clinical dietitian wrote an order dated 06/01/22 for 8 ounces (240 ml) of Glucerna (a nutritional supplement) once a day. Labs taken on 05/31/22 showed that Resident #414 had a lab result of 41 on his GFR (glomerular filtration rate, which measures how well your kidneys filter blood). This placed Resident #414 at stage 3 chronic kidney disease. The Minimum Data Set (MDS) dated [DATE], under section C, showed that Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-09 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions during lunch observation, and failure to date and label all food items in the central kitchen. The findings included: During the initial tour of the kitchen conducted on 06/06/22 at 9:00 AM, accompanied by the facility's Executive Chef, the following was noted: 1. A take-out white container was noted in the food production area, which was not dated (the date the food was made or used by date) or labeled with the food item in the container. 2. The Tray Line's counter was noted with multiple black disposable gloves that were not in a box and were improperly stored. 3. Three large round garbage bins in the food production area, with no lids and debris exposed. 4. The reach-in refrigerator in the food production area was noted with multiple salad containers and multiple dressing containers that had no food labeling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a 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 provide the required specialized Rehabilitative Services for 1 of 4 residents reviewed for Rehabilitation Services (Resident #414). The findings included: A record review showed that Resident #414 was admitted on [DATE] with type 2 diabetes and muscle weakness diagnoses. Order noted to admit Resident to skilled nursing facility on 05/19/22. Another order dated 05/20/22 showed for Occupation Therapy (OT) and Physical Therapy (PT) to evaluate and treat. Further review showed that Resident #414 was placed on isolation for COVID-19 from 05/28/22 to 06/07/22. In an observation conducted on 06/08/22 at 10:00 AM, Resident #414 was noted in an isolation room for positive COVID-19. In this observation, Resident #414 stated that he had been in this room for days and that no therapy was provided to him while here. He further said that he is here for skilled therapy and that to be in isolation for COVID-19, he could have done it at home instead of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-02-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure a homelike environment with overbed lights having pull cords attached for 2 out of 70 occupied beds. The findings included: On 02/17/25 at 10:49 AM, an observation was made in room [ROOM NUMBER]-B of overbed light located on the wall above the head of the bed with no pull cord attached. On 02/17/25 10:56 AM, an observation was made of room [ROOM NUMBER]-B of overbed light located on wall above the head of the bed with no pull cord attached. On 02/18/25 at 9:05 AM, an observation was made in room [ROOM NUMBER]-B of overbed light located on the wall above the head of the bed with no pull cord attached. During a side by side observation conducted on 02/18/25 from 10:15 AM to 10:30 AM with the Maintenance Supervisor who acknowledged the pull cords for the overbed lights were missing in rooms 22-B and 28-B. During an interview conducted on 02/18/25 at 10:30 AM with the Maintenance Supervisor who stated each overbed light should have a pull cord long…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,963 in federal fines across 1 penalty.
- $4,963 — penalty dated 2023-12-15
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 LIFESPACE COMMUNITIES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 3.7 | -1.7 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 14 homes this chain runs (chain average 4.4★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LIFESPACE COMMUNITIES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 07/08/2009 |
| LIFESPACE, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/09/2012 |
| SPAULDING, TAYLOR | Individual | W-2 MANAGING EMPLOYEE | — | since 08/13/2020 |
| BLACKFORD, GARY | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| DARKEY-HRINYA, JOYCE | Individual | CORPORATE DIRECTOR | — | since 01/15/2018 |
| DUTRA, ANA | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| FIELDS, VENITA | Individual | CORPORATE DIRECTOR | — | since 01/15/2018 |
| JENSEN, CLAUS | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| MCDONOUGH, AMY | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SALAMINO, JENIFER | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| SOKEYE, JONATHAN | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| SPANGLER, PATRICK | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| STRETCH, CLYDE | Individual | CORPORATE DIRECTOR | — | since 04/26/2023 |
| WILLIAMS, DAVID | Individual | CORPORATE DIRECTOR | — | since 12/01/2021 |
| YANOFSKY, NEAL | Individual | CORPORATE DIRECTOR | — | since 07/18/2016 |
| GORMAN, JOSEPH | Individual | CORPORATE OFFICER | — | since 07/26/2022 |
| HARSHFIELD, NICHOLAS | Individual | CORPORATE OFFICER | — | since 07/01/2020 |
| JANTZEN, JESSE | Individual | CORPORATE OFFICER | — | since 04/01/2020 |
| KRESSE, NIKKI | Individual | CORPORATE OFFICER | — | since 04/19/2021 |
| POPE, ERIN | Individual | CORPORATE OFFICER | — | since 07/25/2022 |
CMS files one row per role, so the 21 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.2M 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105411. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-20, 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.