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The Terrace Of Delray Beach Nursing And Rehabilita

5430 Linton Blvd, Delray Beach, FL 33484 · For profit - Limited Liability company · 120 certified beds · (561) 495-3188 Medicare & Medicaid certified

Call the home — (561) 495-3188 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 24 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5258 Linton Blvd · (561) 498-5530 · Call to confirm hours
Pharmacy
5130 Linton Blvd · (561) 455-2309 · Call to confirm hours
Grocery
Aldi0.5 mi
4801 Linton Blvd · (855) 955-2534 · Call to confirm hours
Park
Delray Beach Florida · Typically dawn to dusk
Place of worship
16325 S Military Trl · (561) 907-3295

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 2 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.

Overall rating4★
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 increased3.6%8.7%15.4%better
Long-stay residents who lose too much weight2.1%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
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 injury3.8%2.5%3.3%worse
Long-stay residents whose ability to walk worsened1.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication5.9%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.2%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control1.1%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table5.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission31.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit7.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.242.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.291.151.80better

* 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.

43.3% 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 150 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.3%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
78.7%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 78.7% 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 61 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% 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 SNF43.3%CMS range 36.0–52.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.4–16.610.7%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 discharge78.7%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 discharge62.3%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 discharge49.2%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 identified100.0%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 discharge100.0%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 stay0.0%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 worsened0.0%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 hospitalization6.4%CMS range 3.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

1.10
RN hours/ resident / day
0.37
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.72
Total nurse hours/ resident / day
1.01
RN hoursweekends
27.0%
Total nursing turnover
31.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 117.6 residents a day — about 98% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.54 hrs/resident/day on weekends vs 3.80 on weekdays — 7% thinner on weekends. RN hours go from 1.14 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% 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

5
deficiencies at the latest standard inspection (2026-01-29)
13
at the previous standard inspection (2024-07-31)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · D2026-01-29 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 obtain informed consent for residents prescribed psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication review affecting Residents #4, #14, #87, #129. The findings included: Review of the facility's policy, titled, Use of Psychotropic Medication(s), with a reviewed/revised date of 02/05/25 included in part the following: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation…

    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 · D2026-01-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, observations, and record review, the facility failed to allow residents to have consistent access to a functional telephone for communication with family members or an accessible television remote control to support personal choice and self-directed activities, for 1of 2 sampled residents, Resident #12.The findings included:Review of Resident #12's medical record documented the following diagnoses: Dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Major Depressive Disorder, Anxiety Disorder, Poly-osteoarthritis; Waldenstrom Macroglobulinemia, Drug-induced pancytopenia; Muscle wasting and atrophy, and abnormal posture.Review of Resident #12's comprehensive care plan indicated the resident was assessed as able to communicate leisure needs and preferences, preferred a balance of social and independent activities, and was expected to remain engaged in leisure activities of choice. The plan directed staff to encourage in-room leisure activities, including television viewing and telephone or video communication with family…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-29 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 showers per resident request for 1of 5 sampled residents reviewed for choices, Resident #87. The findings included:Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease on Dialysis, Anxiety, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) End of Prospective Payment System (PPS) Part A stay dated 01/06/26 revealed Resident #87 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. On 01/26/26 at 11:29 AM, an interview was conducted with Resident #87, who was asked about bathing preferences. The resident stated he thought he had one shower since he had been in the facility and he would like more, but they won't give him showers.Record review revealed physician orders for a shower on Monday, Wednesday, and Fridays on 3-11 (3PM - 11 PM shifts).An interview was conducted with Staff B,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-29 · 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, and record review, the facility failed to follow resident's preferences for incontinence care for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #73. The findings included: Record review for Resident #73 revealed the resident was admitted to the facility with diagnoses that included: Chronic Obstructive Pulmonary Disease, Encounter for Palliative Care, Anxiety Disorder, Hemorrhoids, Constipation, Crohn's Disease of Large Intestine without Complications, Restlessness and Agitation. Review of Resident #73's Physician's orders revealed apply barrier cream to sacrum area and to Turn and Position every 2-3 hours as indicated, every shift AND as needed. Review of Section C of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. Review of Section GG documented Resident #73 required substantial assistance for toileting hygiene and Section H…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-29 · tag F0679 — failed to provide activities — isolated
    Provide 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, record review, and interviews, the facility failed to coordinate and implement structured activities for 1 of 2 sampled residents reviewed for activities, Resident #13.The findings included:Review of the clinical record documented Resident #13 was admitted to the facility on [DATE]. Review of the Brief Interview for Mental Status (BIMS) score was 5, indicating cognition was severely impaired. The resident's diagnoses included Dementia and Major Depressive Disorder. On 01/26/26 at 11:10 AM, Resident #13 was observed alone in her room with a stuffed animal and two pillows positioned on either side of her body. The television was turned off. Upon interview, as the surveyor prepared to exit the room, Resident #13 made a prayer request to the surveyor. On 01/26/26 at 2:51 PM, Resident #13 was again observed alone in her room with no stimulation other than a doll. She was noted to express herself fluently in a foreign language. The bedroom door was closed, and although the resident had 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 · E2024-07-31 · tag F0914 — pattern
    Provide bedrooms that don't allow residents to see each other when privacy is needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to provide privacy curtains for residents in 14 resident rooms (Rooms 121-133) for Bed A, which is closest to the door, and affecting 2 of 2 sampled Residents #40 and #77. The findings included: During an initial tour on 07/28/24 at 9:39 AM, the surveyor observed that Residents #77, residing nearest the door (Bed A), did have no privacy curtains. On 07/29/24 at 11:28 AM, the surveyor observed that Resident #40, residing by the door, did not have privacy curtains. On 07/30/24 at 12:07 PM, the surveyor observed Staff K, RN (Registered Nurse), providing tube feeding to Resident #40. The nurse stated, I'd pull the privacy curtain, but there is no privacy curtain. During an interview on 07/30/24 at 2:45 PM, the spouse of Resident #40 stated the privacy curtain has been missing for many months. The spouse explained, 'the curtain was there for about two years and then all of a sudden one day it was gone.' Another tour was completed on 07/31/24 at 11:00 AM with the Maintenance Director and Regional Maintenance Director. It was observed…

    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 · Dcited before2024-07-31 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 ensure the provision of showers as per facility schedule for 1 of 4 sampled residents, Resident #48. The findings included: Review of the record revealed Resident #48 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating he had minimal cognitive impairment. Review of the record lacked any evidence of the provision of showers. A progress note dated 04/04/24 at 9:21 AM documented to please have the resident sit in his wheelchair after his shower one time a day every Tuesday, Thursday, and Saturday. This note also documented if the resident refused to get a shower to phone the resident's significant other / power of attorney (POA), and the phone number was provided. A care plan initiated 01/11/23 documented Resident #48 did reject care, including showers, but lacked the newer intervention…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure staff awareness and implementation of DNR (Do Not Resuscitate) status for 1 of 1 sampled resident, Resident #70. The findings included: Review of the Policy, titled, Communication of Code Status, Implemented 05/01/24, documented, in part, it is the policy of this facility to adhere to residents rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 1. The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. 2. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code b. Do Not Resuscitate c. Do Not Intubate d. Do not Hospitalize 3. 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 · D2024-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, safe and comfortable environment for the residents as evidenced by the environment not being homelike, carts broken and wheelchairs in disrepair, on the 100 and 200 units. The finding included: 1. During an initial tour on 07/28/24 of the resident's rooms, observations revealed the following: a. room [ROOM NUMBER] - The bathroom has paint peeling on the wall underneath the soap dispenser. The grout around the toilet was brown and not white. b. room [ROOM NUMBER]A - the sitting chair in the room had a large stain in the middle of the seat as well as a couple of tears on the seat. c. the Linen Cart on hallway 100 was observed to be broken. 2. The following wheelchairs were observed to have torn arm rests: room [ROOM NUMBER] bed A room [ROOM NUMBER] bed B room [ROOM NUMBER]-A room [ROOM NUMBER]-B room [ROOM NUMBER]-B room [ROOM NUMBER]-A. Photographic Evidence Obtained. 3. A secondary tour was completed on 07/31/24 at 11:30 AM with 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 · D2024-07-31 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 1 sampled resident, Resident #54. The findings included: Review of the policy, titled, Restorative Nursing Programs, implemented on 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 10. A resident's Restorative Nursing Plan will include: . c. Frequency of activities d. Duration of activities . 12. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. Record review revealed Resident #54 was admitted to the facility 05/23/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #54 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the resident received 1 day of restorative therapy services during the 7 day look…

    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
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-07-31 · 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 policy review, observation, interview, and record review, the facility failed to ensure timely and ongoing nail care for 1 of 2 sampled residents reviewed for Activities of Daily Living (ADLs), Resident #22. The findings included: Review of the policy, titled, Nail Care, implemented 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. C. The persons responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 7. Procedure: . i. Document completion of task, any complications, or if resident refuses.…

    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 · D2024-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record and policy review, the facility failed to provide timely care and treatment for a skin tear for 1 of 1 sampled resident reviewed for skin conditions, Resident #1. The findings included: The facility's policy, titled, Skin Integrity-Skin Tear, implemented on 05/01/24, documented, in part, the following: When a skin tear is discovered, the nurse shall complete an incident report. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. Interventions will be modified in a resident's plan of care as needed. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection, Heart Failure, and Unspecified Peripheral Vascular Disease. Resident #1 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 on her admission minimum data set. On 07/28/24 at 9:27 AM, an observation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · 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 policy review, observation, interview, and record review, the facility failed to ensure appropriate indwelling urinary catheter care and maintenance for 2 of 2 sampled residents, as evidenced by staff failed to provide appropriate urinary catheter care for Resident #22 and failed to ensure an anchoring device for the urinary catheter of Resident #77. Both residents had a history of urinary tract infections (UTIs). The findings included: Review of the policy, titled, Catheter Care, implemented 05/01/24 documented, in part, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . This policy further instructed care for the male was for staff to first cleanse the penis in the area closest to meatus (insertion site), followed by the shaft of the penis moving down or away from the insertion site, and lastly cleaning the urinary tube cleansing outward away from the body, holding the tubing to ensure the catheter remains in place and is…

    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 before2024-07-31 · 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 observation, interviews, record and policy review; the facility failed to provide pain management for 1 of 1 resident reviewed for pain management (Resident #294); and and failed to provide medications as per physician order for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #4 and #28. The findings included: The policy of the facility, titled, Pain Management implemented 05/01/24, revealed an assessment or evaluation of pain may necessitate gathering the following information, as applicable to the resident The resident's goals for pain management and his/her satisfaction with the current level of pain control. 1. Record review documented Resident #294 was admitted to the facility on [DATE] with diagnoses that included Syncope and Collapse, Other symptoms, and signs involving the musculoskeletal system and Presence of cardiac pacemaker. Her Brief Interview for Mental Status (BIMS) score was 14 on the admission minimum data set with an assessment reference date of 07/27/24,…

    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 · D2024-07-31 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of the policy, titled, Nail Care, implemented 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. C. The persons responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 7. Procedure: . i. Document completion of task, any complications, or if resident refuses. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident needed substantial to maximum assistance from staff for all Activities of Daily Living (ADLs). During an…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the record revealed Resident #22 had a Urinary Tract Infection (UTI) as per the laboratory results reported on 02/09/24. This urinalysis and culture reported the organism was ESBL (extended-spectrum beta-lactamase), classified as an organism resistant to antibiotic, necessitating the use of contact precautions with PPE (personal protective equipment). This infection was treated with an antibiotic for seven days. Further review of the orders and corresponding Medication Administration Record (MAR) revealed contact precautions for just three days as of the evening shift on 02/09/24. During a side-by-side record review and interview on 07/31/24 at 9:54 AM, the Infection Control Preventionist confirmed she would expect the contact precautions for a resident with an active MDRO to be maintained through the entire dose of antibiotics. Review of the current orders revealed Resident #22 had an indwelling urinary catheter,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-31 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have adequate discharge documenation to ensure the facility followed physician orders to provide Home Health Services set up and that services were provided to residents on discharge home for 1 of 3 sampled residents reviewed for discharge, Resident #92. The findings included: Review of Resident #92 electronic medical record (EMR) revealed Resident #92 was admitted to the facility on [DATE] and discharged on 04/18/24. The resident had diagnoses to include Unspecified Fracture of Left Patella, Pain, Difficulty Walking, Hypertension, Type II Diabetes Mellitus, Depression and Anxiety. Review of the physician's orders dated 04/18/24 documented to discharge the resident home with RN (Registered Nurse) evaluation, Physical Therapy (PT), Occupational Thereapy (OT), and Home Health Aide (HHA) and to follow up with Primary Care Physician (PCP) in 1 week. Review of the Progress Notes dated 04/18/24 at 7:30 PM documented, Resident discharged home accompanied 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observation, interview and record review, the facility failed to provide foods that were prepared in a sanitary manner in accordance with professional standards. The findings included: 1. During the initial kitchen tour, on 06/25/23 at 8:53 AM, accompanied by the Food Service Director (FSD) and Staff A, [NAME] the following were noted: a. The air conditioning unit was not working in the kitchen, and the facility had been using portable units to cool the kitchen. The portable units required water to be plumbed to them. The water that was plumbed to the portable units was the cold water from the hand washing sink, located at the end of the production area where meals are plated from the hot holding unit. Due to the units being plumbed to the hand washing sink, the sink was rendered unusable due to only having hot water. The facility converted a food prep sink at the coffee / beverage station into a designated hand washing sink by installing a soap dispenser and paper towel dispenser on the wall over and next to the sink. The designated hand washing sink that was next 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review, the facility failed to notify a resident and/or resident representative of a room change prior to the room change for 1 of 1 sampled resident reviewed for room changes, Resident #60. The findings included: The facility's policy, titled, Room Changes with an effective date of 11/28/12 and revised 11/20/21, 03/01/22, and 04/15/23 revealed social service or designee shall notify the resident and/or resident representative, either verbally or in writing, with as much notice as possible prior to the room change. If initial notification is made verbally, the resident or resident representative shall be offered a copy of the written notice. Notification shall be documented in the clinical record. Resident #60 was admitted to the facility on [DATE] and was placed in a TCU (Transitional Care Unit) room. The resident's diagnoses included Age Related Osteoporosis, Osteoarthritis, and adjustment disorder with other symptoms. The resident has a Brief Interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-28 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow tube feeding physician orders for 2 of 2 sampled residents reviewed for tube feedings (Percutaneous Endoscopic Gastrostomy / PEG), Residents #48 and #62. The findings included: Review of the facility's policy, titled, Gastrostomy Tube / Feeding and Care, with a revised date of 08/20/22 included, in part: To provide nutrients, fluids, and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. A licensed nurse will review the physician's order for type of formula, concentration, rate of flow and method of administration. Label container with resident's name, flow rate, date, and time. Hang times: Record date/time container is hung. 1. Record review for Resident #48 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission date of 11/15/22, with diagnoses that included: Parkinson's Disease, Dysphagia Oropharyngeal Phase,…

    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 before2023-06-28 · 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 observations, interviews, and record review, the facility failed to administer timely and to monitor effectiveness of pain medications for 2 of 2 sampled residents reviewed for pain, Residents #313 and #314. The findings included: Review of the facility's policy, titled, Pain Management Program with a revised date of 02/07/23, included: the purpose was to establish a program which can effectively manage pain in order to remove adverse physiological and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological wellness. The guidelines have a goal of the facility to facilitate resident independence, promote resident comfort, preserve, and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. Documentation of assessments and the resident's response to the pain management plan will be made with each assessment. Pain control will be…

    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 · D2023-06-28 · 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 observation, interview, and record review; it was determined that the facility failed to ensure pharmacitical services were provided that ensured the accurate administration of medications per the physician orders, for 1 of 29 opporunities observed duringa medication observation, affecting Resident #86. The findings included: A review of the facility's Policy, titled Administering Medications dated 2001 and revised in December 2012 revealed Medications ordered for a particular resident may not be administered to another resident and the individual administering the medication will record in the resident's medical record .the dosage. 1. On 06/27/23 at 8:45 AM, a medication observation pass was conducted with Staff D, Licensed Pratical Nurse /LPN, for Resident #86. Resident #86's blood pressure and pulse were taken. The blood pressure was recorded as 133/56 and a pulse of 56. Staff D was observed preparing the resident's medication to include 9 oral medications. The pill count was confirmed to be 9 with Staff D. Staff D was observed entering Resident #86's room and proceeded…

    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
  • No harm found · C2024-07-31 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to state in their admission Agreement (page15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 88 of 88 residents at the time of survey. The findings included: Review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement' was completed on 07/30/24. The separate 'Arbitration Agreement' and 'Arbitration Program Guide' contained all required regulatory language. However, within the admission Agreement (Agreement between the Facility and Resident / Representative), there is a paragraph on page 15 (Item #26) which stated: WAIVER OF RIGHT TO JURY TRIAL. BY SIGNING THIS AGREEMENT RESIDENT AND RESPONSIBLE PARTY ARE WAIVING (A) THE RIGHT TO A JURY TRIAL FOR ANY CLAIM(S) BROUGHT HEREIN AND (B) INSOFAR AS THE ARBITRATION AGREEMENT IS EFFECTIVE ARE AGREEING TO ARBITRATE CLAIMS PROVIDED FOR THEREIN INCLUDING ANY AND ALL CLAIMS ARISING OUT OF OR RELATED 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-07-31 · tag F0582 — pattern
    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

    Based on record review and interview, the facility failured to provide the appropriate Beneficiary Notification Form (CMS Form 10055/SNF ABN) to 2 of 3 sampled residents, Resident #22 and #70. The findings included: On 07/31/24, reviews of the Beneficiary Notices provided by the facility for Resident #22 and Resident #70 revealed they were discharged from Part A Medicare services and the beneficiary notices were completed. The residents were not provided with the required documentation, CMS Form 10055 (SNF ABN), at the time of Medicare Part A discharge, as follows: 1. Record review revealed Resident #22's start date for Medicare Part A services was 07/04/24. His last covered day of Part A Services was 07/09/24. The facility initiated the discharge from Part A services when the benefit days were not exhausted, and Resident #22 chose to remain in the facility. The CMS Form 10123 (NOMNC) was provided to Resident #22 on 07/04/24, but the CMS Form 10055 (SNF ABN) was not provided. The SNF ABN is required if the resident has skilled benefit days remaining and is being discharged from Part…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
TD SNF HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2024
BRONFELD, ANDREWIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/01/2024
BRONFELD, RACHELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/01/2024
AGENOR, IVEYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2025
ESPINEL, MANUELIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 01/13/2025

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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.

$11.3M
Net patient revenuemost recent cost report
-23.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 11%Medicare 10%Other / private 79%

This home reported $1.2M 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

$397per resident / day
operating cost
$12,083per month
≈ monthly operating cost
$323per 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 105475. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.

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