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Fort Myers Rehabilitation And Nursing Center

7173 Cypress Drive SW, Fort Myers, FL 33907 · For profit - Corporation · 120 certified beds · (239) 936-0203 Medicare & Medicaid certified

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Resident-funds citation (F0565)1 immediate-jeopardy citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (25% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2776 S Cleveland Ave · (844) 674-4677 · Call to confirm hours
Pharmacy
12255 S Cleveland Ave · (239) 931-5924 · Call to confirm hours
Grocery
1939 Park Meadows Dr Ste 4 · (239) 275-5100 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1939 Park Meadows Dr · (239) 560-6314

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 3 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 rating3★
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 increased2.8%8.7%15.4%better
Long-stay residents who lose too much weight6.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened2.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control2.6%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 table12.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication7.3%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission30.2%26.1%22.6%worse
Short-stay residents with an outpatient ER visit12.6%9.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.722.131.67typical
Long-stay outpatient ER visits per 1,000 resident days1.571.151.80better

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

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

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

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

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

50.2% 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 154 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.2%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
67.8%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 67.8% 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 174 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.2%CMS range 42.0–57.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 7.0–12.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge67.8%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 discharge67.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.9%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 worsened0.4%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 hospitalization8.3%CMS range 5.3–11.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.79
RN hours/ resident / day
0.82
LPN hours/ resident / day
2.60
Aide hours/ resident / day
4.22
Total nurse hours/ resident / day
0.50
RN hoursweekends
25.4%
Total nursing turnover
29.2%
RN turnover

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 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.60 is at or above 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 3.61 hrs/resident/day on weekends vs 4.46 on weekdays — 19% thinner on weekends. RN hours go from 0.91 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 25% 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

10
deficiencies at the latest standard inspection (2025-04-03)
5
at the previous standard inspection (2022-08-18)

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.

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2021-02-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review and staff interview, the facility failed to follow the manufacturer's specification to clean and disinfect multiuse Evencare G3 blood glucose meters for 5 (Residents #16, #24, #63, #116 and #371) of 5 residents observed with a physician's order for blood glucose monitoring (test that measures the amount of sugar in the blood). The facility failed to apply the disinfectant necessary for the minimum wet contact time per manufacturer's instructions to kill bloodborne pathogens on shared multiuse blood glucose meters. Inadequate disinfection may result in indirect contact transmission (the transfer of an infectious agent through a contaminated inanimate object) of pathogens through the improperly disinfected glucometers. The facility had a total of 12 blood glucose meters used for 42 diabetic residents with orders for blood glucose checks. The failure to properly disinfect the blood glucose meters used for multiple residents resulted in a pattern of noncompliance at Immediate Jeopardy (IJ), scope and severity of K starting on 2/23/21. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interviews, the facility failed to follow proper sanitation procedures for the 3-compartment sink, increasing the risk of cross-contamination and foodborne illness with the potential to impact residents receiving cooked food out of the dietary department. The findings included: The policy for the 3-compartment sink provided by the facility, with no effective date, stated, Sink 1= Wash, sink 2= Rinse, sink 3= Sanitize. Three-compartment sink steps: 1. Preparation: Fill sink (1) with warm Pot and Pan Detergent Solution. Fill Rinse sink (#2) with warm water. Fill the Sanitize sink (#3) with warm sanitizer solution to 200 PPM. 2. Pre-wash: Pre-scrape and rinse all items prior to washing in sink #1. 3. Wash: Scrub all surfaces (including handles). 4. Rinse: Submerge item in rinse water. Let rinse water run back into rinse sink. 5. Sanitize: Submerge item in sanitizer sink for a minimum of 60 seconds. Remove item from sink and let air dry. Do not wipe dry. On 4/2/25 from 11:15-11:25 a.m., during a 3-compartment sink observation, Staff O, a full-time Dietary…

    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 · E2025-04-03 · tag F0679 — failed to provide activities — pattern
    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, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident's physical, mental, and psychosocial well-being for 2 ( Resident #3 and #91 ) of 3 residents reviewed for involvement in the activity programs. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. The findings included: The facility Job Description and Performance Evaluation for the Activity Director documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed…

    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 · E2025-04-03 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility job description for the Activity Director and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all 131 current residents residing in the facility. The findings included: The facility Job Description and Performance Evaluation documented Responsible for the planning, developing, organizing, implementing, evaluating and directing of activity programs in accordance with current exiting federal, state and local standards. Plan develop, organize, evaluate and direct activity programs to ensure all patients/residents assessed needs are met. Record and maintain activity progress notes as well as a record of resident activities. Qualifications Education College specialization, certification preferred. On 4/2/25 at 9:06 a.m., in an interview Activity Assistant Staff C said she did not have a certification for the position of the Activity Director and no training for the position. She…

    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 · E2025-04-03 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedures, record review and staff and resident interviews, the facility failed to ensure urinary catheters were secured to prevent pulling and injury and failed to maintain the catheters in sanitary manner for 3 (Resident #50, #423, and #274) of 3 residents reviewed with an indwelling urinary catheter. The findings included: The facility policy Catheter-Foley documented Completing the procedure, Secure the catheter to the residents thigh (i.e , Stat Lock or Catheter Strap) to prevent movement, irritation and decrease risk of infection. Never leave the catheter hanging to be pulled by the weight of the bag. Place catheter bag in a dignity bag. 1. Review of the clinical record revealed Resident #50 had a readmission date of 7/20/25 with diagnoses including morbid obesity, paraplegia, type 2 diabetes, chronic kidney disease, urinary retention, dementia, anxiety and delusional disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures…

    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 · Ecited before2025-04-03 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 Based on observation, review of the clinical record, review of the facility job description of the Activity Director and staff interviews, the facility failed to ensure resident records were maintained in accordance with accepted professional standards and practices, that are complete, and accurately documented for 2 (Residents #3, and #91) of 28 residents records reviewed. The findings included: The facility Job Description and Performance Evaluation for the Activity Director documented Responsible to Record and maintain activity progress notes as well as a record of resident activities. 1. Review of the clinical record revealed Resident #3 had an admission date of 1/4/24 with diagnoses including dementia with restlessness, anxiety disorder, delusional and adjustment disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 5/19/24 documented Resident #3's preference for routine and activities specified it was very important for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · 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, record review, and interview, the facility failed to ensure a clean, comfortable, homelike environment that allows the resident to use the physical layout to maximize independence and does not pose a safety risk for 4 (#52, #57, #273, #274) of 5 residents reviewed. The findings included: Review of an admissions agreement (no date) revealed, The facility will provide resident with room and board, nursing service, and laundering of linens. 1. Record review of Resident #52 was admitted on [DATE] a Brief Interview for Metal Status (BIMS), with a score of 10 on 3/5/25, indicating that he has moderately impaired cognition. Resident #52's diagnoses included Schizophrenia and Schizoaffective disorder. On 3/31/25 at 9:25 a.m., Resident #52 was observed sitting on the side of his bed dressed in personal clothing. A blue incontinent brief soiled with feces like substance was observed on the bathroom floor. On 3/31/25 at 9:25 a.m., during an interview and continuous observation Resident #52 gestured to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure 1 (Resident #96) of 3 residents with newly evident or possible serious mental disorder, or related condition was referred to the appropriate state-designated mental health or intellectual disability authority for review for a Level II screening. The findings included: Resident # 96 was admitted to the facility on [DATE] with a Level I Preadmission Screening and Resident Review (PASRR) with a diagnosis of Anxiety but did not indicate a need for further review. On 7/29/24 a new Level 1 PASRR was completed with mental illness or suspected mental illness including mental disorder, psychosis, and adjustment disorder with anxiety added and indications of lack of focus and adapting to typical change. The new Level 1 PASRR from 7/29/24 was sent for a second level review, with a response on 8/5/25 that Resident #96 was not considered to have a serious mental illness. A review of Resident #96 record revealed the Medication Administration Record contained…

    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 · D2025-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for personal hygiene, nail care, assistance with dressing, and toileting for 1 (Residents #28) of 5 dependent residents reviewed. The findings included: On 3/31/25 at 4:22 p.m., Resident #28 was observed lying in bed. The nails of the resident's right and left hand extended approximately ¾ inch from the fingertips. The fingers of the left hand were curled with the nails pressing into the resident's palm. On 4/1/25 at 12:31 p.m., observation of Resident #28's fingernails revealed they remained untrimmed and extended approximately ¾ inch from the fingertips. In an interview Resident #28 said he guesses staff would trim his nails if he asked. On 4/1/25 at 5:16 p.m., in an interview Resident #28 said staff asked maybe once or twice if they could trim the fingernails. He said he was not able to trim his own nails due to reduced dexterity and limited range of motion to the left hand. On 4/2/25 at 10:32 a.m., Resident #28 was observed in bed. His fingernails nails remained…

    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 · D2025-04-03 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to maintain ongoing communication, coordination and collaboration between the nursing home and the dialysis staff for 1 (Resident #87) of 1 sampled resident receiving dialysis services reviewed. The findings included: Record review of Resident #87 revealed an admission date of [DATE]. Diagnoses included End Stage Renal Disease. Review of the admission Minimum Data Set (MDS) assessment with a target date of [DATE] revealed Resident #87's cognition was mildly impaired with a Brief Interview for Mental Status score of 12. 1. Review of the physician's orders in the Electronic Medical Record (EMR) revealed Resident #87 dialysis days were scheduled for Monday, Wednesday and Friday. The physician order dated [DATE] noted the resident's code status was Do not resuscitate (DNR) meaning not to initiate Cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. Review of a Circle of Care meeting dated [DATE] revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · 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 Based on observations and staff interviews, the facility failed to establish and maintain an effective infection prevention and control program, which increased the risk of communicable diseases and infections for 3 (Residents #23, #274 and #278) of 3 residents reviewed for catheter care and enhanced barrier precautions. The findings included: 1. The policy for Catheter-Foley Care provided by the facility, last revised on 4/25/22, stated, Keep the bag below the level of the bladder at all times to prevent the backflow of urine and decrease the risk for infection. Never leave the catheter hanging to be pulled by the weight of the bag. Do not leave the catheter bag/tubing laying on the floor. Place the catheter bag in a dignity bag. To avoid this issue and avoid infection control issues, the catheter bag/dignity bag may also be placed in a wash basin to avoid direct contact with the floor. Clinical record review revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included a past medical history…

    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
Show the remaining 12 citations
  • Potential for harm · E2022-08-18 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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, staff and resident interviews, review of facility policy and procedure, and record review, the facility failed to ensure 4 (Residents # 16, #69, #78 and #98) of 5 residents reviewed for accidents were assessed for alternative interventions prior to the use of bed rails. This had the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: The facility policy Side Rail Use/ Enabler Use revised 3/22, documented, The policy addresses safety measures to reduce the risk of bed entrapment related to the use of side rails/enablers. Side rails/enablers will only be used by a resident to assist his or her bed mobility in accordance with the individual's interdisciplinary team assessment. Side rails/enablers will not interfere with the residents' ability to egress from the bed. Review of the facility's Consent for use of side rails showed, . It is the policy of this facility to use side rail(s) only after evaluation…

    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 · E2022-08-18 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review and staff interviews, the facility failed to ensure its medication error rate remains below 5%. Five licensed nurses on two different shifts with 27 opportunities were observed. Four medication errors were observed resulting in a 14.81% error rate. The findings included: The facility policy 1.0, Medication Dispensing System (No effective date), documented, . Crushing oral medications requires a physician's order since some medications are not designed to be crushed (e.g., time release capsules, coated tablets, etc.). Medications are to be crushed in accordance with pharmacy guidelines and /or facility policy . Prior to medication administration: Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. Verify that the MAR [Medication Administration Record] reflects the most recent medication order. 1. On 8/15/22 at 4:25 p.m., Licensed Practical Nurse (LPN) Staff F was observed administering two different medications to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-18 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Record review of the Minimum Data Set (MDS) with Assessment Reference Date of 8/4/22 indicated Resident #108 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS revealed several active diagnoses for Resident #108 including Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Schizophrenia. On 8/15/22 at 4:30 p.m., during an observation and interview with Resident #108 she said she keeps her medicine in her chest drawers. Resident #108 stood up from bed, walked to the chest of drawers across from her bed and removed a red, 7-day pill organizer from the top drawer. She opened one section of the pill organizer and placed several pills in her hand, including a large pink pill identified as Depakote 500 milligrams (mg), which is used to treat seizures and mood disorders. Resident #108 confirmed the chest drawer was not locked and she possessed no key for access to the contents inside. Photographic evidence obtained. Review of the medical record indicated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and resident and staff interviews, the facility failed to implement adequate supervision for 1(Resident #78) of 19 residents reviewed with known unsafe wandering behaviors. The findings included: Review of the clinical record for Resident #78 revealed an admission date of 7/15/22 with diagnoses including altered mental status, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #78 scored a 10 on the Brief Interview for Mental Status, indicative of moderately impaired cognition. On 7/28/22 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #78 had poor insight or judgement, was constantly pacing the halls, and had significant cognitive processing deficits. The APRN ordered to start Xanax 0.25 mg twice a day, and Xanax 0.25 milligram (mg) every two hours as needed for anxiety. On 8/5/22 at 9:57 p.m., the psychiatric APRN documented Resident #78 was very agitated, exit seeking, not responding to the current…

    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 · E2021-02-26 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interviews the facility failed to ensure they considered the views of Resident Council and act promptly upon their grievances, concerns, and recommendations for 7 (8/2020, 9/2020, 10/2020, 11/2020, 12/2020, 1/2021 and 2/2021) of 7 months reviewed. The findings included: On [DATE] at 3:50 p.m., the Director of Activity (DOA) said because of Coronavirus Disease 2019 (COVID-19) and the death of the Resident Council President, the facility residents elected Resident #16 as the Interim Resident Council President (IRCP) in the [DATE] resident council meeting. Since the facility stopped all group meetings, they determined Resident #16 would be the representative for all the residents in the monthly resident council meetings starting [DATE]. The DOA said Resident #16 talked with most of the residents in the facility and when they had the monthly resident council meeting, he voiced all the residents' concerns and grievances for that month. On [DATE] at 10:05 a.m., 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-02-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and staff and resident interviews the facility the facility failed to ensure 10 (#43, #12, #23, #97, #9, #95, #90, #113, #40 and #98) of 14 resident's wheelchairs were clean and kept in a sanitary condition to prevent the spread of disease-causing organisms. The findings included: 1. On 2/22/21 at 9:49 a.m., Resident #43 said the housekeeping staff did not always mop her floor causing it to be sticky. She further said her wheelchair had not been cleaned in the past several months and the wheelchair was very dusty and sticky. Observation of Resident #43's wheelchair noted a thick layer of dust on the frame of the wheelchair. 2. On 2/22/21 at 10:06 a.m., observation of Resident #12's wheelchair revealed a thick layer of dust and dried food on the frame of the wheelchair. Resident #12 said his wheelchair had not been cleaned in a long time even though he had asked staff several times to clean his wheelchair. 3. On 2/25/21 at 9:25 a.m., observation of Resident #23 and Resident #97's wheelchairs revealed a thick layer of dust on the frames of their wheelchairs.…

    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 · E2021-02-26 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, the facility failed to accommodate the food allergies and offer appropriate alternative for 1 (Resident #28) of 3 residents reviewed for food allergies, intolerances, and preferences. The findings included: Review of the clinical record revealed a Patient demographic form from a local hospital printed on 2/9/21 with documentation Resident #28's had an allergy to tea. The reactions to the tea were hives and itching. Review of the progress notes revealed on 10/6/20 the advanced practice registered nurse (APRN) documented Resident #28 was allergic to tea. On 2/23/21 at 3:03 p.m., in an interview Resident #28 said he was given iced tea daily. Resident #28 said he was allergic to tea, it caused him to itch. On 2/23/21 at 3:04 p.m., in an interview resident #93 (Resident #28's roommate) said he had heard Resident #28 tell staff he was allergic to tea. He said Resident #28 was only given options if he raises hell. On 2/24/21 at 12:07 p.m., Resident #28 was observed having lunch. He exclaimed they did it again. He pointed to the cup 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-02-26 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 Based on record review and interview the facility failed to maintain complete and accurately documented medical records for 5 (Resident #2, #30, #40, #59, and #122) of 27 residents records reviewed. Accurate and complete records are necessary to document the course of a resident's care provided by the facility. The findings included: Review of the facility's policy (CN-3) with a revision date of 2/2019 revealed pertinent information should be documented in the individual's record in an accurate, timely, and legible manner. 1. On [DATE] at 8:49 a.m., review of the clinical record for Resident #30 showed multiple missing documentation on the Treatment Administration Record (TAR) for [DATE]. Resident #30 had a daily wound care order with Bactroban ointment 2% to the left and right buttock on the day shift. The treatment was not recorded on the TAR [DATE] through [DATE]. Resident #30 also had daily wound care orders with Santyl ointment to the right buttock. The treatment was not recorded on the TAR [DATE] through…

    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 · E2021-02-26 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and residents and staff interview the facility failed to ensure 4 (Residents #44, #34, #90 and #49) out of 10 siderails checked out of a possible 129 bed with siderails installed were in safe operating condition at all times. The findings include: 1. On 2/25/21 at 9:00 a.m. revealed Resident #49 has 2-upper quarter siderails attached to her bed. Resident #49 said all the residents are required to have siderails/bedrails on their bed. She said she uses the 2-upper quarter siderails to assist her in repositioning herself in bed but due to them being loose she is scared they might break if she pulls to hard. She said she has asked the nurses and housekeeper staff several times if someone could ask the maintenance department to tighten the siderails to her bed but as of this time no one has tighten the siderails as requested. 2. On 2/25/21 at 9:19 a.m. revealed Resident #44 has 2-upper quarter siderails attached to his bed. The left upper siderail is leaning on the mattress and the right upper siderail is loosely attached to the bed. 3. On 2/25/21 at 9:35 a.m.…

    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 · D2021-02-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, the facility failed to promote residents right to dignity and provide care and services to maintain self-esteem and self-worth for 2 (Residents #318, and #116) of 3 sampled residents. This has the potential to cause psychological harm, frustration, and discomfort. The findings included: Facility policy CB-14 (creation date 9/17) titled Bladder and Bowel Training Program read All residents will be given the opportunity to obtain or maintain their highest practicable ability with regards to toileting and continence. The policy's objectives included to minimize episodes of incontinence through a planned intervention program; to improve dignity, maintain self-esteem and self- respect. Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 2/18/21 revealed Resident #318 scored 15 (intact cognition) on the Brief Interview for Mental Status (BIMS). Resident #318 required extensive assistance of one person for transfer,…

    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 · D2021-02-26 · tag F0917 — isolated
    Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, the facility failed to provide private closet space for 2 (Resident #94 and #116) of 2 residents reviewed for physical environment. The failure to provide private closet space inhibits the ability to protect personal effects from casual access by others and allow items to remain clean and accessible to residents. The finding included: 1. Observation on 2/24/21 at 11:37 a.m., revealed Resident #94 and Resident #116 shared a room. The room had one dresser but no private closet space. Resident #94's personal items, including incontinence care items, were observed stacked on a chair in the corner of the room and on the floor. The same observation was made on 2/25/21 at 9:14 a.m. Resident #116 said the facility had not given him his clothes, but he would have nowhere to put them if they did. 2. On 2/25/21 at 9:26 a.m., the Maintenance Director said there were no work orders for closets for the shared room for Resident #94 and Resident #116. He acknowledged the double occupancy room had no closet or armoire with individual closet space…

    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
  • No harm found · C2022-08-18 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, resident council, and staff interview, the facility failed to keep the most recent survey results in a place readily accessible to residents, visitors, and the public. The findings included: On 8/17/22 at 10:02 a.m., a resident council meeting was conducted with six residents (#103, #73, #40, #37, #65 and #31) who regularly attend resident council meetings. Members of the resident council stated they did not know where to locate the results of the State inspections, including the most recent survey of the facility. On 8/17/22 at 11:23 a.m., a joint observation of the facility lobby with the Resident Council President failed to show a posting of the most recent State survey report. Receptionist Staff P present during the observation said she keeps all survey results in a binder behind the reception area. She said the survey results are available upon request. On 8/18/22 at 4:10 p.m., the Director of Nursing said the binder will be moved to an accessible area.

    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.

Part of a chain

This home belongs to JONATHAN BLEIER — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 4 of 53.9+0.1 vs chain
The other 17 homes this chain runs (chain average 2.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
HOLLYWOOD HILLS HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/05/2015
BLEIER, JONATHANIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER100%since 11/30/2015
BREDER, TOBIASIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2016

CMS files one row per role, so the 5 rows in the source record cover these 3 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.

$17.1M
Net patient revenuemost recent cost report
+7.3%
Operating marginrevenue minus expenses
$75K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 64%Medicare 24%Other / private 13%

This home reported $75K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$337per resident / day
operating cost
$10,241per month
≈ monthly operating cost
$363per 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 105427. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-03, 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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