Magnolia Ridge Health And Rehabilitation Center
6517 NW 39th Avenue, Gainesville, FL 32606 · For profit - Limited Liability company · 223 certified beds · (678) 592-3396 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $5,678 in federal fines (most recent 2023-08-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- nursing-staff turnover (71%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| 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 held steady at 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.3% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.6% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.5% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 8.1% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.7% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 7.7% | 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 table | 1.1% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.7% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.3% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.1% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.07 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.15 | 1.80 | better |
‡ 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.
57.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 987 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.7% 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 361 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 0.66 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.4%CMS range 53.9–60.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 9.0–11.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 62.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 4.3–8.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 223 beds and averages 201.9 residents a day — about 91% occupied, or roughly 21 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.37 hrs/resident/day on weekends vs 3.68 on weekdays — 8% thinner on weekends. RN hours go from 0.55 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 71% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · D2026-05-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote and maintain an environment that enhanced resident dignity and respected resident privacy for residents in 3 of 9 hallways (300's, 400's and 700's hallways) reviewed for resident rights. Findings include: 1) During an interview on 05/04/2026 at 11:12 AM, Resident #13 stated, The staff came into my room last night around 4:00 AM, and [Staff H, Registered Nurse (RN)'s name] and another staff member took some items out of my drawer. They told me they were getting medications out of the room because state was coming in the morning. I am not sure what all they took. During an interview on 05/05/2026 at 8:00 AM, Resident #89 stated, The staff came into my room and went through all of my belongings and took some of my personal items, snacks and my brush. They told me that state was coming in the morning, so they had to go through all of my belongings. I felt like it was a major violation of my privacy. During an interview on 05/04/2026…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-08 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 interview and record review the facility failed to notify resident representatives of a change in condition for weight loss for 1, Resident #7, of 7 residents reviewed for nutrition and for 1, Resident #161, of 3 residents reviewed for pressure ulcers.Findings include: Review of Resident #7's admission record documented diagnosis that include displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, muscle weakness generalized, cognitive communication deficit, dysphasia oropharyngeal phase, encounter for other specified surgical aftercare, unspecified protein calorie malnutrition, acute respiratory failure with hypoxia, hypokalemia, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, gastroesophageal reflux disease without esophagitis. Review of Resident #7's physician orders dated 4/9/2026, read, Weekly Weights every day shift every Thur [Thursday] for monitoring for 4 weeks. Review of Resident #7's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 out of 12 residents reviewed. Findings Include: 1) Review of Resident #17's Minimum Data Set [MDS] admission assessment dated [DATE], Section I, active diagnoses did not include glaucoma, atrial fibrillation [A-fib] and protein malnutrition. Review of Resident #17's admission record documented resident was admitted on [DATE] with diagnosis that included unspecified glaucoma [onset date 04/15/2026] unspecified atrial fibrillation [onset date 04/15/2026] and unspecified protein-calorie malnutrition [onset date 04/15/2026]. During an interview on 05/06/2026 at 12:41 PM, Staff C, RN [Registered Nurse] MDS Lead, stated, Section I of the MDS should have had protein malnutrition, glaucoma and A-fib for [Resident #17's Name]. 2) Review of Resident #34's MDS admission/medicare 5 day assessment dated [DATE], Section K documented weight loss of 5% in one month…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to obtain physician orders to provide wound care for 2, Residents #38 and #199, of 2 residents, reviewed for skin conditions. Findings include: During an observation on 5/4/26 at 9:51 AM, Resident #38 was sitting at bedside. Resident #38 lower leg right extremity had a 2x2 had a dressing that was not dated, and the gauze around the wound was loose. [see photographic evidence] During an interview conducted on 05/05/2026 at 9:49 AM, Resident #38 stated, My dressing does not get changed as often as it should. The last time the dressing was changed was approximately one week ago. Review of Resident #38's physician orders did not document wound care dressing change orders in place. Record review of Resident #38's wound care progress notes for dated 4/16/26 read Primary Dressing 1: Calcium Alginate and Dressing Frequency: Daily for the left foot digit 2 and left foot digit 3 wounds. Record review of Resident #38's wound care progress notes dated 4/23/26 read Primary Dressing 1: Calcium Alginate and Dressing Frequency:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-08 · tag F0697 — failed to manage pain — isolatedProvide 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
Based on observation, interview and record review the facility failed to provide pain medications and follow physician orders for pain medication for 1, Resident #6, of 3 residents reviewed for pain management. Findings include:Review of Resident #6's admission record documents diagnosis that include aftercare following joint replacement surgery, klebsiella pneumonia as the cause of diseases classified elsewhere, urinary tract infection, presence of right artificial knee joint, unilateral primary osteoarthritis left knee, rheumatoid arthritis unspecified. Review of Resident #6's nursing progress note dated 5/4/2026 at 1940 (7:40 PM) read, admitted from hospital. Physician notified of admission, orders reviewed and verified. Resident representative notified of admission. The resident is currently taking opioids. Review of Resident #6's physician orders dated 5/5/2026 read, Oxycodone HCL[Hydrochloride] Oral Tablet 15 MG (milligrams) (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain scale 6-10. Review of Resident #6's physician orders dated 5/5/2026 read,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure staff used appropriate personal protective equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on contact precautions to prevent the possible spread of infection and communicable diseases for 2 residents, Resident #6 and #78, of 3 residents reviewed for transmission based precautions, for transporting soiled linens, and for urinary catheter care and maintenance for 1, Resident #99, of 3 residents reviewed for urinary catheter care. Findings include: 1) During observation on 5/5/2026 in the memory care unit at 2:02 PM, Staff D, Floor Technician/Housekeeping picked up the soiled trash behind the nurses station and held it to his body to remove the excess air out of the soiled trash bag and twisted it around 5 times then put it in a large gray bin that read soiled linen only that had the lid open, then he went into the soiled utility room and took out the soiled linen bags and held it to his body to remove the excess air out of the soiled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while performing midline care for the residents who were on enhanced barrier precautions (EBP) to prevent the possible spread of infection and communicable diseases for 1 of 2 residents reviewed for intravenous (IV) therapy (Resident #4). Findings include:During an observation on 11/20/2025 at 10:05 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #4's room, performed hand hygiene with hand sanitizer, and donned gloves. Staff A proceeded to turn off the IV pump and then disconnected the IV tubing from Resident #4's midline. Staff A wiped the midline port with an alcohol wipe and flushed 10 milliliters of normal saline into the midline. Staff A wiped the midline port with another alcohol wipe and applied a green cap to the midline. Staff A doffed the gloves and performed hand hygiene using hand sanitizer on her way out of the room. Staff A did not wear a gown.During an interview on 11/20/2025 at 10:07 AM, Staff A, LPN, stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 ensure food products were stored properly in the main kitchen and 1 of 6 nourishment rooms, 700 Hall Nourishment Room. Findings include: During an observation while conducting the initial tour of the main kitchen with the Dietary Assistant on 12/2/2024 at 9:26 AM, there were two unlabeled and undated bags of unidentified patties with one bag being open and unsealed, and one unlabeled and undated bag of mixed vegetables in the reach-in cooler. During an interview on 12/2/2024 at 9:30 AM, the Dietary Assistant stated that the food items should be labeled, dated and the bags needed to be sealed. During an observation on 12/2/2024 at 9:40 AM, the ice machine had a brownish color, soft buildup at the lip of the inside top rim of the maker. During an interview on 12/2/2024 at 9:40 AM, the Dietary Assistant confirmed that the ice machine had a buildup. During an observation of 700 Hall Nourishment Room with the Dietary Assistant on 12/2/2024 at 10:25 AM, there were plastic wrapped burritos and one opened ice cream…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 complete comprehensive assessments for the admission Minimum Data Set (MDS) for 4 of 9 residents reviewed, Residents #41, #57, #112, and #176. Findings include: 1) Review of Resident #41's admission record documented an admission date of 11/21/2024. Review of Resident #41's MDS Entry assessment dated [DATE] documented a status of accepted. There was no documentation of a completed or accepted Medicare 5-day assessment. Review of Resident #176's admission record documented an admission date of 11/19/2024. Review of Resident #176's MDS Entry assessment dated [DATE] documented a status of accepted. There was no documentation of a completed or accepted Medicare 5-day assessment. Review of Resident #112's admission record showed the resident was admitted on [DATE] and discharged home on 8/16/2024. Review of Resident #112's electronic medical records showed no discharge MDS completed. During an interview on 12/5/2024 at 10:00 AM, the Regional MDS Coordinator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 resident assessments were accurate for 2 of 7 residents reviewed, Residents #27, and #90. Findings include: 1) Review of Resident #90's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE]. Review of Resident #90's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident is receiving anticoagulant medication under Section N0415- High-Risk Drug Classes: Use and Indication. Review of Resident #90's physician orders showed an order for Eliquis Oral Tablet 2.5 milligram by mouth twice daily for DVT (Deep Vein Thrombosis) with the start date of 9/7/2024 and end date of 10/7/2024. There was no active order for anticoagulant medication. During an interview on 12/5/2024 at 10:36 AM, the Regional Minimum Data Set (MDS) Coordinator confirmed that Resident #90 did not have an active order for anticoagulant. 2) Review of Resident #27's admission record showed the resident was initially admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-12-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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
Based on observation, interview, and record review, the facility failed to prevent possible aspiration and/or vomiting when staff failed to verify the gastrostomy tube (G-tube) placement prior to water and medication administration for 1 of 8 residents observed for medication administration, Resident #160. Findings include: During an observation on 12/4/2024 at 1:50 PM, Staff B, Licensed Practical Nurse (LPN), administered water into Resident #160's G-tube and allowed it to drain via gravity. Staff B did not aspirate the resident's stomach content to verify for correct G-tube placement prior to the administration of the water. Staff B then administered 10 milliliters (ml) of Guaifenesin Syrup (cough syrup) and allowed it to flow in via gravity and flushed the G-tube with water. During an interview on 12/4/2024 at 1:58 PM, Staff B, LPN, stated, It used to be the standard that we would check for tube placement by aspirating fluid, but we don't do that anymore. During an interview on 12/5/2024 at 2:35 PM, the Director of Nursing (DON) stated, The process for administering medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff followed appropriate infection prevention and control practices and used appropriate personal protective equipment (PPE) during medication administration via gastrostomy (G-tube) to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 12/4/2024 at 8:30 AM, Staff A, Registered Nurse (RN), placed liquid medication, oral medications, and an inhaler on the overbed table for Resident #162. There was a urinal, which was half full of a dark yellow liquid, on the overbed table. Staff A did not remove the urinal or provide a barrier or clean surface between the urinal and the medications. During an interview on 12/4/2024 at 8:35 AM, Staff A, RN, stated, I should have emptied the urinal. During an interview on 12/4/2024 at 11:47 AM, the Director of Nursing (DON) stated, I would advise the nurse not to use a surface where there were bodily fluids, such as urine, to store medications for administration. I would consider it an infection control issue.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #4) of 3 residents reviewed for pain management. Findings include: Review of Resident #4's admission record documented the resident was admitted on [DATE] with diagnoses that included left femur fracture, left knee pain, heart disease and history of falls. Review of Resident #4's physician's order dated 11/29/2023 read Hydrocodone 5-325mg (milligrams) give 1 tablet by mouth every 4 hours as needed for acute pain 6-10. Review of Resident #4's physician's order dated 12/10/2023 read Hydrocodone 5-325mg (milligrams) give 1 tablet by mouth every 6 hours as needed for nonacute pain 6-10. Review of Resident #4's Medication Administration Record (MAR) for 12/1/2023 through 12/31/2023 documented Resident #4 was administered Hydrocodone 5-325 mg for pain four times when pain was assessed and rated less than parameters written by 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.
- Potential for harm · Dcited before2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy and procedure review the facility failed to ensure medications were locked to permit only authorized personnel to have access. Findings include: During an observation on 02/14/2024 at 9:22 AM it showed there was a medication cart that was facing toward a resident's room on the 600 hall. The staff member in the room was not facing the medication cart, looked up, saw this writer, and then entered the bathroom. There were no other staff present in the area. The Administrator was walking by and when asked if there was a concern related to the medication cart, the Administrator walked around the cart, and verified the lock was not engaged and there was no staff member present. Staff A, Licensed Practical Nurse (LPN), the staff member in the room, returned to the cart at 9:24 AM. During an interview on 02/14/2024 at 9:23 AM the Administrator stated, The medication carts should be locked. During an interview on 02/14/2024 at 9:24 AM Staff A, LPN, in front of the Administrator, stated, I wasn't aware I had left the cart unlocked. According 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.
- Potential for harm · Dcited before2024-02-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record reviews, the facility failed to ensure that resident records were complete and accurate for 1(Resident #3) of 3 residents reviewed. Findings include: 1. During an observation on 2/15/2024 at 1:50 PM, Resident #3 requested pain medication from Staff C, License Practical Nurse (LPN). Staff C, LPN did not discuss with Resident #3 pain characteristic, location, or request Resident #3 to rate his pain on a scale of 1 - 10. Staff C, LPN left the room and returned at 1:56 PM and administered Hydrocodone Acetaminophen Tablet 5-325 mg (milligrams) to Resident #3. Staff C, LPN did not discuss pain location, characteristic of the pain or request Resident #3 to rate his pain on a pain scale of 1-10. Staff C, LPN was observed documenting on the electronic medication record medication given and did not document pain scale rating. During an interview on 2/15/2024 at 1:52 PM, Resident #3 stated I'm always in pain and right now my pain is a 11 on scale of 1 -10. During an interview on 2/15/2024 at 1:57 PM, Staff C, LPN stated, I've taken care of [Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure food products were stored in a safe and sanitary manner and failed to ensure dishes and utensils were cleaned under sanitary conditions in the main kitchen and in 2 of 2 nourishment rooms. Findings include: A tour of the kitchen was conducted on 8/21/2023 beginning at 9:08 AM with the Cook. On 8/21/2023 at 9:17 AM, the [NAME] tested the chemical solution in the low temperature dishwasher that was being used to wash dishes. The parts per million (PPM) of the sanitizer solution registered 50 PPM free chlorine following two tests of the sanitizer solution. During an interview on 8/21/2023 at 9:17 AM, the [NAME] confirmed the parts per million (PPM) of the low temperature dishwasher registered 50 PPM free chlorine and the kitchen would need to use disposable dishware until the dishwasher could be repaired. On 8/21/2023 at 9:18 AM, the [NAME] tested the chemical solution in the 3-compartment sink that was being used to wash dishes. The parts per million (PPM) of the sanitizer solution registered 0 PPM free…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 6 of 8 medication carts, and failed to ensure medications were secure. Findings include: 1) During an observation on 8/21/2023 at 9:09 AM with Staff A, License Practical Nurse (LPN) of the 600 Hall medication cart there was open bottle of Pro-stat not labeled with an open date, a bottle of Latanoprost with an open date of 6/27/2023, and an open bottle of Latanoprost with no open date. Review of the manufacturer's recommendation for Pro-Stat read, Record date on bottom of container upon opening. Discard 3 months after opening. Review of the manufacturer's recommendation for Latanoprost read, You may keep the opened bottle in the refrigerator or at room temperature for up to 6 weeks. During an interview on 8/21/2023 at 9:17 AM Staff A, LPN stated, Medication should be dated once opened. I think eye drops are good for 30 days after opening. If medication is expired, it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 assessments were completed accurately for 2 of 7 residents, Residents #140 and #7 reviewed for hospitalization. Findings include: Review of Resident #7's Minimum Data Set Assessment (MDS) dated [DATE] documented under Section O, the resident was receiving tracheostomy care while a resident in the facility. Review of Resident #7's medical record diagnoses list does not document Resident #7 being dependent on the use of a tracheostomy. During an interview with the Director of Nursing (DON) conducted on 08/24/23 at 10:00 AM, she stated, [Resident #7's name] has never had a tracheostomy. Review of Resident #140's electronic health record showed Resident #140, age [AGE] was admitted to the facility on [DATE] and left the facility against medical advice (AMA) on 7/26/23. Review of Resident #140's AMA form dated 7/26/23 at 9:23 PM showed it was signed by Resident #140's spouse and witnessed by two facility staff. Review of Resident #140's Discharge…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0644 — isolatedCoordinate 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
Based on record review and interview, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 5 residents Resident #95, reviewed with a possible serious mental disorder, intellectual disability Findings include: Review of the electronic health record for Resident #95 documented the resident was admitted to facility on 2/8/23 with diagnoses including fracture of upper and lower end of left fibula, mood affective disorder, cognitive communication deficit, schizophrenia and hypertension. Review of Resident #95's care plan dated 2/8/23 documented focus: The resident has a potential for behavior problem related to schizophrenia. Review of Resident #95's medical record contained an encounter form from [Name of the afterhours clinic] dated 1/17/23 which documented Resident #95 with the diagnosis of schizophrenia, dementia, and bipolar disorder. Review of Welcome Meeting Questionnaire from [Name of Health Care Provider] dated 2/9/23 documented Resident #95 as having a diagnosis of schizophrenia. Review of Resident #95's PASRR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide care and services for central venous catheters in accordance with professional standards of practice for 1 of 4 residents, Resident #291. Findings include: Review of Resident #291's medical record documented the resident was admitted to the facility with the following diagnoses: unspecified fracture of shaft of humerus, right arm, malignant neoplasm of unspecified bronchus or lung, malignant neoplasm of brain, history of falling, fracture part of neck of right femur, chronic obstructive pulmonary disease, obstructive sleep apnea, and pulmonary embolism without acute cor pulmonale. During an observation on 8/21/2023 at 1:14 PM Resident #291 was resting in bed with a right arm soft cast. Resident #291 had a right subclavian single lumen central line, the date on the dressing was 8/17/2023; there was gauze over the insertion site that was covered with a transparent dressing. During an observation on 8/23/2023 at 8:09 AM Resident #291 was resting in bed. The right subclavian central line dressing was dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were assessed by the Registered Dietician and/or measures were put into place to maintain an acceptable parameter of nutritional status to prevent significant weight loss for 2 of 7 residents, Residents #91 and #120 reviewed for nutrition. Findings Include: 1. Review of the admission record documented Resident #91 was admitted to the facility on [DATE] with the following diagnoses: Pneumonia, anemia, hyperlipidemia, alcohol use, unspecified, uncomplicated, encephalopathy, scoliosis, and spinal stenosis. Review of Resident #91's physician orders dated 5/29/2023 read, Weekly weights every day shift every Monday for monitoring for 4 weeks. Review of Resident #91's medical record under vital signs documented the following weights: on 5/27/2023 the admission weight was documented as 194.2 pounds, dated 6/5/2023 the weight was documented as 189.8 pounds, dated 7/20/2023 the weight was documented as 165.2 pounds and dated 8/3/2023 the weight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-24 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 observation, interview, and record review the facility failed to provide appropriate milliliter per hour of auto flushes via feeding tube for 1 of 4 residents, Resident #5, reviewed for enteral feedings. Findings include: During an observation on 8/21/2023 at 11:10 AM Resident #5 was lying in bed and was observed to have a gastric tube with tubing connected to a feeding pump with auto [automatic] flushes running at 40 milliliters per hour. During an observation on 8/22/2023 at 8:15 AM Resident #5 was resting with eyes closed with a gastric tube with tubing connected to a feeding pump with auto flushes running at 40 milliliters per hour. During an observation on 8/22/2023 at 3:03 PM with Staff H License Practical Nurse (LPN), Resident #5 was lying in bed with a gastric tube with tubing connected to a feeding pump with auto flushes running at 40 milliliters per hour. During an interview on 8/22/2023 at 3:04 PM Staff H, LPN stated, Oh no, [Resident #5's name] pump auto flushes are running at 40 milliliters…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice and physician orders for 3 of 6 residents, Residents #291, #294, and #34, reviewed for oxygen administration. Findings include: 1. During an observation on 8/21/2023 at 1:14 PM Resident #291 was resting in bed with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/22/2023 at 2:15 PM, Resident #291 was resting in bed with oxygen being administered at 3 liters per minute via nasal cannula. During an observation on 8/23/2023 at 8:09 AM, Resident #291 was in bed with oxygen being administered a 3 liters per minute via nasal cannula. Review of Resident #291's medical record documents the resident was admitted to the facility with the following diagnoses: malignant neoplasm of unspecified bronchus or lung [lung cancer], malignant neoplasm of brain [brain cancer], chronic obstructive pulmonary disease, obstructive sleep apnea, pulmonary embolism [a blood clot in the lung], and anemia.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 interview and record review, the pharmacist failed to recommend as needed (prn) anti-anxiety medications did not extend 14 days without physician's justification in a timely manner for 1 of 5 residents, Resident #6. Findings include: Review of Resident #6's physician order dated 4/26/2023 read, Ativan oral tablet 0.5 milligrams give 1 tablet by mouth every 4 hours as needed for anxiety. Review of the Consultant Pharmacist's Medication Regime Review: Listing of Residents Reviewed with No Recommendations for Resident #6's dated 6/1/2023 and 6/30/2023 documented there were no recommendations. Review of the Consultant Pharmacist's Recommendation to Physician dated 7/26/2023 documented for Resident #6, Order: Lorazepam 0.5 mg po q 4 hr PRN [Ativan 0.5 milligrams by mouth every 4 hours as needed] In accordance with State and Federal Guidelines, revised regulation F Tag 758, Psychotropic Drugs PRN, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure as needed (prn) psychoactive medications did not extend 14 days without physician's justification for 2 of 5 residents, Residents #6 and #73, reviewed for unnecessary medications. Findings include: Review of Resident #6's physician order dated 4/26/2023 read, Ativan oral tablet 0.5 milligrams give 1 tablet by mouth every 4 hours as needed for anxiety. Review of Resident #6's medical record failed to reveal documentation the attending physician or prescribing practitioner documented their rationale in the resident's medical record and indicated the duration for the PRN order for Ativan. Review of Resident #73's physician order dated 7/21/2022 read, Prochlorperazine Maleate [a first-generation antipsychotic, Federal Drug Administration indications include schizophrenia, schizoaffective, and other conditions presenting with symptoms of psychosis] 10 milligrams give 1 tablet by mouth every 6 hours as needed for anxiety/nausea. Review of Resident #73's medical record failed to reveal documentation the attending physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-24 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure garbage and refuse was disposed of properly in a sanitary manner. Findings include: On 8/21/2023 at 9:52 AM, a tour of the facility dumpster area was conducted with the Cook. The gates leading to the dumpster were open and the top of the cardboard dumpster was opened. There were four plastic bags of garbage, used disposable gloves and Styrofoam cups strewn about the left of the refuse dumpster. There were used disposable gloves lying on the ramp leading to the refuse dumpster. During an interview on 8/21/2023 beginning at 9:52 AM, the [NAME] verified the gates leading to dumpsters and the lids of the dumpsters should be closed. She verified the grounds surrounding the dumpsters should be free of refuse and debris. Record review of the policy titled Dietary Services Monitoring/Action Plan, last reviewed 1/11/2023 read, The Registered Dietician and/or Dietary Manager conducts ongoing monitoring of the Dietary Department for appropriate production, serving, storage, sanitation and cleanliness. This includes reviewing all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to maintain accurately documented medical records for 1 of 3 residents, Resident #49. Findings include: Review for Resident #49's medical record documented diagnoses including: acute respiratory failure, pneumonia, wedge compression fracture of T5-T6 [thoracic] vertebra, depression, unspecified heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, Type II DM [diabetes mellitus], hyperlipidemia, COPD [chronic obstructive pulmonary disease], pelvic fracture, malignant neoplasm right kidney, non-rheumatic aortic valve stenosis, essential primary hypertension, paroxysmal atrial fibrillation, Review of the physician order for Resident #49 dated 6/1/2023 read, Cured oil emulsion dressing ointment, apply to left calf topically every day shift for skin management, cleanse area with NS [normal saline] and apply oil emulsion, cover with abd [abdominal] pad, wrap. Review of Resident #49's July treatment administration record (TAR) for Cured oil emulsion wound care dressing was not documented on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow infection control standards during respiratory services for 2 of 5 residents, Residents #5 and #291, reviewed for respiratory services. Findings include: 1) During an observation on 8/21/2023 at 11:10 AM Resident #5 was lying in bed. There was a nebulizer mask on top of the nightstand that was not in a bag and there was no date on the tubing. During an observation on 8/22/2023 at 8:15 AM Resident #5 was resting in bed with her eyes closed. The nebulizer mask was on top of the nightstand and was not in a bag and there was no date on the tubing. During an observation on 8/22/2023 at 1:35 PM with Staff H, License Practical Nurse (LPN), Resident #5 was lying in bed and the nebulizer mask was on top of the nightstand and was not in a bag. Staff H looked for a plastic bag in the drawers, around the room, and no bag could be found. During an interview on 8/22/2023 at 1:37 PM Staff H, LPN stated, The nebulizer mask should be in a bag when not in use and the tubing should be dated. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$5,678 in federal fines across 1 penalty.
- $5,678 — penalty dated 2023-08-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ALACHUA 223, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| ALACHUA COUNTY HRC, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| AWRT ALACHUA LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| CRK ALACHUA LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| JNK SBK III ALACHUA, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| LP DESIGNS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| MVS ALACHUA, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/16/2014 |
| ANDY WILKES RETIREMENT TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 10/16/2014 |
| CHARLOTTE R. KELLETT GST TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 32% | since 10/16/2014 |
| JNK SBK III GST TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 32% | since 10/16/2014 |
| MARGARET V SMITH GST TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 10/16/2014 |
| PARTEE, LESLIE | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/03/2025 |
| BRANCH BANKING AND TRUST COMPANY | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 05/30/2019 |
| CLEAR CHOICE HEALTH CARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/30/2019 |
| SBK LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/16/2014 |
CMS files one row per role, so the 18 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
14 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $120K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106149. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-08, 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.