Terrace Healthcare & Rehabilitation Center
7207 SW 24th Ave, Gainesville, FL 32608 · For profit - Limited Liability company · 138 certified beds · (352) 333-0600 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,674 in federal fines (most recent 2024-01-22)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (62%) 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
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 improved from 1 to 5 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 | 3.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 13.3% | 4.6% | 6.5% | worse |
| 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 | 2.6% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.0% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 1.5% | 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 | 4.3% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 1.8% | 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 | 1.9% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.9% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.1% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.0% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.83 | 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.
44.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.8% 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 204 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 0.61 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 44.3%CMS range 37.0–52.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 8.5–14.9 | 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 | 60.8% | 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 | 62.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.6% | 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 | 2.8% | 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 | 10.5%CMS range 7.2–15.1 | 7.1% | Oct 2023–Sep 2024 | worse than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 138 beds and averages 132.4 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.17 hrs/resident/day on weekends vs 3.71 on weekdays — 14% thinner on weekends. RN hours go from 0.49 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% 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 unchanged from the previous inspection. 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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2026-05-05 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to make prompt efforts to resolve grievances and keep residents appropriately apprised of progress toward resolution of grievances for one (Resident #1) of four residents reviewed for grievances.Findings include:Review of the Grievance/Complaint Log from February 2026 through April 2026 documented no grievance by or on behalf of Resident #1.During an interview on 5/04/2026 at 3:55 PM, Resident #1 stated that he had spoken with the Social Services Director about the situation with the heater and his roommate, but he hadn't heard back from her. When he made a complaint he got a lot of lip service but no follow-through. During an interview on 5/05/2026 at approximately 9:00 AM, the DON (Director of Nursing) stated she had received a 6-page grievance for Resident #1 on April 13th [2026]. She confirmed that the grievance had not been documented on the Grievance/Complaint Log. She had not specifically discussed the grievance with Resident #1 or her efforts to address or resolve it.Review of the policy and procedure, titled…
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 · D2026-03-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 care plan was revised for oxygen administration for 2 of 4 residents reviewed for respiratory care (Residents #71 and #116).Findings include:1) Review of Resident #116's physician order dated 2/10/2026 read, Oxygen at 5 liters/minute via nasal cannula with humidification when on concentrator. May be without humidification when on a tank every shift.During an observation on 3/17/2026 at 7:57 AM, Resident #116 was in bed, being administered oxygen at 4 liters per minute via nasal cannula, with an empty humidity bottle.Review of Resident #116's comprehensive care plan showed a focus for a potential for complications of respiratory distress related to chronic obstructive pulmonary disease and pneumonia, with the interventions that included administration of oxygen as ordered. There was no intervention to address adjustment of oxygen by the resident.During an interview on 3/19/2026 at 9:33 AM, Staff E, Licensed Practical Nurse (LPN), stated, He will adjust his oxygen levels as he sees fit. He has been using…
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 before2026-03-19 · 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 record review and interview, the facility failed to ensure residents on hospice received the care and services ordered by the hospice physician for 1 of 2 residents reviewed for hospice services (Resident #117) and failed to ensure residents received medications via gastrostomy tube consistent with standard of practice for 2 of 3 observations of medication administration via gastrostomy tube (Resident #151). Findings include: 1) Review of Resident #117's physician order dated 12/2/2025 read, [Name of the hospice] Hospice Services – [Name of the hospice] Hospice & Palliative Care. Review of Hospice-Skilled Nursing Facility Agreement between the facility and hospice, with an effective date of 11/6/2025, read Article II. Responsibilities of Hospice. 2.2 Professional Responsibility. Hospice shall be responsible for determining the appropriate course of hospice care, including the determination to change the level of services provided, including making arrangements for any necessary continuous care or hospice-related inpatient care in a participating Medicare/Medicaid facility…
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 · D2026-03-19 · 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
Based on record review and interview, the facility failed to ensure acceptable parameters of nutritional status, specifically residents' body weight, were maintained for 1 of 7 residents reviewed for nutrition (Resident #68).Findings include:Review of Resident #68's Weights and Vitals Summary revealed the resident weighed 124.2 pounds on 10/16/2025 and 118.6 pounds on 11/6/2025, which shows a 4.51% weight loss. The resident weighed 109 pounds on 12/8/2025, which shows 8.09% weight loss from 11/6/2025. The resident weighed 111 pounds on 1/7/2026, 107 pounds on 2/5/2026, and 108.1 pounds on 3/16/2026. The resident had a 12.96% weight loss between 10/16/2025 and 3/16/2026.Review of Resident #68's SBAR (Situation, Background, Assessment, Recommendation) read, Situation. The change in condition, symptoms, or signs observed and evaluated is/are: Weight loss. This started on 01/06/2026. There was no documentation of notification of the Registered Dietitian.Review of Resident #68's dietary narrative note dated 1/16/2026 read, 88 y/o [year old] F [female] evaluated for a change in condition…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-19 · 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 record review, the facility failed to ensure medications were stored in a safe and secure manner.Findings include:During an observation on 3/16/2026 at 9:45 AM, there were three pills and two tablets on cup of medications on top of the medication cart. There was no staff present at the medication cart. Residents were going by the medication cart and staff members were at the desk. Staff D, Licensed Practical Nurse (LPN), returned to the medication cart at 9:52 AM.During an interview on 3/16/2026 at 9:53 AM, Staff D, LPN, stated, I should not have left those on the medication cart. I went to answer the telephone. I should have brought them with me.During an observation on 3/19/2026 at 5:10 AM, Staff C, LPN, went to the medication room, poured a refrigerated liquid medication, Gabapentin 22.5 milliliters, returned to the medication cart, and verified the order for the resident. Staff C removed 2.5 milliliters of the medication from the medication cup and left the remaining medication on the medication cart while Staff C administered gastrostomy…
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 · D2024-10-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 4 residents reviewed for skin conditions, Resident #3. Findings include: During an observation on 10/1/2024 at 9:09 AM, Resident #3 was lying in bed. Resident #3's left arm had bruising and scabbed skin tears. During an interview on 10/1/2024 at 1:20 PM, Staff B, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #3's name] will get skin tears once a week. If she bumps against something her skin will open up and she will have a skin tear. Review of Resident #3's Weekly Skin Check/Nurse dated 9/2/2024 read, Description: Wound to left upper arm. Wound to left knee. Bruising to BUE [Bilateral Upper Extremities] and to BLE [Bilateral Lower Extremities]. Dry scabs to left hand and to bilateral feet/toes. Review of Resident #3's Wound Evaluation dated 9/17/2024 read, Site: Lt [Left] forearm. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: Epithelialized and resolved. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-04 · 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 ensure residents received treatment and care according to standard of practice for 1 of 4 residents reviewed for skin condition, Resident #374, and for 1 of 3 residents reviewed for pain management, Resident #116. Findings include: 1) During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/1/2024 at 9:46 AM, Resident #374 stated, I do not know what happened to my leg. It probably happened while I was sleeping. During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room.…
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 before2024-10-04 · 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, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 4 residents reviewed for skin conditions, Resident #374. Findings include: During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear…
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 before2024-10-04 · 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 performed hand hygiene while providing wound care according to the practice standard for 1 of 4 residents reviewed for skin conditions, Resident #76, and failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care for 1 of 6 residents reviewed, Resident #274, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 10/2/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, was inside Resident #274's room adjusting the IV (intravenous) tubing and turning the IV pump off. Staff A did not have gloves or gown on. There was a signage on the resident's room that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene,…
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 · D2024-04-26 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
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 received copies of their medical records in a timely manner for 1 of 3 residents reviewed, Resident #1. Findings include: During an interview on 4/26/2024 at 11:26 AM, Resident #1's Daughter stated, I still have not received the medical records. I requested them in January 2024 and still get excuses. Review of the Durable Power of Attorney signed by Resident #1 on 7/28/2004 showed the resident appointed Resident #1's Daughter as the attorney-in-fact to manage all her affairs. Review of the email communication between Resident #1's Daughter and the Admissions Assistant dated 3/4/2024 read, I am touching base back with you since I had the meeting with the care plan staff on [DATE]. I discussed a few things and asked some questions that I have not gotten a response to yet . 2. Where are the copies of my dad's medical records that I have already requested to you since there has not been a medical records staff person yet? Review of email…
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 6 citations
- Potential for harm · Ecited before2023-06-07 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 record review, observation, and interview the facility failed to ensure residents were provided treatments, wound care, and services in accordance with professional standards of practice and physician orders for 4 of 8 residents, Residents #18, #274, #80, and #113. Findings include: 1) Review of Resident #18's medical record documented the resident was admitted on [DATE] with medical diagnosis to include lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), congestive heart failure (heart does not pump well), respiratory failure (difficult to breath), diabetes mellitus, chronic kidney disease, abnormalities of gait and mobility, and atrial fibrillation (irregular heartbeat). Review of the physician order dated 4/13/2023 for Resident #18's documented, Apply ace wrap to bilateral lower extremity every day shift for chronic edema. Review of Resident #18's care plan dated 3/30/2023 read, Focus: Potential for complications r/t [related to] an alteration in cardiac function.…
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 · E2023-06-07 · 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 observations, interviews, and policy review, the facility failed to ensure stored food is labeled and dated, thawed according to professional standards, and that food is distributed in a safe manner. Findings Include: During a walk-through tour of the kitchen on 6/04/23 at 09:16 AM with the morning cook, an observation was made in the walk-in cooler in the kitchen of a large pan of what appeared to be diced chicken; the food item was not labeled identifying the content or dated and a quart size container with what appeared to be gravy or sauce that was not labeled identifying the contents or dated. An interview was conducted with the morning cook on 6/04/2023 at 9:20 AM. The cook stated, That is a large pan of chicken, and the quart container was breakfast gravy, and both items should have had a label and date. An observation was made on 6/04/23 at 9:25 AM of four 5# (pound) rolls of raw ground beef being thawed in a prep sink of 12 of standing water. An interview was conducted with the Dietary Manager (DM) on 06/04/2023 at 10:00 AM regarding thawing of frozen foods. The DM…
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 before2023-06-07 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 ensure residents' medical records were complete and accurately documented for 7 of 12 residents, Residents #44, #54, #18, #274, #80, #85, and #113. Findings Include: 1) Review of the Health Status Note dated 5/16/23 at 11:09 PM [eINTERACT form] for Resident #54 read, At approximately 2200 [10:00 PM] this writer was notified by the CNA [Certified Nursing Assistant] that resident was not responding. On arrival to the residents room resident was noted laying on the bed with eyes closed and mouth breathing. Resident was not wearing her O2 [oxygen] as ordered. Pulse ox noted to be 76. B/P [blood pressure] noted to be 179/78 with HR [heart rate] at 104. Or [sic] at 5L [liters] via non-rebreather mask was applied O2 noted to increase to 91%. Resident remained unresponsive. Accu check was performed and noted to be 25. Glucagon injection administered and 911 called. Resident transported to [Hospital's name] for further eval. Review of Resident #54's Nursing Home to Hospital Transfer Form dated 5/16/2023 at 11:17 PM read, Key…
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 · D2023-06-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 3 of 7 residents, Residents #12, #80, and #113, reviewed for respiratory services Findings include: 1) Review of Resident #12 medical record documented the resident was re-admitted into the facility on 5/12/2023 with diagnosis to include pneumonia, emphysema, chronic obstructive pulmonary disease, respiratory failure, diabetes, abnormal finding of lung field, hypertension, anemia. During an observation on 6/4/2023 at 11:33 AM Resident #12 was being administered oxygen via nasal cannula at 2 liters per minute. During an interview on 6/4/2023 at 11:33 AM Resident #12 stated, My oxygen is set at 3. During an observation on 6/5/23 at 11:59 AM Resident #12 was sitting in a wheelchair. Oxygen was being administered at 3 liters per minute via nasal cannula. Review of Resident #12's physician's orders did not document an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-07 · 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 — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to store medications under proper temperature for 1 of 4 medication carts. Findings include: During an observation on 6/6/23 at 3:15 p.m. of the medication cart for the 300 Hall, a bag of intravenous bag of Vancomycin 1.75 GM/500 ML D5W [1.75 grams/500 milliliters dextrose 5% water] dated 6/4/23. a use by date of 6/13/23, labeled for Resident #44 was located in the bottom drawer of the medication cart. The solution was at room temperature. There was no condensation on the bag. There was no indication the bag had been refrigerated. There was no date or time on the bag indicating when the bag was removed from the refrigerator. During an interview on 6/6/23 at 3:15 p.m. Staff F stated, I gave the 8:00 a.m. dose of Vancomycin. I don't know where this bag came from. I had not noticed it in the cart until just now. Vancomycin must be refrigerated. I did not take that bag out. I don't know how long it has been in the cart. During an interview on 6/7/23 at 8:17 a.m. the Consultant Pharmacist stated, Vancomycin is always refrigerated.
- Potential for harm · Dcited before2023-06-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for 1 of 3 residents reviewed, Resident #1. Findings include: During an observation conducted on 06/04/23 at 11:10 AM, Resident #1's catheter bag was lying on the floor next to the bed without a protective barrier between it and the floor. Review of Resident #1's clinical record documented Resident #1 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis of vertebra, sacral and sacrococcygeal, sepsis, pulmonary embolism, type II diabetes mellitus, protein calorie malnutrition, and neuromuscular dysfunction of bladder. Review of Resident #1's physician orders dated 6/5/23 read, insert/maintain indwelling catheter (14 French), change indwelling catheter for leakage or blockage as needed, catheter care every shift and as needed for soiling or leakage. Review of Resident #1's care plan dated 4/24/23 read, Focus: Resident has a urinary catheter with interventions including…
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
$13,674 in federal fines across 1 penalty.
- $13,674 — penalty dated 2024-01-22
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| TERRACE SNF HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/27/2022 |
| MATHURIN, LISENA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 106046. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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.