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Boca Ciega Center

1414 59th St S, Gulfport, FL 33707 · For profit - Corporation · 120 certified beds · (727) 344-4608 Medicare & Medicaid certified

Call the home — (727) 344-4608 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$13,520 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,520 in federal fines (most recent 2026-03-25)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5709 1st Ave S · (727) 341-7676 · Call to confirm hours
Pharmacy
5701 Gulfport Blvd S · (727) 344-3701 · Call to confirm hours
Grocery
5227 Gulfport Blvd S · (772) 672-6000 · Call to confirm hours
Park
1820 55th St S · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.3%8.7%15.4%better
Long-stay residents who lose too much weight3.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.0%2.5%3.3%better
Long-stay residents whose ability to walk worsened7.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.0%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers6.2%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control6.2%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 table11.9%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.7%94.7%79.4%better
Short-stay residents rehospitalized after admission22.4%26.1%22.6%typical
Short-stay residents with an outpatient ER visit7.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.232.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.781.151.80better

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

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

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

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

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

26.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

26.3%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
57.4%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 57.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 68 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF26.3%CMS range 13.2–41.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.7–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.3%CMS range 4.6–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.321.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
0.50
LPN hours/ resident / day
2.00
Aide hours/ resident / day
3.17
Total nurse hours/ resident / day
0.45
RN hoursweekends
52.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 105.2 residents a day — about 88% occupied, or roughly 15 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 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 2.97 hrs/resident/day on weekends vs 3.25 on weekdays — 9% thinner on weekends. RN hours go from 0.76 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

12
deficiencies at the latest standard inspection (2024-05-02)
12
at the previous standard inspection (2022-02-17)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2026-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent resident to resident altercation for two (#5 & #6) of thirteen sampled residents. Findings included: A review of Resident #6's admission record showed an admission in 02/2020. The diagnosis information included: chronic pain syndrome; neuromuscular dysfunction of bladder; muscle wasting and atrophy not elsewhere classified; idiopathic progressive neuropathy; generalized anxiety disorder; bipolar disorder; type 2 diabetes; atherosclerotic heart disease of native coronary artery without angina pectoris; . A review of Resident #6's BIMS, dated 02/03/2026, documented a score of 14, which indicated cognitively intact. A review of Resident #5's admission record showed an admission of 01/05/2026. The diagnosis included: cerebral infarction; dysarthria following cerebral infarction; encephalopathy; difficulty in walking; unspecified dementia without behavioral disturbance; psychotic disturbance, mood disturbance and anxiety; cognitive communication deficit; . A 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility did not ensure timely Activities of Daily Living (ADL) related to incontinence care for two (#1 and #2) of three residents. Findings include: On 8/08/2024 at 10:30 a.m., an interview and observation were conducted with Resident #2 in his room. Resident #2 was in his bed and when asked when was the last time his incontinence needs were addressed, he stated last night and agreed no one had come in this morning to change him. Resident #2 agreed he needed incontinence care now. On 8/08/2024 at 11:00 a.m., an interview and observation were conducted with Resident #1 in her room. She stated the last time she had her incontinence care addressed was 3:30 a.m. and currently was waiting for her morning needs to be met. Resident #1 agreed she was wet and in need of incontinence care stating, they will get around to it eventually, they are so busy. Resident #1 agreed she felt uncomfortable in her briefs but stated, there is nothing I can do about it. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and policy review the facility failed to ensure a clean and sanitary kitchen on three of three observations regarding areas that were not clean or were in disrepair. Finding included During an observation on 4/29/2024 at 11:00 a.m. showed on an initial tour in the kitchen a dirty trash can next to the hand washing station. Food trays were observed piled up on kitchen sink, next to the hand washing station during meal preparation. Dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up kitchen visit on 04/31/2024 at 11:00 a.m., showed the kitchen stove dirty with grease stuck on the side of the stove and missing stove knobs covers. An open garbage can was observed next to cooked food on the stove. The kitchen floor was observed dirty multiple times throughout the survey. During an interview on 5/3/2024 at 2:00 p.m., with the Certified Dietary Manager, CDM. She stated that there are areas in the kitchen that need to be cleaned up. She has tried to clean the walk-in refrigerator floor, but it is very hard to clean…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms, during four days (4/29, 4/30, 5/01, and 5/02/24) of four days observed, in three of four hallways observed. Findings included: 1) On 4/29/2024 at 9:53 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the middle drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the bottom drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:00 AM the door to the bathroom in the occupied room [ROOM NUMBER] was observed with a cylindrical metal piece protruding from where the doorknob should be. No doorknob was found. (Photographic Evidence Obtained). On 4/29/2024 at 10:08 AM the wall behind the occupied bed of 415 A was observed with a deep gouge in the drywall, leaving a hole in the wall behind the bed. The head of the bed was resting on the wall and floor, not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-02 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility 1) failed to revise and review one resident (#60) care plan with the appropriate staff/professionals and resident out of forty-one sampled residents, 2) failed to review and revise the care plan for four residents (#55, #1, #47, and #85) related to psychotropic medications, falls, activities of daily living (ADL), and range of motion (ROM) out of forty-one sampled residents. Findings included: 1. Review of Resident #60's admission Record revealed the resident was initially admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, unspecified peripheral vascular disease, and unspecified sequelae of cerebral infarction. During an interview on 4/30/24 at 9:46 a.m., Resident #60 reported no participation in care planning meetings and stated, They're supposed to do all that?, then began chuckling and clapping hands. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE],…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-02 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to provide restorative therapy related to applying splints for Resident #30 and did not prevent the further decrease in range of motion for Resident #85 out of twelve residents. Findings included: On 04/29/24 at 10:25 a.m., an observation was made of Resident #30 in his room with his eyes closed. Resident #30 had a blanket covering his body from chest to feet with his arms on top of the blanket. Resident #30's hands were in a curled loose fist bilaterally on top of his chest. Record review of Resident #30's admission Record had an original admission date of 6/30/2018 with a readmission date of 04/15/2024. Resident #30 has a primary diagnosis of Multiple Sclerosis (MS) with secondary diagnoses to include but not limited to aphasia and dysphagia following nontraumatic subarachnoid hemorrhage, major depression, and contracture of muscle multiple sites. A record review of Resident #30 physician orders shows orders for Physical/Occupational and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-02 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure medication was administered in a clean manner, ensure staff doffed PPE (personal protective equipment) appropriately, and residents were offered hand hygiene prior to meals. Findings included: On 4/30/24 at 11:00 a.m., an observation was made of the main dining area prior to lunch service of residents self-propelling with their arms to dining tables. Staff were present waiting for lunch tray delivery and/or bringing residents to the dining area. Residents were not offered hand hygiene prior to the delivery of lunch. The Activities Director was witnessed washing a resident's hands with a wet paper towel and then sitting next to this resident to assist with feeding. On 5/01/23 at 1:38 p.m., an observation was made during incontinence care of two Certified Nursing Assistants (CNAs) and a resident on Enhanced Precaution Isolation. Both CNAs were wearing appropriate personal protective equipment (PPE) during the care provided 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to accommodate the needs for one resident (#85) related to placing the call light within the resident's reach out of six residents sampled for environmental concerns. Findings included: On 4/29/2024 at 9:58 AM Resident #85 was observed in the bed, facing the ceiling, arms crossed at the waist. The call light was around the bed rail on the left side near the head of the bed. Resident #85 was on an air mattress with a perimeter cover, in front of the bed rail. Resident #85 was not able to reach the call light when requested. An interview was conducted with Staff S, Licensed Practical Nurse (LPN) on 4/29/2024 at 10:00 AM. Staff S, LPN confirmed Resident #85 uses the call light and call lights should be within the resident's reach. Staff S, LPN confirmed Resident #85's call light was not within reach. Staff S, LPN assisted resident and placed the call light within the resident's reach. On 4/29/2024 at 3:15 PM Resident #85 was observed in the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#81 and #13), were provided with Activity of Daily Living(ADL) assistance related to hair and fingernail care out of forty one sampled residents. Finding Included: 1. During an observation on 04/29/2024 at 11:00 a.m., Resident # 81 was observed laying down in bed dressed in his nightgown with his call light within reach. Resident # 81 fingernails were observed long and dirty and he had thick facial hair. Resident # 81 stated he has asked staff to cut his hair and his fingernails, but they will not assist him. During an observation on 04/30 /24 at 02:24 PM Resident #81 was observed laying down in bed with his call light in reach, dressed in his nightgown. Resident # 81 said he has asked his aide to cut his facial hair and his fingernail, but she did not assist him with his care. Review of an admission Record, dated 05/02/2024, showed Resident #81 was admitted initially on 06/17/2023 and readmitted 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the failed to ensure two residents (# 68, 13) residing on the same hall were provided with activities out of eight residents sampled. Finding Include: 1.During an observation made on 04/29/2024 at 10:00 a.m., 11:30 a.m., and again at 3:00p.m., Resident# 68 was observed in bed, leaning off the side of her bed. Resident # 68 was dressed in her nightgown, with her call light out of her reach. During an observation made on 04/30/24 at 9:00 a.m. and 11:30 a.m., Resident # 68 was observed in bed, dressed in a nightgown with her call light out of reach. Resident # 68 was observed leaning to the side. Review of an admission Record dated 05/02/2024 showed Resident # 68 was admitted on [DATE] with diagnoses to include but not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Cognitive Communication Deficit, Need for assistance with Personal Care Review of a Minimum Data Set, MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to assess and obtain physician orders for the wounds of two (#60 and #45) out of three residents sampled for skin conditions. Findings included: 1. On 4/30/24 at 9:51 a.m., Resident #60 was observed lying in bed and a tan-colored foam dressing was observed covering the left below the knee amputation (LBKA), the dressing was dated 4/28 11-7 and initialed, EC, with a pencil eraser-sized discoloration. Photographic evidence was obtained. On 5/1/24 at 2:22 p.m., Resident #60 was observed sitting in wheelchair and stated the dressing (to LBKA) had not been changed. The resident reported yesterday's nurse stated the 11 p.m. - 7 a.m. (11-7) shift nurse was going to change it. The dressing was observed and continued to be dated 4/28 11-7 EC with a pencil eraser-sized discoloration. Photographic evidence was obtained. Review of Resident #60's evaluations did not show a Change of Condition or Wound evaluation had been completed on 4/28 in regards to the skin condition covered by the dressing covering the LBKA. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2024-05-02 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (#53) out of eight residents related to timely assessment and vital signs post dialysis. Findings included: A record review of Resident #53's admission Record has an original admit date of 05/24/2021 with a readmission date of 03/16/2024. Resident #53 has a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Secondary diagnoses include but are not limited to end stage renal disease requiring dialysis, Type 1 diabetes mellitus with diabetic autoimmune polyneuropathy and personal history of other venous thrombosis and embolism. A review of physician orders for Resident #53 include resident to have dialysis on days: Monday, Wednesday, Friday dialysis center, document vital signs upon resident returning from dialysis every Monday, Wednesday and Friday, monitor for signs and symptoms of bleeding, notify MD (physician) of bleeding, monitor for bruit and thrill AV (Arteriovenous) shunt…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-02 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to obtain blood pressures for one (#60) out of 5 residents sampled for unnecessary medications related to the physician ordered vasodilator, Hydralazine. Findings included: On 05/1/24 at 8:06 AM, Resident #60 was observed lying in bed with eyes closed. Review of Resident #60's admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to essential (primary) hypertension and unspecified sequelae of cerebral infarction. Review of Resident #60's March Medication Administration Record (MAR) revealed the following physician orders related to the resident's diagnosis of hypertension: - Hydralazine hydrochloride (HCL) 25 milligram (mg) - Give 25 mg by mouth every 8 hours as needed for Hypertension (HTN) related to essential (primary) hypertension, for systolic blood pressure (SBP) greater than 160. Ordered 8/31/23. - BP and pulse weekly every evening shift every Sunday (Sun)…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to ensure medications were stored in a safe and secure manner and failed to ensure medications were discarded after manufacturer expiration date and failed to label medications with shortened shelf lifes with open dates. Findings included: On 4/29/24 at 11:45 a.m., Resident #29 was observed with a bottle of eye drops, for the relief of redness of the eye due to minor eye irritant, on the over-bed table next to the resident's bed and on the bedside dresser was a bottle of nasal spray with a large green top. The resident stated the nasal spray did not work. Review of Resident #29's physician orders revealed an order for Fluticasone Propionate Nasal Suspension 50 microgram (mcg/act) - 1 spray in both nostrils one time a day for allergic rhinitis. The review did not reveal an order for any eye drops. Photographic evidence was obtained. On 4/30/24 at 9:51 a.m., Resident #60 was observed and interviewed in the resident room. The observation revealed on top of the bedside dresser was a large jar of 1% Silver…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-02-17 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews and record review, the facility failed to treat residents with respect and dignity as evidenced by five staff members (A, B, D, E, F) failing to knock or announce themselves prior to entering occupied resident rooms in two halls (300 and 400) of four halls for four of four days observed (2/14/2022, 2/15/2022, 2/16/2022, and 2/17/2022). Findings include: During the days from 2/14/2022 to 2/17/2022 staff were observed to not consistently knock, announce or identify themselves prior to entering occupied resident rooms. The observations were as follows: - On 2/14/2022 at 10:08 a.m., Staff A, Certified Nursing Assistant (CNA) was observed to walk in resident room [ROOM NUMBER] and did not first knock and or announce herself. There were two residents in the room at the time. - On 2/14/2022 at 10:14 a.m. Staff B, CNA was observed to walk in resident room [ROOM NUMBER] without first knocking or announcing herself. There were two residents in the room at the time. - 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-02-17 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure activities were provided for seven dependent residents (#64, #83, #10, #39, #72, #66, and #75) on one hall (Hall 200) of three halls out of a total of twenty one sampled residents. Findings include: On 02/14/22 at 10:19 a.m. and 1:21 p.m., Resident #64 was observed in her room, lying on the bed. Resident #64 was non-verbal and dependent on staff for all activities of daily living (ADLs). Resident #64 was observed not engaged in any activities or receiving interaction from staff. On 02/14/22 at 2:28 p.m. seven dependent residents on Hall 200 (Resident #64, #10, #75, #72, #39, #66 and #83) were observed to be in bed, without staff interaction. Review of the electronic medical records (EMR) for the residents showed the following: An admission Record for Resident #64 showed she was admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-17 · tag F0885 — failed to notify residents/families about COVID-19 — pattern
    Report COVID19 data to residents and families.
    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 inform representatives of five residents (#34, #9, #54, #93, & #69) of positive cases of COVID-19 in the facility on eight days (1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22) by 5 p.m. the next calendar day, out of five residents sampled for notification of COVID-19 status. Findings include: Review of the facility's listings for COVID-19 positive staff and residents revealed positive COIVD-19 cases documented on 1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22. Review of five resident (#34, #9, #54, #93, & #69) medical records for notification of families or representatives by 5:00 p.m. the next calendar day for January 2022 did not show notification by mail was received by 5:00 p.m. the next day. Review of the medical records for notification of positive COVID-19 cases showed: Resident # 69's family member was notified last on 1/5/22 of a positive COVID-19 case. Resident #34's family member was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure a change in condition was identified and addressed in a timely manner for one resident (#83) of fifty sampled residents. Findings include: During a facility tour on 02/14/22 at 9: 53 a.m., Resident #83 was observed in his room laying on the bed. His roommates were observed eating their breakfast meal. Resident #83's breakfast tray was noted untouched. Resident #83 did not eat anything from his tray, and staff assistance, supervision or cueing was not observed. On 02/14/22 at 10:05 a.m., Resident #83 was observed from the doorway, noted to be throwing up. Emesis was observed on his gown and bed linens. Staff O, Certified Nursing Assistant (CNA) and Staff P, Registered Nurse (RN) were notified. An immediate interview was conducted on 02/14/22 at 10:08 a.m. with Staff O, after responding to Resident #83. Staff O stated, He makes himself throw up and then hides it. Staff O said this had been going on since the resident was admitted to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to identify and develop a care plan with problem areas, goals, and interventions to include the use of an antibiotic and diagnosis of a Urinary Tract Infection (UTI), timely, for one (#62) of fifty sampled residents. Findings include: On 2/15/2022 at 1:45 p.m. Resident #62 was observed in his room. The side of the bed was observed with a properly placed urinary catheter drain bag, and catheter tubing. In a subsequent interview, Resident #62 revealed he currently had a Urinary Tract Infection and was receiving antibiotics; he could not remember how long he had been on antibiotics. On 2/15/2022 at 2:00 p.m. an interview with Staff I, Unit Nurse confirmed Resident #62 was recently readmitted from the hospital and is being treated with an antibiotic for a UTI. On 2/16/2022 at 10:00 a.m. an interview with the Staff T, 300/400-Unit Manager also confirmed Resident #62 had a UTI and is receiving antibiotics. Review of Resident #62's medical record…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to update and revise a care plan to reflect non-use of an antidepressant for one (#81) of fifty sampled residents. Findings include: On 2/16/2022 at 7:30 a.m. Resident #81 was observed in her room. She did not present with any behaviors, pain, or discomfort. Resident #81 was pleasant to speak with and had no immediate concerns. Review of Resident #81's medical record revealed she was admitted to the facility on [DATE], with diagnoses to include but not limited to: Adult Failure to Thrive, Need for assistance with personal care, Abnormality of gait, Depression, Insomnia. Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/21/2022 revealed: -Cognition/Brief Interview for Mental Status (BIMS) score - 15 of 15, indicating intact cognition, -Behaviors - None exhibited, -Mood - None exhibited, ADL (activities of daily living) - Extensive to total care with most to all ADLs to include Toilet use Total dependence with one…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and medical record review, the facility failed to ensure nail care was provided for one resident (#87) of five sampled residents reviewed for assistance with activities of daily living (ADLs). Findings include: On 2/14/2022 at 9:55 a.m., and 1:00 p.m. Resident #87 was in his room in bed and all fingernails, on both his left and right hands, were observed to be elongated approximately three quarters of an inch to one inch in length past the tips of the fingers. Further observation revealed built up brown matter beneath all ten of the fingernails and some of the nails appeared cracked, peeling, and with sharp edges. Resident #87 explained he could pretty much do everything on his own to include showering, dressing, moving out of bed, eating, and personal hygiene. However, when asked about his fingernails, he explained, I would cut them myself but they won't give me scissors to cut my hair and won't give me clippers to cut my nails because they think I will hurt…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure four (#4, #54, #69 and #93) of fifty sampled residents received comprehensive skin assessments weekly in accordance with professional standards, and facility policy. Findings include: 1. An observation of Resident #4 on 2/15/22 at 11:28 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. An observation of Resident #4 on 2/16/22 at 8:10 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. During an interview and observation of Resident #4 on 2/16/22 at 1:40 p.m. with Staff L, Licensed Practical Nurse (LPN), the LPN stated the resident's leg had a lot of dryness and she had lotion ordered three times a day. The LPN said they document weekly skin checks on her condition. Review of physician orders for Resident #4 revealed: -Lac-Hydrin lotion 12% (ammonium lactate) apply to affected areas topically every shift for dry skin dated 4/23/21. Review of the treatment administration record (TAR) for February 2022, documented the resident receiving the lotion every…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 one resident (#67) received services to maintain or promote further range of motion of a contracture related to the application of hand, elbow, knee, and boot splints for four days (02/14/22, 02/15/22, 02/16/22 and 02/17/22) of four days observed of a total sample of 29 residents with contractures. Findings include: On 02/14/22 at 10:31 a.m. Resident #67 was observed in his room, lying in bed. Resident #67's left hand appeared contracted and was positioned on his chest area. Resident #67 was not wearing a splint on his left hand during the observation. Further observation revealed blue, gray and black splints on top of the dresser in Resident #67's room. On 02/14/22 at 11:23 a.m. another observation was made, and the splints were observed again, on top of the dresser. (Photographic Evidence Obtained) On 02/15/22 at 9:38 a.m. Resident #67 was observed in his room, lying in bed. Resident #67 stated the splints had not been applied at any time yesterday. The splints were observed again, on top of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (#4) received care and services to prevent a urinary tract infection of three residents sampled. Findings include: An observation of Resident #4's catheter on 2/15/22 at 11:41 a.m. revealed yellow urine draining into a patent catheter. An observation of Resident #4's catheter on 2/16/22 at 8:10 a.m. revealed the catheter draining yellow. An observation of Resident #4's catheter and interview with Staff L, Licensed Practical Nurse (LPN) on 2/16/22 at 1:45 p.m. confirmed the catheter bag and tubing turned deep purple. The urine was amber in color. During an interview and observation with the Director of Nursing (DON) on 2/16/22 at 4:41 p.m. she confirmed they were calling the doctor to get an order for a urinalysis and would change the catheter bag. The DON stated she would have expected documentation about the catheter changing to purple. The DON confirmed her expectation was the documentation would indicate the color 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 ensure respiratory care was consistent with professional standards of practice for one resident (#9) of three sampled residents. Findings include: An observation of Resident #9 on 2/15/22 at 10:08 a.m. revealed the resident was on 3 liters of oxygen via a nasal cannula. An observation of Resident #9 on 2/15/22 at 4:40 p.m. revealed the resident sitting up in bed with the head of bed at 45 degrees and revealed the resident was on oxygen via a nasal cannula infusing at 3 liters. An observation of Resident #9 on 2/16/22 at 8:49 a.m. revealed the resident using a nasal cannula with foam around the ears, infusing at 2 liters. An observation of Resident #9 on 2/16/22 at 10:37 a.m. revealed the resident was sitting up in bed with a nasal cannula with foam around her ears and infusing 2 liters of oxygen. At this time, Staff K, Certified Nursing Assistant (CNA) confirmed the resident wore the nasal cannula with foam around her ears, an infusing the oxygen all the time. An observation and interview with Staff L,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-17 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure medical records were complete and accurate for one resident (#69) related to hospice care of fifty sampled resident records. Findings include: Review of the Order Summary Report as of 2/17/22 revealed Resident #69 had an active physician order for: Resident followed by [Hospice Provider Name] for diagnosis of Adult Failure to Thrive, dated 10/20/21. Review of the care plan focus area initiated on 10/20/21 revealed the resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis: adult failure to thrive. Interventions included: collaborate with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, initiated on 10/20/21; Hospice to provide supplemental services per order/ plan of care. (See hospice documentation for more detail.) initiated on 10/20/21; Notify physician/hospice for change in condition, initiated on 10/20/21. Review of progress notes dated 12/8/21 revealed Resident #69…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-12-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a dignified existence for two residents (#3 and #39), with impaired cognitive status and communication deficits, of seven residents, related to direct care staff standing over the residents while assisting them with eating for two of two days. Findings included: During an observation on 12/08/20 at 12:27 p.m., Resident #3 and Resident #39 were seen sharing the same room. Staff A, Licensed Nurse Practitioner (LPN) entered [Room Number] and stood beside Resident #3 with a meal tray. Resident #3 was lying in bed under the covers with her bed in a low position. Staff A placed the meal tray onto the side table and adjusted Resident #3's bed into the highest position and lifted the headboard upwards. Staff A prepped Resident #3's tray and began assisting her with eating by bringing the fork to her mouth. Staff A remained standing. Simultaneously, Staff E, Certified Nursing Assistant (CNA) entered the room and asked Resident #39 if she…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-12-10 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate and timely completion of grievance reporting, documentation, and resolution for three residents (#2, #51, and #63) of three residents related to maintenance, repair, and replacing of electric wheelchairs and missing personalized wheelchair equipment and an assistive walking device. Findings included: 1. An observation on 12/09/20 at 11:04 a.m. revealed two electric wheelchairs in the [Unit Number] hallway with blue tarps covering them. An interview with Staff A, Licensed Practical Nurse (LPN) revealed the wheelchair on the left belonged to a resident who was recently discharged to the hospital. Staff A was unable to identify who the second electric wheelchair belonged to and stated she would need to speak with someone to find out. Staff A walked away and returned a moment later with the Social Services Director (SSD). The SSD stated she knew the electric wheelchair on the left belonged to a resident who was discharged to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-12-10 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility did not ensure that four vials of a Schedule IV medication, Ativan, were stored in a locked, permanently affixed compartment for one medication storage room (300/400 hall) of two medication storage rooms sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 12/9/2020 at 3:55 p.m. Staff G, Registered Nurse (RN), and Staff H, RN accommodated the observation of the locked medication storage room located behind the nurse's station between the 300 hall and 400 hall. The refrigerator in the room was not locked and contained a locked plastic box that contained four vials of Ativan 2mg/ml (milligram/milliliter), a Schedule IV medication. (photographic evidence obtained). The plastic box was not permanently affixed and was easily removed from the refrigerator. Staff G, RN, and Staff H, RN were then asked if they were aware that Schedule II-V medications stored in the refrigerator were to be stored in a locked, permanently affixed compartment. Staff G, RN replied that she…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-12-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 that annual influenza vaccine was offered to one (Resident #73) out of five sampled residents. Findings included: Record review of Resident #73's medical record revealed no documentation regarding influenza vaccination. There were no orders or administration record for vaccination, no documentation that the vaccination was offered, and no documentation that the vaccination was declined. The admission Record revealed an admission date of 10/26/20 and a readmission date of 11/5/2020. On 12/10/20 at 10:48 a.m. the facility Director of Nursing (DON) was interviewed about the facility influenza vaccination program. She confirmed that attempts were made to offer the vaccine to all residents starting at the end of September 2020 and the beginning of October 2020. She stated that the corporation had required for all residents to be offered the vaccine by the beginning of November 2020, that the facility had met that goal, and that currently efforts were ongoing to re-offer the vaccine to anyone who had refused it. The DON…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$13,520 in federal fines across 1 penalty.

  • $13,520 — penalty dated 2026-03-25

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 HEARTHSTONE SENIOR COMMUNITIES — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 1 of 51.7-0.7 vs chain
Staffing 3 of 52.6+0.4 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 7 homes this chain runs (chain average 1.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BOCA CIEGA REHABILITATION CENTER LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2009
HEARTHSTONE SENIOR COMMUNITIES, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/01/2009
GARNER, ALVINIndividualCORPORATE OFFICERsince 04/01/2009
JAFFE, HOWARDIndividualCORPORATE OFFICERsince 04/01/2009
ROMBOLD, LORIIndividualCORPORATE OFFICERsince 04/01/2009
WYATT, BRIANIndividualCORPORATE OFFICERsince 04/01/2009
CONSULTING SUPPORT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2025
FACILITY SUPPORT COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/19/2025
KANE FINANCIAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/19/2025
THEMIS HEALTH MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/07/2025
DAVIS, DANNYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2020
WILSON-SAWYERS, DEONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/05/2021
OMEGA HEALTHCARE INVESTORS, INCOrganizationADP OF THE SNFsince 07/01/2003
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 08/19/2016

CMS files one row per role, so the 21 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$11.3M
Net patient revenuemost recent cost report
-3.2%
Operating marginrevenue minus expenses
$210K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 9%Other / private 8%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $210K 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

$345per resident / day
operating cost
$10,497per month
≈ monthly operating cost
$335per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105271. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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