Golfcrest Nursing Center
600 North 17th Ave, Hollywood, FL 33020 · Non profit - Corporation · 67 certified beds · (954) 927-2531 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,755 in federal fines (most recent 2025-04-10)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 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 | 0.5% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| 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 | 0.0% | 2.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 12.5% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.2% | 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 | 4.5% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 10.6% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.1% | 8.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.2% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.8% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 4.83 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.50 | 1.15 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 53.9% 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 26 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 0.32 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.1–16.5 | 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 | 53.9% | 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 | 57.7% | 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 | 46.1% | 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 | 90.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 3.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 67 beds and averages 59.1 residents a day — about 88% occupied, or roughly 8 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.40 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.59 hrs/resident/day on weekends vs 3.74 on weekdays — 4% thinner on weekends. RN hours go from 1.48 to 1.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%. 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-04-10 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide nutritional assessments and interventions in a timely manner which resulted in significant weight loss for 1 of 1 sampled resident (Resident #51); The facility also failed to follow tube feeding Physician's orders for 2 of 5 sampled residents (Resident #167 and Resident #169). The findings included: A review of the facility's policy titled Weighing and Weight at-risk Protocol and revised in March 2020 showed the following: Weights: Nursing to complete all weights with reweights on the following parameters: 0-175 pounds - variances of 4 pounds - loss or gain. Identification: When all weights (weekly and monthly) are completed, the Dietary Department will review weights for significant weight loss and at risk weight loss and determine variances with reweights as noted above. The Dietary Department will notify nursing staff of significant and at risk residents the next day during the morning meeting. Investigation: The Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-21 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 review of policy and procedure, interview and record review, the facility failed to timely order to obtain and document proper admission physician orders for immediate care involving surgical site and Foley catheter care, and for pain medication for a resident; re-assess and document a resident's pain level; and administer routinely ordered medications to a resident, for 1 of 2 sampled residents reviewed for admission orders after surgery, Resident #1. The findings included: Review of the facility policy and procedure titled, Pain Observation and Record, provided by the Director of Nursing (DON) reviewed April 21, 2021, documented in the Policy Statement: Pain Observation and Record UDA will be completed on every resident as part of the admission process. Pain will be re-observed and recorded any time a resident states that his/her pain level has changed/when pain medication or dosage is changed, or anytime the resident's condition significantly changes. Purpose: The management of pain is essential 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.
- Potential for harm · D2025-04-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 ensure call lights are within reach for 2 of 20 sampled residents (Residents #2 and #10). The findings included: 1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Osteoarthritis Left Knee, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side, Pain and Muscle Weakness (Generalized). The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. On 04/07/25 at 9:15 AM an observation was made of Resident #10 sitting up in bed with the call light draped behind the head of the bed and out of the reach of the resident. On 04/07/25 at 11:15 AM an observation was made of Resident #10 being assisted by a staff member while in bed. The call light continued to be in the same place, draped over the head of the bed and inaccessible to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 and interviews, the facility failed to ensure the residents have a right to a safe, clean, comfortable and homelike environment for 6 of 27 resident rooms observed in the facility. The findings included: 1). On 04/07/25 at 9:20 AM an observation made in room [ROOM NUMBER] A revealed the following: *The wall behind the bed, was noted to be unsmooth and peeling paint. *The standing fan across from the resident's bed was covered with dust and debris. 2). On 04/07/25 at 11:30 AM an observation made in room [ROOM NUMBER] revealed an uncovered fluorescent bulb in the entryway, inside of the room. 3). On 04/07/25 at 11:40 AM an observation made in room [ROOM NUMBER] revealed the following: * An uncovered fluorescent bulb in the entryway, inside of the room. * The A/C vents were covered with dust and debris. * The lightbulb in the bathroom was out. * Unpainted plaster on the bathroom wall, next to the soap dispenser *A leaky faucet in the bathroom sink. 4). On 04/07/25 at 11:30 AM an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for pressure ulcer for 1 of 1 sampled resident reviewed for pressure ulcer (Resident #37) and failed to develop and implement a comprehensive person-centered care plan for psychotropic medication for 1 of 1 sampled resident reviewed for Mood/Behavior (Resident #59). The findings included: 1. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Type 2 Diabetes Mellitus, Muscle Weakness, and Unspecified Abnormalities of Gait and Mobility. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #37 revealed an order dated 04/04/25 for sacrum pressure ulcer stage 1 cleanse with normal saline (N/S), pat dry, apply calcium alginate daily and PRN (as needed)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, record review and interview, the facility failed to: 1) promptly notify the ordering physician and promptly administer oral Antibiotics to a resident, in a timely manner, for a resident with a Urinary Tract Infection (UTI) for 1 of 1 sampled resident (Resident #16); and, 2) failed to accurately document and assess the status and condition for a resident with a skin condition for 1 of 1 sampled resident (Resident #2). The findings included: 1) Record review of the facility policy and procedure titled General Laboratory Information provided by the Director of Nursing (DON), reviewed 2024, documented in the Policy Statement: Communicating Urgent Results Notification will be provided to the Principal Investigator, Physician, or his/her authorized representative, as permitted or required by state and federal law, and these authorized personnel will have the responsibility of interpreting the result (s) in the context of the patient's clinical condition. The authorized…
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 · D2025-04-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 1 sampled resident reviewed for pressure ulcers (Resident #37). The findings included: Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Type 2 Diabetes Mellitus, Muscle Weakness, and Unspecified Abnormalities of Gait and Mobility. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #37 revealed in part the following orders: *An order dated 02/06/24 Weekly skin assessment every Tuesday 7:00 AM to 7:00 PM Shift. *An order dated 04/04/25 for sacrum pressure ulcer stage 1 cleanse with normal saline (N/S), pat dry, apply calcium alginate…
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 · D2025-04-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications for 2 of 5 sampled residents reviewed for Unnecessary Medication (Resident #1); for 1 of 1 resident sampled residents reviewed for Mood/Behavior (Resident # 59); and failed to ensure adequate monitoring of side effects of residents prescribed anticoagulants (blood thinner) for 1 of 1 sampled residents reveiwed for Unnecessary Medications (Resident #45). The findings included: 1. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Degenerative Disease of Nervous System Unspecified, Pain, Restless Agitation, and Depression. The Minimum Data Set assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status could not be done due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #59 revealed in…
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 · D2025-04-10 · 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 review of policy and procedure, observation, interview and record review, the facility failed to wear or don appropriate personal protective equipment (PPE), preventing infection control, during high-contact resident care activity for 1 of 1 sampled resident observed for Indwelling Urinary Catheter, Resident #171. The findings included: Record review of the facility policy and procedure titled Enhanced Barrier Precautions provided by the Director of Nursing (DON) reviewed November 2019 documented in the Policy Statement: Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-resistant Organisms (MDRO) to staff hands and clothing Record review of the facility policy and procedure titled Catheter Care, Urinary provided the DON reviewed July 2015 documented in the Policy Statement: This procedure may…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food, in accordance with professional standards for food service safety, for potentially 55 of the facility's 61 residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 01/16/24 at 8:50 AM, and accompanied with the Food Service Director (FSD), the following were noted: a) Staff A was noted to be washing resident dishware in the facility dish machine. Staff A stated to the surveyor that the dish machine is at a low temperature and sanitizes by Chlorine chemical. The surveyor requested the FSD to test the final rinse chemical level. Following 3 separate Chlorine Strip tests, it was noted that there was presence of chemical in the final rinse water. The surveyor requested that the washing of resident dishware cease until the machine was properly sanitizing and to re-sanitize the washed dishes in the 3-compartment sink. A review of the chemical testing log noted that the level was checked for regulatory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-19 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the approved menu was not being followed that potentially affected 55 facility residents who eat orally, which included 11 of 11 sampled residents reviewed for nutrition (Resident #7, #10, #17, #19, #33, #37, #39, #44, #45, #55, and #63). The findings included: 1) During the review of the approved facility menu for the lunch meal of 01/16/24, the following were noted: * Broccoli Florets (Alternative Lunch Vegetable and to be served to Dysphagia Advanced, Dysphagia Mechanical, and Dysphagia Pureed) * Pureed Vegetable Quiche (Dysphagia Pureed Diet) * Cheese Sauce (2 ounces to be served over Vegetable Quiche (Regular Diet, Dysphagia Pureed) * Snickerdoodle Cookie - 2 ounces- (Regular Diet) Observation of the lunch tray assembly line in the main kitchen on 01/16/24 at 11 AM accompanied with the FSD (Food Service Director) and Corporate FSD noted the following: -Broccoli Florets - not prepared and no alternative was prepared. During interview with the FSD it was revealed that the Broccoli was not delivered in time…
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 11 citations
- Potential for harm · Dcited before2024-01-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy and procedure, observation, interview and record review, the facility failed to ensure that it followed physician's orders for medications and supplements for 2 of 6 sampled residents observed during a Medication Administration Observation (Resident #16 and Resident #166). The findings included: Review of the facility policy and procedure titled, Medication Administration, provided by the Director of Nursing (DON) dated 04/14/23, documented in the Policy Statement: Medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: .10. Review Medication Administration Record (MAR) to identify medications to be administered .14. Administer medication as ordered in accordance with manufacture specifications 20. Correct discrepancies and report to nurse manager . 1) Resident #16 was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nutritional supplements as ordered, for 1 of 9 sampled residents reviewed for nutrition, Resident #57. The findings included: Record review revealed Resident #57 was admitted to the facility on [DATE]. According to the resident's most recent 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status score of 10, indicating that the resident was 'moderately' cognitively impaired. The resident's diagnoses at the time of the assessment included: Hip fracture, Seizure disorder, Bipolar disorder, Chronic lung disease, History of falling, Osteoporosis without pathological fracture, Hypothyroidism, Vitamin D deficiency, Constipation and Pain. The assessment documented that the resident had no swallowing disorders, no dental concerns and the resident was able to eat independently with setup and clean up assistance. Record review revealed Resident #57's dietary orders included:…
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 before2024-01-19 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident #17), selected for nutrition review, received physician ordered thickened liquids (Honey), prepared in a design to meet the individual's needs. The findings included: During the review of the clinical record of Resident #17, the following were noted regarding the resident: Date of admission: re-admission on [DATE] Diagnoses: Dysphagia, Parkinsonism, Hypokalemia, Protein-Calorie Malnutrition Current physician's orders: 09/8/23: Dysphagia Pureed Diet, Honey Thick Liquids - Dysphagia 08/9/23: Magic Cup BID (twice daily) - Nutritional Supplement 01/16/24: Promod Oral Liquid 30 ml BID - Wound Care Weight History: 01/4/24 = 131 # (pounds) 12/4/23 = 139 # 10/4/23 = 146# 07/5/23 = 149 # 06/5/23 = 154# Height = 66 (inches) Body Mass Index (BMI) = 21.2 MDS (Minimum Data Set) assessment: 12/23/23 Section C: BIMS (Brief Interview for Mental Status Score) = 5 (Cognitive Impairment) Section GG: Eating =…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include: ensure dishware are are chemically sanitized as per regulation, holding of foods are regulatory temperatures, maintenance of refrigeration unit to maintain temperatures as per regulation, maintenance of the exhaust hood to prevent food contamination, and failure to defrost foods as per regulation. This has the potential to affect 53 residents, who reside at the facility and eat orally. The findings include: Review of the facility policy and procedure titled, Ware Washing, revised 9/2017, provided by the Director of Nursing (DON), documented in the Policy Statement: All dishware, service ware and utensils will be cleaned and sanitized after each use. Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water…
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 before2022-09-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in resident rooms and laundry area. The findings included: 1) During the initial resident screening tour conducted on 08/30/22 and environment observation tour conducted on 09/01/22 at 1 PM, and accompanied with the Director of Maintenance and Director of Housekeeping, the following were noted: Main Dining Room - Five wall mounted air-conditioning vents were noted to be full of condensation and were dripping down onto dining room tables (5) and the floor. It was also noted that resident food tray carts and staff was under the dripping condensation. Laundry Room - The covers of 2 soiled linen transportation carts were noted to have large cracks and pieces of the covers were missing. The wash room floor had large areas of black stains and 4 areas that appeared to have black mold type matter. Staff Bathroom and room [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 · Ecited before2022-09-02 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow the approved menu for potentially 53 of the 56 facility residents that included 38 of the 39 sampled facility residents. The findings include: During the review of the approved menu for the lunch meal of 08/30/22 , the following were noted to be served for the meal to regular diet, mechanical soft diets, renal diets, and pureed diets: ½ cup - Sauteed [NAME] Beans ½ cup - Chopped [NAME] Beans ½ cup - Sugar Snap Peas ½ cup - Parmesan Noodles ½ cup - Chocolate Pudding Parfait ½ cup - Mashed Potatoes ½ cup - Pureed Marinated Chicken Thigh During the observation of the lunch meal in the main kitchen and interview with the lunch cook on 08/30/22 at 11 AM, the following were noted: (a) Observation noted that a tong was being utilized for a serving of green beans. The menu documented a 4 ounce (#8 scoop) be utilized as a standard portion. Observations noted that the portion size being served varied for residents. (b) Observation noted that a 2-ounce portion of ground green beans was being served. The menu…
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 · E2022-09-02 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that 29 residents, including 9 sampled residents (Resident's #4, #10, #11, #21, #25, #33, #49, #104, and #254) failed to receive physician ordered Fortified Meals (High Protein/High Calorie diet). The findings included: During the review of the approved menu for the lunch meal of 08/30/22, it was noted that residents with physician orders were to receive a portion of Fortified Potatoes and review of the approved breakfast meal noted residents with fortified foods were to receive fortified Cooked Cereal (Oatmeal). During the observation of the lunch meal in the main kitchen on 08/30/22 at 11 AM, it was noted that there was a half pan of mashed potatoes to be served. Interview with the cook at the time of the observation revealed that the potatoes were regular and when asked about fortified the cook stated that she was not aware that fortified mashed potatoes were required to be made, and that residents requiring fortified mashed potatoes would receive regular. During the lunch meal, it was noted that the was no…
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 · D2022-09-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observation, interview, record review and review of the facility's policy and procedure, the facility failed to provide nail care for 1 of 5 sampled residents (Resident #11) reviewed for Activities of Daily Living (ADLs). The findings included: Review of the facility policy and procedure titled Nail Grooming with a last review date of 07/24/18, provided by the facility's Director of Nursing (DON) documented, regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary . Review of Resident #11's clinical record documented an initial admission to the facility on [DATE] under hospice care. The resident's diagnoses included Dementia, Anemia, Hypertension, Pain, Depressive episodes and Unsteadiness on feet. Review of Resident #11's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 of 15, indicating that the resident had…
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 · D2022-09-02 · 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 that a resident who requires respiratory care is provided such care as ordered by the physician and failed to document O2 (oxygen) saturations for every shift, as ordered by the physician for 1 of 1 sampled residents (Resident #254). The findings include: Review of the policy, titled Respiratory Oxygen Administration - Nasal Cannula Clinical Practice Guideline last reviewed on 07/25/22, included the purpose: oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Humidification of oxygen is used for a flow rate of four liters per minute or greater, or if requested by a patient. Record review for Resident #254 revealed that the resident was admitted to the facility on [DATE] and discharged to hospital on [DATE] at 11:00 PM. The residents diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Unspecified Acute Lower…
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 · D2022-09-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured medications in 1 of 3 Medication carts and 1 of 2 Treatment carts, during an initial observational tour; 2) ensure that it discarded expired medications in 1 of 2 Medication Storage Rooms; and 3) ensure that it properly supervised medications, during Medication Pass Observation for 2 of 7 sampled residents observed (Resident #25 and #155). The findings included: 1) Review of the facility policy and procedure titled Medication Storage/Storage of Medication, reviewed 10/07 provided by the Director of Nursing (DON), documented in the Policy Statement: Medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized 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.
- Potential for harm · Dcited before2022-09-02 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a form designed to meet the individual needs of 3 of 3 sampled residents with physician ordered pureed/dysphagia diet (Resident's #3, #25, and #49) . The findings included: 1) During the review of the approved menu for the lunch meal of 08/30/22, it was noted that sauteed green beans were to be served for physician ordered pureed diets. During the observation of the lunch meal on 08/30/22, in the main kitchen it was noted that there was a small pan of what appeared to be a green vegetable located in the steam table. The breakfast/lunch cook identified the pureed vegetables as green beans, and that there were 2 residents that were to be served the pureed green beans. Further observation noted that there were visible large pieces of green beans in the mixture. The surveyor pointed out the pieces of green beans in the mixture and confirmed the surveyors observation. Further discussion noted that the breakfast/lunch cook was unaware that the pureed mixture is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$40,755 in federal fines across 1 penalty.
- $40,755 — penalty dated 2025-04-10
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 BENJAMIN LANDA — 48 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 | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 4 of 5 | 2.3 | +1.7 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 47 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 47; lowest-rated first.
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 |
|---|---|---|---|---|
| GOLFCREST NURSING MEMBER LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/07/2022 |
| BR FAMILY HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| FLNHO CAPITAL GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2023 |
| SOUTH FLORIDA 3 OPCO PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| ZBL-18 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| RUBINSTEIN, BERISH | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| PENA, STEPHANIE | Individual | W-2 MANAGING EMPLOYEE | — | since 10/08/2022 |
| LANDA, BENJAMIN | Individual | CORPORATE OFFICER | — | since 09/01/2023 |
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105009. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-10, 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.