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Windsor Woods Rehab And Healthcare Center

13719 Dallas Dr, Hudson, FL 34667 · Non profit - Other · 103 certified beds · (727) 862-6795 Medicare & Medicaid certified

Call the home — (727) 862-6795 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7412 Community Ct · (727) 861-1000 · Call to confirm hours
Pharmacy
13910 Fivay Rd · (727) 857-4837 · Call to confirm hours
Grocery
14134 US 19 · (727) 863-9298 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
13438 US Highway 19 · (727) 857-7615

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 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.5%8.7%15.4%better
Long-stay residents who lose too much weight6.6%5.5%5.4%worse
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 infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened9.8%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.1%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers9.4%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control4.6%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table15.6%8.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.5%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine96.9%94.7%79.4%better
Short-stay residents rehospitalized after admission14.6%26.1%22.6%better
Short-stay residents with an outpatient ER visit7.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.622.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.421.151.80better

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.

35.7% 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 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

35.7%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
46.1%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 46.1% 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 65 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF35.7%CMS range 27.7–46.551.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 8.8–15.510.7%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 discharge46.1%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 discharge35.4%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 discharge26.1%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 identified96.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened8.3%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 hospitalization9.8%CMS range 6.3–16.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 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

0.42
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.24
Total nurse hours/ resident / day
0.14
RN hoursweekends
26.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 99.1 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.10 hrs/resident/day on weekends vs 3.30 on weekdays — 6% thinner on weekends. RN hours go from 0.54 to 0.14 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%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2024-06-06)
7
at the previous standard inspection (2022-08-04)

Deficiencies are fewer than at the previous inspection — improving. 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.

16 citations, most serious first. The 11 most serious are shown; the remaining 5 are one tap away and print in full.

  • Actual harm · G2022-08-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and interviews the facility failed to ensure proper nutritional enhancements were provided as ordered for one resident (#56) of three residents sampled for nutrition resulting in a 6.1% wieght loss in 48 days. Findings included: On 8/02/22 at 3:00 P.M., An observation and interview was conducted with Resident #56. The resident stated the menus never change and she does not get what she orders. She stated if she gets food she does not like and the alternate is not good she just does not eat at all. Resident #56 stated she has lost weight. On 8/3/22 at 8:45 A.M.an interview was conducted with Resident #56. The resident stated no one from Dietary has been in to see her and/or talk with her regarding supplements or her weight loss. She asked if there was a way for her to have supplements added to her meal tickets. On 8/03/22 at 10:30 A.M.a review of the medical record revealed the following weights recorded for Resident #56: 06/05/22- 120.2 pounds 07/08/22- 113.1 pounds 07/16/22- 112.3 pounds 07/23/22-112.9 pounds A review of the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-24 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure accurate and complete documentation related to Activities of Daily Living (ADLs) for toileting hygiene for four (#2, #4, #5, #6) out of four sampled residents. Findings included: During an interview on 04/24/2025 at 1:08 p.m. the Director of Nursing (DON) stated the aide staff works 8-hour shifts. The DON verified after reviewing the toilet hygiene documentation that the aides were not documenting every day, every shift they were providing incontinence care / toileting hygiene. The DON confirmed documentation was missing. The DON verified the incontinence care was to be documented under the toileting hygiene. 1. Review of Resident #2's admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses included but not limited to generalized osteoarthritis, dysphagia, Chronic Obstructive Pulmonary Disease, diabetes, anemia, seizures, pressure ulcers dementia, mood affective disorder, osteoporosis, neuromuscular…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · 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 observation, interviews and record reviews, the facility failed to follow the comprehensive person-centered care plan related to providing toileting care with a two-person assist for one (#2) of eight sampled residents. Findings included: During an interview on 04/24/25 at 1:08 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated Resident #2 initially told the 7 a.m. to 3 p.m. shift aide on 02/26/2025 about her finger hurting. The DON stated she went to Resident #2s room, and Resident #2 alleged a person (unknown at the time) came into her room the night before and hit her hand a couple hundred times. The NHA and the DON stated during their investigation Staff A, Certified Nursing Assistant (CNA) who cared for Resident #2 on the 11 p.m. to 7 a.m. shift on 02/26/2025 stated she provided incontinence care alone. The NHA stated Staff A, stated the resident was combative during care. The NHA stated during the investigation it was noted that Resident #2 was dependent for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a hospice plan of care was developed and coordinated to include communication between the facility and hospice provider related to activities of daily living (ADLs) for one (#3) of three residents reviewed for hospice care. Findings included: Review of an event progress note for Resident #3 revealed on 4/21/25 at 1: 00 p.m., a Hospice CNA (Certified Nursing Assistant) reports to nurse that open areas occurred while giving [Resident #3] a shower. The resident has provided the following description of the event: Unable to say what happened. The following type of event is noted: Skin alteration - Details of the event are as follows: Hospice CNA was showering Resident when open areas were obtained and reported. Preventative interventions related to this event included - continue with protective sleeves. A Change in Condition evaluation completed on 4/21/25 showed Resident #3's skin changes were - skin tear Left elbow, right forearm, and right…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-06 · 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 record review, interview, and record review, the facility failed to provide incontinent supplies to meet resident needs for five (Residents #73, #35, #22, #49, #61) of 47 residents sampled. Findings Included: 1. An interview was conducted on 06/03/24 at 11:45 a.m. with Resident # 61. She stated staff ran out of incontinent briefs yesterday evening and she was not able to be changed. She stated staff only had a size small, and she wears an extra-large and/or extra extra-large and a small would not fit. She stated staff had to run to [local store] to pick up briefs for residents. Review of the electronic medical record (EMR) showed Resident #61 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder, unspecified convulsions, primary insomnia, and anxiety disorder. Review of Minimum Data Set (MDS) dated [DATE] showed: - Section C Brief Interview Mental Status (BIMS) score of 14 indicating no cognitive impairment. - Section I with heading genitourinary…

    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 · D2024-06-06 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and record review, the facility failed to ensure the Level I readmission Screening and Resident Review (PASRR) was accurate for four residents (#15, #18, #68, #98) of 21 residents sampled for PASRR review. Findings Included: 1. Review of the electronic medical record (EMR) revealed Resident #68 was admitted to the facility on [DATE] with diagnoses that included depression, and unspecified dementia. Review of the Level I PASRR dated 10/25/23 showed qualifying diagnoses were not checked or indicated, and that no Level II PASRR was required. An interview was conducted on 06/06/24 at 12:55 p.m. with Director of Nursing (DON). She stated Resident #68 PASARR dated 10/25/23 was incorrect as Depression was not marked under Mental Illness or Suspected Mental Illness and a Level II should have been completed as resident had a secondary diagnosis of dementia and diagnosis of depressive disorder. The DON stated this (PASRR) would need to be corrected. 2. A review of the admission 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 · D2024-06-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility did not ensure compression stockings were ordered for one (Resident #46) of one resident sampled for chronic right lower leg swelling. Findings included: On 6/3/24 at 10:45 a.m. during an interview and observation with Resident #46, he said his left leg swelling was constant because the compression stockings the facility provided was too small to fit his leg. Resident #46 presented a package of extra-large white compression stockings. (Photographic Evidence Obtained). Resident #46 said the swelling in his leg was making it difficult for him to walk. Observation of Resident #46's right lower leg and foot was noticeable larger than the left leg. (Photographic Evidence Obtained). A review of Resident #46's admission record showed diagnoses to include generalized muscle weakness, abnormalities of gait and mobility and fatigue. Review of the occupational therapy (OT) daily treatment note dated, 4/30/24 by Staff D, OT, showed attempted to see patient…

    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 · D2024-06-06 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to identify triggers related to Post Traumatic Stress Disorder (PTSD) which may retraumatize a resident and failed to develop and implement an individualized care plan with interventions that could minimize or eliminate the effect of the triggers for two (Resident #15 and #12) out of two sampled residents. Findings included: 1. A review of the admission Record for Resident #15 showed he was initially admitted to the facility on [DATE] with diagnoses to include major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, anxiety disorder, and post-traumatic stress disorder (PTSD). Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. Section I Active Diagnoses of the MDS showed the resident had diagnoses 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 · D2024-06-06 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure antibiotics were administered timely for one (Resident #87) out of six residents reviewed for unnecessary medications. Findings included: A review of the admission Record for Resident #87 showed the resident was initially admitted to the facility on [DATE] with a primary diagnosis of encephalopathy. The lab report with an order date of [DATE] showed a wound culture was rejected on [DATE] at 1:01 p.m. due to unable to process specimen due to collection with expired supplies. Swab received expired on [DATE]. The urinalysis with micro, reflux to urine culture lab report conduced on [DATE] showed preliminary results were received on [DATE] that showed the resident had >100,000 colony-forming unit per milliliter (cfu/ml) gram positive cocci possible enterococcus species identification and sensitivities to follow. The final report approved [DATE] showed >100,000 cfu/ml gram positive cocci enterococcus faecium this isolate is vancomycin resistant…

    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 · D2024-06-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and record review, the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed, and three errors were identified for two residents (#38 and #7) of five residents observed. These errors constituted a 7.14% medication error rate. Findings included: On 6/5/24 at 9:00 a.m., Staff N, LPN was observed preparing and administer administering Resident #38's medications. She prepared and administered the following medications aspirin Low dose 81 mg, hydrochlorothiazide Oral Tablet 12.5 mg, vitamin D and Tylenol regular str 325 mg. A review of Resident #38's physician orders revealed aspirin EC tablet delayed release 81 mg was ordered (photographic evidence obtained) and not administered as prescribed. On 6/5/24 at 9:15 a.m., Staff N, LPN was observed preparing and administer administering Resident #7's medications. She prepared and administered the following medications Aricept 10 mg, Aspirin EC Tablet Delayed Release 81 mg, vitamin B-12 1000 mcg, Claritin 10 mg, Colace 100 mg, Effexor XR…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to store medications in a safe and secure manner 1) in four medication carts (two A Wing and two C Wing) of four medication carts observed, and 2) for three residents (#16, #63, and #82) of forty one residents sampled. Findings included: 1) A review of the facility provided policy titled 4.1 Storage of Medications, dated 09/18 revealed the following: Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations to maintain their integrity and to support safe effective drug administration. The medications supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Procedures: 1. The provider pharmacy dispenses medications is containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). On 08/03/2022 at 2:59 p.m., an observation of the (C Wing) 200 Back Hall…

    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
Show the remaining 5 citations
  • Potential for harm · E2022-08-04 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview and facility record review, the facility failed to ensure one of one walk in freezers were operating appropriately during two of four days observed (08/01/2022 and 8/4/2022). It was determined the freezer door would not latch closed in order to keep warm air from getting in, and as a result, there was ice build up inside the freezer compartment. Findings included: On 8/1/2022 at 9:45 a.m. the kitchen was toured with the Dietary Manager. During the tour, it was noted the kitchen had a walk in refrigerator and within the walk in refrigerator was the walk in freezer. Once the walk in refrigerator was approached, the door was opened and the inside temperature revealed 38 degrees F., per the inside analog thermometer. Further observations and while inside the walk in refrigerator, there was a large metal door that led into the walk in freezer. The door appeared slightly ajar and the door handle was not latched all the way. The door, when attempting to open, was slightly stuck. Upon pulling open the door with force, the entire inside of the door…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-04 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 policy reviews the facility failed to ensure privacy of personal health information for three residents (#344, #351 and #352) out of forty-one sampled residents. Findings included: An observation was made on 8/2/22 at 12:56 PM of a map on the wall indicating which rooms in the facility were positive for COVID-19. The map was posted outside of Resident #351's room. The resident's name was displayed on the door next to the map. Resident #344's room and Resident #352's room were also indicated on the map. All three rooms were single occupancy and had the residents name posted on the plaque outside the door. Each of the three rooms where highlighted on the map as being COVID positive. (Photographic evidence and copy of the map identifying diagnosis obtained) A review of medical records indicated Resident #351 was admitted on [DATE] with diagnoses including but not limited to COVID-19. A review of current orders indicated an order for COVID-Droplet precaution. Lab results…

    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 · D2022-08-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure air conditioning (A/C) units were maintained in a sanitary manner in 7 rooms (room [ROOM NUMBER], 128,130,219, 217, 216 and 218) out of 19 rooms in the front hall of the facility during four of four days of the survey Findings included: During a facility tour on 08/01/22 from 09:37 a.m. to 10:11 a.m., observations were made of air conditioning (A/C) units with dark moisture lint on the surfaces and filters with debris and dust in resident rooms 126, 128, 130, 216, 217, 218 and 219. The observations of A/C units with dark moisture lint on surfaces and filters with debris and dust were made on 08/02/22 at 11:32 a.m., 08/03/22 10:00 a.m., and 08/04/22 11:20 a.m. A review of a maintenance logbook documentation dated, 7/29/22, 7/22/22 and 7/15/22 showed boxes not checked to indicate cleaning of air filters was conducted in these rooms. On 08/04/22 at 11:00 a.m., an interview was conducted with the Housekeeping Manager. He stated 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 · D2022-08-04 · 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, interviews and record review, the facility did not ensure a dependent resident (#16) was assisted to activities during three of four days of survey out of 41 residents sampled. Findings included: During a facility tour on 08/02/22 at 10:19 a.m., Resident #16 was observed sitting on the edge of his bed. Resident #16 stated he does not participate in activities. Resident #16 stated he would like to but he is just not invited. Resident #16 said, I thought the activities are for residents with insurance. Immediately following this tour, an observation was made of the Director of Activities (DOA) with a group of residents in the dining room playing bingo. A review of an admission record for Resident #16 dated 08/04/22 showed Resident #16 was admitted to the facility on [DATE] with diagnosis to include but not limited to muscle wasting and atrophy, transient cerebral ischemic attack unspecified and difficulty in walking. A review of the Minimum Data Set (MDS) for Resident #16, dated 05/22/22,…

    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 · D2022-08-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy reviews the facility did not ensure 1) proper infection control practices were followed for three Covid-19 positive residents (#344, #351, and #352) regarding personal protective equipment and 2) proper infection control practices were followed for one contact isolation resident (#67) regarding personal protective equipment out of forty one sampled residents. 1) An observation was made on 8/1/22 at 1:01 PM of Staff D, Licensed Practical Nurse (LPN), entering Resident #344's room with no goggles in place, only regular eyeglasses. Signage on the door indicated droplet precautions, stating everyone must clean hands when entering/exiting room, wear N95 mask, wear eye protection, and gown and glove at the door. A review of admission records indicated Resident #344 was admitted on [DATE] with diagnoses including pneumonia due to SARS-associated Coronavirus. Lab results indicated the resident tested positive for COVID-19 on 7/17/22. A review of orders indicated an active…

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 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 3 of 52.2+0.8 vs chain
Health inspection 3 of 51.9+1.1 vs chain
Staffing 3 of 53.2-0.2 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 16 homes this chain runs (chain average 2.2★, 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
FI-WINDSOR WOODS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/13/2003
FLORIDA INSTITUTE FOR LONG TERM CARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/18/2025
OMEGA HEALTHCARE INVESTORS, INCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 07/01/2003
JAFFE, HOWARDIndividualCORPORATE OFFICERsince 07/01/2014
KATZ-HALL, KATHYIndividualCORPORATE OFFICERsince 07/01/2014
MULLARKEY, JAMESIndividualCORPORATE OFFICERsince 07/01/2014
RICHMOND, PENNYIndividualCORPORATE OFFICERsince 07/01/2014
CONSULTING SUPPORT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/18/2025
ELEUS HEALTH MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/18/2025
FACILITY SUPPORT COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
KANE FINANCIAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
CROUCHER, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/15/2020
VANBELKUM, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/16/2019
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 08/19/2016

CMS files one row per role, so the 22 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.

$11.5M
Net patient revenuemost recent cost report
+2.9%
Operating marginrevenue minus expenses
$136K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 12%Other / private 16%

About 71% 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 $136K 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

$334per resident / day
operating cost
$10,161per month
≈ monthly operating cost
$344per 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 105568. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-06, 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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