Citrus Health And Rehabilitation Center
701 Medical Court East, Inverness, FL 34452 · For profit - Limited Liability company · 111 certified beds · (352) 860-0200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2022
- inspectors cited 4 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 20.2% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.3% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.1% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.2% | 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 | 3.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.8% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.7% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 17.8% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.9% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.89 | 1.15 | 1.80 | typical |
‡ 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.
60.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 192 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 78.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 89 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 0.50 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 60.6%CMS range 53.0–66.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 17.1%CMS range 14.0–20.3 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 78.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 77.5% | 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 | 69.7% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 99.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 1.0% | 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 | 7.0%CMS range 4.1–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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 111 beds and averages 100.6 residents a day — about 91% occupied, or roughly 10 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.30 hrs/resident/day on weekends vs 3.82 on weekdays — 14% thinner on weekends. RN hours go from 0.52 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 14 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2022-09-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents reviewed for changes in condition, Resident #29 and #42, resulting in the residents having to be treated by IV (intravenous) antibiotic therapy due to infection. Delay in notifying the physician of a wound, critical labs, and resident change in condition due to infection can result in the spread of the infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic…
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.
- Immediate jeopardy · J2022-09-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 residents were free from medical neglect when they did not immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents, Residents #29 and #42, resulting in a delay of care. Delay in notifying the physician of a wound, critical labs, or resident change in condition can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina pectoris (chest pain), acute systolic (congestive) heart failure (a chronic condition in which 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.
- Immediate jeopardy · J2022-09-16 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 administration failed to administer the facility in a manner that enables it to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: Review of the job description for the Administrator with an effective date of 1/17/2022 reads, Purpose of your job position: The primary purpose of your position is to direct the day-to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing…
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.
- Immediate jeopardy · J2022-09-16 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 utilize the Quality Assessment and Process Improvement (QAPI) process when the administrative staff failed to investigate, develop, and implement appropriate plans of correction to identify and correct quality deficiencies of the facility failing to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings Include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following diagnoses: encounter for surgical aftercare following surgery on the circulatory system, atherosclerotic heart disease of native coronary artery (heart disease) with angina…
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 before2025-05-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 3 of 5 units. Findings include: 1) During an observation on 5/12/2025 at 10:27 AM, Resident #55 was lying in bed. On top of the resident's nightstand, there were two clear vials of Budesonide Inhalation Suspension next to the nebulizer machine (Photographic evidence obtained). During an interview on 5/12/2025 at 10:27 AM, Resident #55 stated, Sometimes I do not want to do the treatment and the nurse will leave it there. No one is going to drink it. The nurse that is here is not the one who left it there. Review of Resident #55's physician order dated 3/9/2025 read, Budesonide Inhalation Suspension 0.25 MG/2 ML [0.25 milligrams per 2 milliliters] (Budesonide Inhalation), 2 ml inhale orally two times a day for respiratory failure. Review of Resident #55's physician orders did not show an order for medication self-administration. During an interview on 5/12/2025 at 1:54 PM, Staff D,…
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 · D2025-05-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 3 of 7 residents reviewed for nutrition (Resident #13, #65, and #69), and 1 of 6 residents reviewed for hospice services (Resident #349). Findings include: 1) Review of Resident #65's physician order dated 4/16/2025 read, CCHO [Consistent Carbohydrate Diet] diet, Pureed texture, Nectar Thick consistency. Review of Resident #65's significant change in status Minimum Data Set (MDS) assessment dated [DATE] showed no mechanically alerted diet under Section K- Swallowing/Nutritional Status. During an interview on 5/15/2025 at 12:40 PM, the MDS Coordinator Registered Nurse (RN) stated, [Resident #65's name] MDS has to be corrected. [Resident #65's name] was a pureed diet, which would be a mechanically altered diet. Normally, we do not do Section K on the MDS that would be the Registered Dietician, but I need to correct it. 2) Review of Resident #69's physician order dated 12/24/2024…
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 · D2025-05-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise the residents' care plans to meet the current needs of the residents for 1 of 11 residents reviewed for enhanced barrier precautions (Resident #56) and 1 of 2 residents reviewed for dialysis services (Resident #15). Findings include: 1) Review of Resident #56's care plan on 5/12/2025 at 12:00 PM read, Focus: [Resident #56' name] is at risk for infection and enhanced barrier precautions (EBP) are indicated due to: positive COVID-19 virus. Date Initiated: 12/09/2025. During an observation on 5/12/2025 at 9:36 AM, Resident #56 was sitting in her wheelchair in her room watching television. There was no enhanced barrier precaution signage on her door. During an interview on 5/12/2025 at 12:25 PM, the Minimum Data Set (MDS) Coordinator stated that the care plan focus of EBP for COVID-19 was initiated on 12/9/2024. It should have been resolved after the resident was no longer contagious for the virus. Review of the facility policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure residents received services according to professional standar of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #151). Findings include: Review of Resident #151's physician order dated 4/28/2025 read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical)), Apply to affected areas. The order had no dosage or specific area for application of the medication. During an interview on 5/13/2025 at 3:11 PM, the Director of Nursing (DON) stated that Voltaren order did not have dosage or area to be applied. She stated her expectation was that orders had a dosage and location of application. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by…
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 before2025-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 2 of 7 residents reviewed for medication administration (Residents #29, and #55), and failed to ensure enteral tube dressing was changed for 1 of 1 resident reviewed for enteral feeding (Resident #349). Findings include: 1) During an observation on 5/14/2025 at 2:35 PM, Staff F, Registered Nurse (RN), entered Resident #29's room, performed hand hygiene, and donned gloves and a gown. Staff F disconnected the IV (intravenous) tubing from Resident #29's needleless connector. Staff F used an alcohol wipe to sanitize the needleless connector and flushed the needleless connector with 5 ml (milliliters) of normal saline. Staff F removed her personal protective equipment, preformed hand hygiene, and exited the room. Staff F did not follow with 5 milliliters of Heparin solution. Review of Resident #29's physician order dated 5/7/2025 read, Normal Saline Flush Solution (Sodium Chloride Flush) use 10 cc [milliliters] intravenously two times a day 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.
- Potential for harm · D2025-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to keep resident environment free of accident hazards. Findings include: During an observation on 5/12/2025 at 10:17 AM, Resident #89 was sitting in bed. There was one oxygen cylinder in the right corner of the room, which was not secured on a stand (Photographic evidence obtained). Review of Resident #89's physician order dated 4/23/2025 read, Administer oxygen 2-4 L/Min [liters per minute] via NC [nasal cannula]. Humidification PRN [as needed] as needed Every shift monitor skin behind ears, necks, and face every shift for irritation or breakdown and apply tube padding PRN. During an interview on 5/14/2025 at 3:35 PM, the Director of Nursing (DON) stated, Oxygen cylinders must be secured on the cart and should not be stored loose in a resident room. There is a risk the cylinder can fall. We secure the oxygen cylinder for safety. Review of the facility policy and procedure titled Standards and Guidelines: Compressed gases and Oxygen usage with the last review date of 1/20/2025 read, Guidelines: Personnel…
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 · D2025-05-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents #12 and #19). Findings include: Review of Resident #12's physician order dated 4/24/2025 read, Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth one time a day for GERD [Gastroesophageal Reflux Disease] . Order Status: Active. Review of Resident #12's Medication Regimen Review (MRR) showed the consultant pharmacist's recommendation dated 8/6/2024 that read, This patient is currently receiving a PPI [Proton Pump Inhibitors] for > [more than] 12 weeks, Due to the updated F757, Unnecessary Medication Tag, the use of the PPI should be periodically reviewed and the necessity for continuation documented as well as monitoring done for any adverse consequences. The current order is: Protonix 40 mg [milligram] po [by mouth] Q AM [every morning] (05/24). Reduce dose to: Protonix 20 mg po Q QM. The physician's response read,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 1 resident reviewed for enteral feeding (Resident #349) and 1 of 6 residents reviewed of 5 residents reviewed for immunizations (Resident #29). Findings include: 1) During an observation on 5/14/2025 at 8:24 AM, Staff E, Licensed Practical Nurse (LPN), administered medication to Resident #349 via gastric tube (G-tube). The split gauze around the gastric tube was dated 5/11/2025 and had staff initials written with black marker. During an interview on 5/14/2025 at 8:55 AM, Staff E, LPN, stated, [Resident #349's name] gauze is dated 5/11/2025. The gauze should be changed daily. Normally the wound care nurse does the dressing change. Review of Resident #349's physician order dated 4/25/2025 read, Wound Care to G-tube site: Cleanse with wound wash, pat dry and place split gauze around tube, tape to secure in place every day shift for maintenance. Review of Resident #349's Treatment Administration Record (TAR) for May 2025 showed split gauze was changed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-15 · 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
3) During an observation on 5/14/2025 at 9:19 AM, Staff C, RN, gathered wound care supplies for Resident #29. Staff C removed bandage scissors from his pants pocket and cut the wound dressing and calcium alginate. Staff C removed the dressings from Resident #29's left lower leg and foot and right lower leg, using the bandage scissors to cut away the external gauze portion of the dressings. Without removing his gloves or performing hand hygiene, Staff C then used the prescribed cleanser on three wounds on Resident #29's left lower leg and patted them dry with gauze. Staff C removed the remaining dressing from Resident #29's right lower leg, and without removing his gloves or performing hand hygiene, applied the prescribed cleanser and patted it dry with gauze. During an interview on 5/14/2025 at approximately 9:35 AM, Staff C, RN, stated that he did not believe it was necessary to remove his gloves and perform hand hygiene between removing Resident #29's dressing and applying the prescribed cleanser, because the wound was considered dirty until after he applied the cleanser. During…
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 · D2025-05-15 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to ensure call light cords and buttons were placed within resident's reach while they were in bed for 1 of 8 residents reviewed (Resident #40). Findings include: During an interview on 5/12/2025 at approximately 10:30 AM, Resident #40 stated that she did not have a call light, and that she had been instructed just to call out (verbally) if she needed assistance. During an observation on 5/12/2025 at 2:48 PM, Resident #40's call light was on the resident's bedside table (Photographic evidence obtained). During an observation on 5/13/2025 at 9:00 AM, Resident #40's call light was inside the drawer of the resident's bedside table (Photographic evidence obtained). During an observation on 5/13/2025 at 1:35 PM, Resident #40's call light was clipped to the handle/drawer pull of the resident's bedside table (Photographic evidence obtained). During an interview on 5/13/2025 at 1:35 PM, Resident #40 stated, I did not put my call light on the bedside table. I am not supposed to get out of bed on my own. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · Ecited before2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered and labeled in the areas of the kitchen coolers and freezers and failed to ensure the equipment and storage containers were kept in a clean condition. Findings include: During a walk-through tour of the kitchen on 2/19/2024 at 9:08 AM with the Certified Dietary Manager (CDM), there were 102 unlabeled and undated large and small bowls filled with food items in the walk-in cooler and numerous boxes with flaps open exposing food items including veggie burgers and waffles in walk-in freezer. The can opener had food debris on it. During an interview on 2/19/2024 at 9:12 AM, the CDM confirmed that the 102 bowls contained gelatin and they should have identifying labels and dates. The CDM stated that all boxes in the freezer should be closed to protect the food from freezer burn and as a cover for the food contents.The CDM verified the can opener was dirty with food debris and should have been washed on the previous night shift. During an observation on 2/20/2024 at…
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 before2024-02-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration in 6 of 12 observations for medication administration. Findings include: During an observation on 2/22/2024 at 8:45 AM, Staff G, Registered Nurse (RN), prepared medications for Resident #73. Staff G entered Resident #73's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:50 AM, Staff G prepared medications for Resident #54. Staff G entered Resident #54's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:52 AM, Staff G prepared medications for Resident #59. Staff G entered Resident #59's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:55 AM, Staff G entered Resident #72's room to obtain the resident's blood pressure prior to administering the resident's medications. Staff G exited the room after obtaining the resident's blood pressure and returned to the medication cart. Staff G…
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 · D2024-02-22 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were reviewed for level II pre-admission screening and resident review (PASARR) for 1 of 4 reviewed residents, Residents #41. Findings include: Review of Resident #41's admission record revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, cognitive communication deficient, paranoid schizophrenia (with onset date of 9/29/2023), generalized anxiety disorder (with onset date of 5/26/2023), bipolar disorder (with onset date of 3/10/2023), and major depressive disorder (with onset date of 12/30/2022). Review of Resident #41's medical records revealed a Level I PASRR completed on 12/30/2022 that listed anxiety disorder and depressive disorder as diagnoses and indicated that the resident may be admitted to a nursing facility due to no diagnosis or suspicion of serious mental illness or…
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 · D2024-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status to prevent weight loss for 1 of 6 reviewed residents, Resident #660. Findings include: During an interview on 2/19/2024 at 10:11 AM, Resident #660 stated, I have lost weight and do not always receive foods I request on my tray. During an observation on 2/20/2024 at 12:20 PM, Resident #660 was eating lunch with only bites taken from his plate. During an interview on 2/20/2024 at 12:21 PM, Resident #660 stated lunch was not a favorite meal, and he did not get the bowl of soup he requested. Review of Resident #660's records showed the resident weighed 148 lbs (pounds) on 11/22/2023, 147.5 lbs on 11/24/2023, 146.5 lbs on 11/27/2023, 141 lbs on 12/20/2023, 138.0 lbs on 1/1/24 and, 135 lbs on 2/1/2024, which is a -8.78 % loss. Review of Resident #660's dietary note authored by the Registered Dietician (RD) dated 11/28/2023 read, At risk for weight loss and malnutrition. RD to monitor. Review of Resident #660's care plan dated 11/22/2023 showed…
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 · D2024-02-22 · 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 administer oxygen per physician orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #55 and #64. Findings include: Review of Resident #64's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD), and multiple subsegmental pulmonary emboli without acute cor pulmonale. Review of Resident #64's physician order dated 6/26/2022 reads, May apply O2 [oxygen] @ [at] 2 LPM [liters per minute] via nasal cannula prn [as needed] for respiratory distress. During an observation on 2/19/2024 at 10:50 AM, Resident #64 was sitting in a wheelchair, receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 liters per minute and was across the room and out of the resident's reach. During an interview on 2/19/2024 at 10:50 AM, Resident #64 stated, I pretty much use my oxygen all the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards. Findings include: 1. During an observation on 2/19/2024 at 10:20 AM, there were Orajel tooth ache cream, Afrin Nasal Spray, and Prednisolone Acetate on Resident' #48's bedside table (Photographic evidence obtained). Review of Resident #48's records revealed no physician order or care plan related to self-administration of medications. During an interview on 2/20/2024 at 10:30 AM, Staff B, RN (Registered Nurse), stated, Those medications should not have been left at [Resident #48's name] bedside. 2. During an observation on 2/19/2022 at 10 AM, there was Spiriva Respimat 2.5 mcg/actuation inhaler on Resident #712's bedside table (Photographic evidence obtained). During an interview on 2/19/2024 at 10:05 AM, Resident #712 stated, I use that when I need it. Review of Resident #712's records revealed no physician order or care planned intervention related 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 before2024-02-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were accurate and complete for 1 of 3 residents reviewed for insulin administration, Resident #93, and for 1 of 3 residents reviewed for changes in condition, Resident #108. Findings include: 1. Review of Resident #93's admission record revealed the resident was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes mellitus with diabetic neuropathy, acute on chronic systolic (congestive) heart failure and atherosclerotic heart disease of the native coronary artery with angina pectoris (chest pain). Review of Resident #93's physician order dated 11/17/2023 reads, Humalog Kwikpen Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Lispro) inject as per sliding scale if: 0-59= Notify provider, 60-150= 0, 151-200= 2, 201-250= 4, 251-300= 6, 301-350= 8, 351-400= 10, 401-999= 10 Notify MD [Medical Doctor], subcutaneously before meals and at bedtime for DM2 [diabetes mellitus type 2]. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-16 · 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 — the official record, unedited, may be distressing
Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety in 1 of 2 nutrition room refrigerators containing food for resident consumption. Findings include: On 9/13/2022 at 12:02 PM an observation of the refrigerator in the nutrition room on the 400-hallway contained two cartons of regular milk that were expired, dated 9/7/2022 and 9/12/2022 respectively. During an interview on 9/13/2022 at 12:05 PM the Certified Dietary Manager stated, Yes the milk is expired. The evening shift kitchen staff is supposed to put nutritional supplements including milk in the refrigerator in the afternoon and the day shift staff is to check the nutritional refrigerators in the mornings and remove any expired nutritional items.
- Potential for harm · Ecited before2022-09-16 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 2 of 3 residents, Residents #42 and #29, reviewed with a central venous access devices out of a total sample of 36 residents. Findings include: During an observation conducted on 9/12/2022 at 12:14 PM with the Director of Nursing (DON) Resident #42 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. During an interview on 9/12/22 at 12:19 PM the Director of Nursing (DON) confirmed Resident #42's dressing was dated 9/8/2022 and that there is gauze under the transparent dressing. The dressing should be changed, it does have gauze under the dressing, and it needs to be changed after 48 hours if there is gauze under it. The line was placed on 9/8. It is the original dressing. Dressings with…
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 · E2022-09-16 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the proper disposal of garbage and refuse. Findings include: During an observation on 09/12/2022 at 10:22 AM with the Certified Dietary Manager (CDM) of the dumpster area showed a large quality of paper and boxes in front of the dumpster. There were four pieces of wood in front of and beside the dumpster. A large white bucket with a pink/red liquid was to the front left of the dumpster. A blue mattress was just behind and to the right of the dumpster. During an interview on 9/12/2022 at 10:22 AM the CDM stated, The trash should not be around the dumpster. I do not know when the dumpster was last emptied or how often it is emptied. I do not know what the pink liquid is in the white bucket. I think the staff takes the buckets home with them and leave the buckets by the trash can until they take the buckets home. The boards/wood and the mattress should not be around the trash can. During an observation of the dumpster area on 09/12/2022 at 12:20 PM showed the lid of the dumpster was propped up with a piece…
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 before2022-09-16 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain accurate and complete medical records for midline catheter dressing changes for 2 of 3 residents, Residents #42, and #29, and Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents, Resident #79. Findings include: 1. During an observation on 9/12/2022 at 12:14 PM Resident #42 was observed resting in bed with a left upper arm single lumen midline catheter. The transparent dressing was dated 9/8/2022 and there was a piece of gauze under the transparent dressing. Review of the admission record documented that Resident #42 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic pain, generalized anxiety disorder, bipolar disorder, essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), and primary osteoarthritis right shoulder. Review…
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 before2022-09-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to prevent the possible spread of infection during wound care and medication administration. Findings include: 1. During an observation on 9/14/22 beginning at 10:20 AM of Staff B, Licensed Practical Nurse (LPN), performing wound care to the coccyx and right below the knee amputation stump for Resident #29 it showed Staff B, LPN reached into her pocket for scissor with a gloved hand. Staff B proceeded to use the scissors to cut a piece of dressing, Calcium Alginate, without sanitizing the scissors. Staff B applied the Calcium Alginate to Resident #29's coccyx wound. Staff B, LPN, was observed to clean the right below the knee amputation stump wound from the outer edges of the skin to the center of wound. The wound is observed to be open in the center with white tissue and reddened edges. Staff B was observed to cut a second piece of Calcium Alginate with the same scissors and applied Calcium Alginate to Resident #29's right below the knee amputation stump. Resident #29 was receiving intravenous antibiotic therapy…
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 · D2022-09-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 2 residents (Resident #16 and Resident #19) of 12 residents reviewed for advanced directives were informed and provided written information concerning their right to choose and formulate an advance directive. Findings include: Review of the admission record for Resident #16 documented the resident was admitted into the facility on 9/13/2019 with diagnoses that included trigeminal neuralgia, unspecified calorie-protein malnutrition, major depressive disorder, anxiety disorder, unspecified atrial fibrillation, and chronic obstructive pulmonary disease. Review of the records failed to reveal Resident #16 had an advanced directive or was informed of the right to choose an advanced directive. Review of the admission record for Resident #19 documented the resident was admitted into the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified protein-calorie…
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 · D2022-09-16 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the privacy of 1 resident, Resident #69, of 2 residents reviewed for dementia care. Findings include: On 9/12/2022 at 9:08 AM, Resident #69 was observed from the hallway lying in his bed attempting to use a urinal. Resident #69's privacy curtain was not pulled around Resident #69's bed. Resident #69 was not clothed, and his unclothed body was exposed through the open door of his bedroom to passersby. During an interview on 9/12/2022 beginning at 9:10 AM, Staff A, Licensed Practical Nurse, stated Resident #69 is still trying to use the urinal. She confirmed Resident #69's unclothed body was visible through the open door of his bedroom. She reported that she spoke to Resident #69 and told him his door was open so everyone walking down the hall can see you. Staff A added Resident #69 replied oh, that's not good. Review of the facility policy titled ADL (Activities of Daily Living) Care and Assistance, issued 4/1/2022 read 3. Staff should be mindful to provide ADL care with dignity, privacy, and respect 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.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SNF AA 03 LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/16/2015 |
| AMSELEM, ALEX | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 02/16/2015 |
| DIMENNA, ALEXANDER | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2022 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 105858. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-15, 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.