Dolphin Pointe Health Care Center
5355 Dolphin Point Blvd, Jacksonville, FL 32211 · For profit - Limited Liability company · 146 certified beds · (937) 434-8820 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 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.
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 | 7.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.1% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 9.4% | 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 | 4.0% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 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 | 8.6% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.1% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.8% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.3% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.0% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.58 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.22 | 1.15 | 1.80 | worse |
‡ 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.
57.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 497 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.6% 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 296 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 0.71 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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 | 57.3%CMS range 53.3–62.1 | 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 | 10.8%CMS range 8.9–12.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 43.6% | 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 | 48.3% | 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 | 39.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.8% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 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 | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 4.2–7.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 146 beds and averages 134.3 residents a day — about 92% occupied, or roughly 12 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 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above 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 3.54 hrs/resident/day on weekends vs 4.31 on weekdays — 18% thinner on weekends. RN hours go from 0.46 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · Fcited before2026-01-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations of kitchen food preparation and storage areas and interviews with staff, the facility failed to adhere to acceptable food storage practices to prevent food contamination or foodborne illness by failing to ensure opened foods were sealed, labeled and dated, and food preparation and storage equipment was clean and sanitary. Food storage and kitchen sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices present a potential source of pathogen exposure and has the potential to affect all residents who consumed foods from the facility, An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 1/26/26 at 2:15 PM. Inspection of the commercial ice machine's ice chute cover revealed an a 2-inch square area covered with wet, dark matter resembling biological growth such as mildew. Condensation had formed on the surface of the cover, which could drip into the ice below. When the CDM wiped the matter with a paper towel-covered finger, the matter easily wiped off. Seemingly puzzled, he…
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 · E2026-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure residents who were dependent on staff for grooming and personal care received necessary assistance with activities of daily living (ADLs), specifically related to fingernail and toenail trimming and cleaning, for four of six residents reviewed for ADLs (Residents #76, #116, #67, and #45).The findings include: 1. On 1/27/26 at 10:40am, Resident #76 was observed with elongated fingernails on her right hand with brown debris noted under each fingernail. The resident stated she likes her fingernails long and she likes to get them painted. They were not observed to be painted or polished. She was asked if staff clean under her fingernails. She stated no but they should. Her left hand was observed contracted and she stated she can't really open that hand. Unable to observe left hand fingernails. (Photographic evidence obtained.) On 1/28/26 at 10:05am, Resident #76 was observed awake in her bed. Her right-hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-30 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, it was determined that the facility failed to ensure residents' rights to self-administer medications was consistently assessed and safely implemented, as evidenced by the failure to complete required self-medication assessments and to ensure medications approved for self-administration were securely stored for three of three residents reviewed (Residents #116, #80, and #37). The findings include: 1. On 1/27/26 at 4:30pm, during an interview with Resident #116, she stated she has always had her eye drops and Flonase nasal spray left for her at the bedside per her request and stated yesterday afternoon staff took them away and said she couldn't have then in her room. She stated she wants her eye drops and nasal spray in her room, and that she has always administered them herself. On 1/28/26 at 10:00am, a Flonase nasal spray box and Artificial Tears box were observed on bedside table of Resident #116. She stated the staff gave them back to her. The boxes were observed to be empty, and she stated she put the medications into her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-30 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record reviews the facility failed to ensure staff followed policy and procedure for reporting and investigating allegations of abuse for one of one resident sampled for abuse (Resident #38) and failed to ensure staff participated in annual training on abuse, neglect and exploitation for two of 10 staff members reviewed (Staff members J, and the Assistant Director of Nursing).The findings include: 1. On 01/26/26 at approximately 2:25 PM, an observation was made of Resident #38 who was standing in the doorway of her room. The resident stated, Someone just tried to hurt me and They came into my room. At this time, staff member J, Dietary Aide, was observed in the hallway and was told by the surveyor what the resident had said. Staff member J entered the resident's room and assisted the resident back to her bed. On 1/26/26 at approximately 3:27 PM, an interview was conducted with Staff member I, Licensed Practical Nurse (LPN), who was assigned to care for Resident #38, during which she was asked if she had been informed of the resident's report of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-30 · 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 observations, interviews, and record review, the facility failed to ensure accurate medical records were reflective of residents' care for one of one resident (Resident #155) observed with edema and ordered to wear compression stockings (snug knee-high socks that provide pressure to the legs, ankles, and feet to improve circulation, reduce swelling, and prevent blood clots), out of a total of 45 residents in the sample. An observation conducted of Resident #155 on 1/27/26 at 10:29 AM found her barefoot and in bed. During an interview at this time, she was asked if she had any socks available to wear. Resident #155 answered, Yes, but they are over there. (pointing across the room to a pair of slippers) No socks or stockings were observed in the vicinity. Resident #155 was able to provide a detailed medical history leading up to her transfer to this facility. During an observation on 1/28/26 at 2:47 PM, Resident #155 was sitting on the side of her bed barefoot. Some mild edema (swelling caused by an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain temperature logs for the 3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted on 2/12/24 at 10:55 AM. During the tour, there was no temperature log sheet maintained for the 3-compartment sink. During the initial tour on 2/12/24 at 11:05 AM, [NAME] G reported that he washed, rinsed, and sanitized dishes in the 3-compartment sink and there was no sheet to document…
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 · D2024-02-15 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance for one (Resident #77) of one resident reviewed for personal property (missing clothing) from a total sample of 53 residents. The findings include: On 02/13/24 at 12:54 pm, Resident #77 stated he lost his pants on two different occasions. He could not remember the exact dates, but stated it was around August 2023 and December 2023. He added that he notified the certified nursing assistant (CNA), but he could not recall the employee's name. He also notified the housekeeping director. Per the resident, the facility had not done anything about it. He stated at one time he even provided the receipt when he bought replacement pants, but the facility never reimbursed him. He stated he had already lost the new pants that he bought despite putting his name on them. He was frustrated because he liked a particular brand of pants. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/11/23, revealed that the resident had a Brief Interview for Mental…
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 · D2024-02-15 · 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
Based on observation, medical record review, and staff interviews, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was conducted for one (Resident #38) of two residents reviewed for PASARR completion from 53 residents in the sample. Resident #38 had psychiatric diagnoses that were not documented on the original PASARR and should have been screened for a Level II after admission to the facility. The fndings include: A review of the medical record for Resident #38 revealed an admission date of 12/13/23 and included the following diagnoses: schizophrenia and dementia with mood disorder. The current PASARR received by the facility on 12/12/23 noted no diagnoses checked under Section I, and under Section II, a diagnosis of dementia was checked no. An interview was conducted with the Assistant Administrator on 02/15/24 at 11:38 a.m. She stated she was filling in for the Social Services Director while she was on leave. She stated a PASARR was needed for admission to the facility and was reviewed and discussed in morning meetings. The PASARR was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #6) of four residents reviewed for wound care, from a total sample of 53 residents, received wound care according to professional standards of practice to promote healing. The findings include: A review of the medical record revealed that Resident #6 was admitted to the facility on [DATE] with diagnoses including acute obstructive pulmonary disease with acute exacerbation, hypertension, sleep apnea, chronic pain, unspecified dementia - unspecified severity with psychotic disturbance, and depression - unspecified. On 02/13/24 at 9:50 AM, Resident #6 was observed with an undated adhesive wound care wrapping on her right forearm. On 02/14/24 at 10:05 AM, a second observation was made of Resident #6. She had the same undated adhesive wound care wrapping on her right forearm. On 02/15/24 at 10:47 AM, a third observation was made of Resident #6 with the same undated adhesive wound care wrapping on her 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.
- Potential for harm · D2024-02-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #22) of two residents reviewed for pressure ulcers, from a total sample of 53 residents, received pressure ulcer care according to professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. The findings include: On 02/13/24 at 11:16 AM, Resident #22, was observed lying in an upright position in bed, covered by a blanket with a nasal cannula in place. When greeted, she moaned and pointed to the corner where a family member was seated. The family member introduced herself as Resident #22's daughter, and stated her mother recently returned from the hospital and should be receiving treatment for the two sores on her bottom. She said the hospital ordered wound care treatment along with frequent re-positioning, but she felt the facility was not addressing the wounds, and she feared the wounds would worsen. A review of Resident #22's record revealed her…
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 9 citations
- Potential for harm · D2024-02-15 · 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
Based on observations, record review, staff interviews, and a review of the policy and procedure for Oxygen Therapy, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for two (Residents #29 and #129) of six residents reviewed for oxygen use, from a total sample of 53 residents. The findings include: 1. An observation was made of Resident #29 in her room on 2/12/14 at 11:00 a.m. She was observed with oxygen infusing via a concentrator through a nasal cannula. She reported her oxygen flow rate should have been set at 3 liters per minute (LPM). Her oxygen concentrator was observed with a flow rate set at 2.5 LPM. A medical record review for Resident #29 revealed an admission date of 1/22/24 with the following diagnoses: chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and atrial fibrillation. A 1/23/24 physician's order noted oxygen at 2 LPM as needed (PRN) for oxygen saturations of less than 92% for COPD. The care plan, updated on 1/23/24, noted: Resident has altered respiratory status/difficulty breathing related to COPD…
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 · D2024-02-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less. There were six errors out of 26 opportunities for error, resulting in an error rate of 23% and involving two (Residents #123 and #166) of three residents observed for medication administration. Failure to administer medications appropriately as ordered could result in side effects leading to harm to the residents. The findings include: During a medication administration observation on 2/14/24 at 8:52 a.m., Licensed Practical Nurse (LPN) A was observed preparing medication for Resident #123. She obtained Potassium Chloride (KCL), 20 miliequivalent (meq) tablet and Rytary extended release (ER) 48.75 -195 milligrams (mg) capsule (A combination of carbidopa and levodopa used to treat symptoms of Parkinson's disease). She crushed each medication separately and mixed with applesauce. She did not crush the KCL she mixed in apple sauce. She opened the Rytary capsule and poured the powder in applesauce. She then proceeded to the resident's room and administered…
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 · D2024-02-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure medications were stored in locked medication carts for three (Residents #16, #22, and #77) of 53 residents in the total sample. Pain creams and other creams were found in residents' rooms, which could lead to overdosing or harm to other residents. The findings include: 1. An observation was made of Resident #16 in her room on 2/12/24 at 11:57 a.m. She was sitting up in bed with a neck brace on and Voltaren, Triamincolone, and Bacitracin were sitting on her dresser at bedside. The resident reported using her Voltaren for arthritis pain. She was asked about the other creams but did not respond. An observation was made of Resident #16's room on 2/13/24 at 9:30 a.m. The resident was not in the room. Voltaren and Triamincolone were observed at bedside. An observation was made of Resident #16 on 2/14/24 at 9:20 a.m. in her room. She reported not using Triamincoline. She said it came from the hospital. She used Voltaren before therapy and 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 · Dcited before2024-02-15 · 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 record reviews, interviews, and a review of the Medication Pass Guideline Policy and Procedure, the facility failed to ensure to maintain complete, accurately documented medical records for one (Resident #50) of 53 sampled residents for blood pressure medication with parameters. Documenting the blood pressures before administration ensures nurses are following the physician's orders and not administering medication if the resident's blood pressure is too low. The findings include: On 2/14/24 at 9:45 a.m., Resident #50 was observed in her room sitting up in bed. She reported she had a sore throat this morning. She reported receiving her medications this morning. A medical record review was conducted for the resident which noted an admission date of 1/20/22 with diagnoses including dementia and hypertension. The active physician's orders were reviewed, which noted Lisinopril 2.5 milligrams (mg) every day for blood pressure and Metoprolol extended release 25 mg daily, hold if systolic blood pressure is below 110. The February 2024 Medication Administration Record (MAR) was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-03-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, dietary staff interview, facility document review, and facility policy and procedure review, the facility failed to store, prepare, and serve food under sanitary conditions when the dietary staff failed to wash hands between glove changes and change gloves when contaminated, as required. Food was stored in the walk-in cooler and walk-in freezer uncovered and not date marked. Food was kept beyond the allowed use by date. Baking sheets were wet nesting. Cutting boards were deeply grooved and in need of replacement. Handwashing sinks had no signage posted to indicate the sink was for handwashing only. The handwashing sink in the dish room was blocked by a mop bucket, broom, and dustpan. Food was observed on the floor of the freezer. Paper products to be used by residents were stored on the floor in the nutrition room. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a…
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 · F2022-03-24 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the Facility Assessment, CMS (Centers for Medicare and Medicaid Services) form 672 (Census and Condition of Residents), and interviews with staff, the facility failed to update the Facility Assessment on an annual basis in order to assess the population's acuity level and determine what resources were needed to provide care for its residents during not only day-to-day operations, but during an emergency. The facility also failed to employ the input of facility staff members including the Medical Director, Director of Nursing, any member of the governing body, residents or their representatives. This had the potential to affect all 124 residents in the facility. Without a comprehensive assessment of the residents' diagnoses, conditions and needs, the facility was not able to determine staff competencies required to provide appropriate care, nor the environment or equipment needed to perform such care. The findings include: A review of CMS form 672, Census and Condition of Residents, found there were 124 residents in the building at the time of the survey. Some of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and a review of resident records, the facility failed to provide medication and treatments as ordered and in accordance with professional standards of practice for one (Resident #121) of one resident who reported problems receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her…
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 · D2022-03-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure that psychotropic medications were used to treat a specific, diagnosed condition and failed to ensure as-needed (PRN) anti-anxiety medications were limited to a use of 14 days for one (Resident #57) of five residents reviewed for unnecessary medications. The findings include: A review of Resident #57's medical record revealed an admission date of 1/14/22. She received hospice services for end-of-life care related to her primary medical diagnosis of Alzheimer's disease. Secondary diagnoses included dementia, major depressive disorder, and anxiety. A review of the resident's physician's orders revealed the following medication orders: An order dated 2/18/22 for Seroquel (antipsychotic medication) 25 milligrams(mg) to be given twice daily for behavior management. An order dated 2/18/22 for Seroquel 50 mg to be given by mouth at bedtime for behavior management. An order dated 1/25/22 for Depakote (anticonvulsant medication)125 mg to be given two times a day for a diagnosis of anxiety. An order dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · 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 observations, resident and staff interviews, and a review of resident records and facility policies, the facility failed to accurately document resident medication and treatment records for one (Resident #121) of one resident who reported problems with receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample. The findings include: An observation of and an interview with Resident #121 was conducted on 03/22/22 at 10:24 AM. During the interview, she commented that by this time of day, her legs should already be wrapped. They were still not wrapped. She explained that staff were supposed to wrap her legs daily with ace bandages, however, some days it was after 4:00 PM or 5:00 PM by the time they finally applied the wraps. Some days, the staff did not apply them at all. Resident #121 added that her doctor recently prescribed her some nasal spray, but she still had not received it. It was intended for her wheezing 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.
“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 |
|---|---|---|---|---|
| DOLPHIN POINTE MEDICAL INVESTORS, LLC I | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 07/15/2016 |
| DOLPHIN POINTE MEDICAL INVESTORS, LLC II | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 07/15/2016 |
| DOLPHIN POINTE MEDICAL INVESTORS, LLC III | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 20% | since 07/15/2016 |
| OLT II, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | since 07/15/2016 |
| CLEVELAND, JEFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 07/15/2016 |
| FRASER, GEOFFREY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 20% | since 07/15/2016 |
| NELSON, SEAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 20% | since 07/15/2016 |
| FIFTH THIRD BANK | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 02/24/2017 |
| NELSON, DENISE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/15/2016 |
| KALLEN, JASON | Individual | ADP OF THE SNF | — | since 12/04/2025 |
CMS files one row per role, so the 14 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.1M paid to related parties (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
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 106135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, 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.