Riverside Post Acute
1750 Stockton St, Jacksonville, FL 32204 · For profit - Corporation · 240 certified beds · (904) 308-4700 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,777 in federal fines (most recent 2023-11-16)
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
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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 | 3 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 improved from 1 to 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 | 12.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.3% | 0.9% | worse 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 | 25.7% | 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 | 5.6% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.2% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.5% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.5% | 10.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.6% | 8.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 75.9% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 23.4% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.9% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.19 | 1.15 | 1.80 | better |
‡ 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.
53.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 228 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.8% 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 164 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 | 53.2%CMS range 47.0–60.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.8–14.1 | 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 | 51.8% | 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 | 49.4% | 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 | 35.4% | 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 | 97.3% | 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 | 99.4% | 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 | 94.7% | 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 | 0.9% | 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 | 7.1% | 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 | 5.3%CMS range 3.2–8.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 240 beds and averages 218.1 residents a day — about 91% occupied, or roughly 22 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.19 hrs/resident/day on weekends vs 3.50 on weekdays — 9% thinner on weekends. RN hours go from 0.59 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2023-11-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent falls for one (Resident #135) of seven residents reviewed for falls, from a total sample of 41 residents. The findings include: A review of Resident #135's medical record revealed that he was admitted to the facility on [DATE], with his most recent readmission occurring on 7/31/23. Resident #135's diagnoses included unspecified fall, unspecified motor vehicle accident with injury; other injury of unspecified body region; and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of the resident's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/14/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. No behaviors were documented. His functional status was documented as follows: Bed Mobility/Self Performance - Total…
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 before2025-12-04 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure completion of the Pre-admission Screening and Resident Review (PASRR) process for two (Residents #51 and #127) residents who were identified with a newly evident or a possible serious Mental Disorder (MD), Intellectual Disability (ID) or related condition, from a total survey sample of 33 residents who were reviewed for PASRR.The findings include:1.A 12/2/25 review of Resident #51's PASRR, dated 9/14/22, revealed in Section I: PASRR Screen Decision-Making, that the resident did not have diagnoses or suspected diagnoses of anxiety disorder, bipolar disorder, depressive disorder, or schizophrenia. (Copy obtained)A review of Resident #51's record revealed an admission date of 12/31/22. Her diagnoses as of 8/7/24 included schizophrenia, unspecified; depression, unspecified; generalized anxiety disorder, and bipolar disorder, unspecified.A review of Resident #51's physician's orders included:Alprazolam (benzodiazepine often used to treat anxiety) oral tablet 0.25 mg…
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 before2025-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, interviews, and a review of facility policies and procedures, the facility failed to provide appropriate fingernail care for two (Residents #182 and #196) residents who required assistance with grooming out of 56 residents whose fingernails were observed. Failure to provide consistent grooming and hygiene for residents who require assistance can negatively impact their sense of self-worth and dignity, as well as potentially spread infection and/or contribute to skin tears or other injuries. The findings include:1.A review of Resident #182's medical record revealed an admission date of 7/15/24 and diagnoses including hemiplegia/hemiparesis following a cerebral infarction (stroke) affecting the resident's right dominant side and seizures.On 12/01/25 at 12:33 PM, Resident #182 was observed propelling himself in a wheelchair down a corridor within the facility. He was observed to be speech impaired but was able to answer simple yes or no questions. He was able to understand what was being conveyed, but could only answer verbally, yeah. He also used…
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 before2025-12-04 · 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 observations, interviews, record review, and facility policy and procedure review, the facility failed to provide respiratory therapy, consistent with professional standards of practice, for three (#9, #63, and #181) of 21 residents receiving oxygen therapy. Oxygen flow rates set for these residents were not in accordance with their physicians' orders. The findings include: 1.On 12/01/25 at 11:46 AM, Resident #9 was observed resting in bed with oxygen infusing at 4 liters per minute (LPM) via nasal cannula (NC). (photographic evidence obtained) On 12/02/25 at 9:25 AM, a review of the resident's active physician's orders revealed an order for oxygen at a flow rate of 3 LPM via NC for Congestive Heart Failure (CHF) (ordered 10/29/25). On 12/02/25 at 1:37 PM, Resident #9 was observed sitting up in bed with her lunch meal on the bedside table in front of her. Oxygen was infusing at 4 LPM via NC. (photographic evidence obtained) A review of Resident #9's medical record revealed an admission date of 2/13/24…
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 · D2025-12-04 · 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
Based on observation, interviews, record review, and a review of facility policies and procedures, the facility failed to demonstrate safe, sanitary infection control and prevention procedures while providing resident care and services. The findings include:On 12/04/25 at 12:18 PM, an observation was made of Registered Nurse (RN) G performing scheduled fingerstick blood glucose testing/monitoring. After checking the resident's blood glucose, the nurse discarded the used lancet in a trash container in the resident's bathroom. When the act of throwing the used lancet in the trash container was brought to RN G's attention, she acknowledged that she had disposed of the lancet in the trash container and not the used sharps container. RN G then extended her ungloved hand into the trash container and retrieved the used lancet. She stated, It doesn't have a sharp end on it after we use it. She did not wash her hands before returning to her medication cart. Once there, she applied hand sanitizer and proceeded to move her medication cart to the next resident she intended to service. 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 · D2025-09-02 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide a safe, functional, sanitary, and comfortable environment for residents in regard to 1) call light not properly working in Resident #6's room, and 2) water dripping from a vent in the ceiling going into a trash bin in Resident #5's room, out of 8 resident rooms sampled. The findings include:1.During a tour of the Memory Care unit in the facility on 9/2/2025 at 10:05 am, a flashing red light making an audible sound was observed above room [ROOM NUMBER]. Two (2) staff members were at the nurses' station approximately 5 feet away room as well as several residents in the lounge area approximately 3 feet away from the room. Several staff members were observed walking on the unit. None of them made an effort to respond to the flashing red call light or the audible sound that it was making. Further observation revealed a housekeeper was cleaning the room. The light remained flashing, making an audible sound after the housekeeper exited…
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 · E2024-04-24 · tag F0585 — failed to handle grievances — patternHonor 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 interviews, facility grievance log review, and complaint and grievance policy review, the facility failed to follow facility policy in providing required written notification of the outcome of the grievance investigation for 5 of 5 grievances submitted by four (Residents #4, #5, #6, and #7) residents. The findings include: On 4/24/24 at 10:34 am, an interview was conducted with Registered Nurse-A, Manager 1 North regarding resident grievances. He explained that if a resident has a complaint or grievance, staff is to let the manager know. The manager will then try to resolve the issue at bedside, if unable, the manager will contact social services and the issue will be discussed in morning meeting. On 4/24/24 at 11:25 am, an interview was conducted with Licensed Practical Nurse-B. She stated that if a resident or family member complains, she attempts to resolve the issue at bedside. If she's unable to resolve the issue, then she would let the manager know. A review of the facility grievance log from December 2023 to present revealed the following: (Copy obtained) 12/22/23:…
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 · F2023-11-16 · 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 — an excerpt from the official record, may be distressing
Based on observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene and disposable glove use during meal service, as well as proper sanitation practices when cleaning and using the meat slicer to prevent cross contamination, with the potential to affect all of the residents in the facility who received food from the facility's kitchen. Specific instruction on 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. Failure to thoroughly clean and sanitize the meat slicer could result in the development of a cross-contamination infection and clinical compromise. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the kitchen on 11/13/2023 at 9:30 a.m., the meat slicer was covered with a large…
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 · D2023-11-16 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the the facility failed to provide documented evidence that all alleged violations of abuse, neglect, exploitation, and/or mistreatment were thoroughly investigated for one (Resident #75) of 41 residents sampled. Failure to thoroughly investigate alleged violations places other residents at risk for abuse, neglect, exploitation and mistreatment. The findings include: On 11/13/23 at 1:54 p.m., Resident #75 stated last week she noted that $400.00 of her money was missing. She stated she notified the nurse and added that she was afraid to leave her room, as she did not know what else might come up missing. A review of Resident #75's record revealed that she was admitted to the facility on [DATE] with a readmission on [DATE]. Her diagnoses included type 2 diabetes with diabetic neuropathy, anxiety disorder, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 9/29/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15…
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 · D2023-11-16 · 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 observation, interview, resident record review, and facility policy review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid, to the maximum extent practicable, to avoid duplicative testing and effort for one (Resident #17) of 41 residents sampled. The facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disability, or a related condition for a level II resident review. The findings include: A record review for Resident #17 was conducted on 11/14/23 at 10:45 a.m. The PASARR could not be located. The facility was asked to provide the documentation. Two PASARRs were provided, one dated 4/24/2015 and the other dated 12/31/2015. Neither of the PASARRs reflected the resident's diagnosis of dementia or unspecified psychosis. The record revealed that Resident #17 was readmitted to the facility on [DATE] after having been hospitalized . Her diagnoses included unspecified…
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 before2023-11-16 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #2) of 41 residents sampled, was appropriately screened for a mental disorder (MD), intellectual disability (ID) or other related conditions prior to admission. Failure to ensure residents are pre-screened for MD/ID or a related condition, prior to admission to the facility, could prevent the resident from attaining or maintaining his/her highest practicable level or result in decline in the resident's physical, mental or psychosocial well-being. The findings include: A review of Resident #2's medical record revealed that a Level 1 PASARR (Pre-admission Screening and Resident Review) evaluation was documented and dated 07/28/2010, which was more than 10 years prior to her admission to this facility on 02/17/2021. Per the resident's Annual, Comprehensive Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/1/2022, there was no indication of where…
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 · D2023-11-16 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility policy and procedure review, the facility failed to provide an ongoing activity program that met residents' interests and supported the physical, mental, and psychosocial well-being of one (Resident #73) of 41 sampled residents. Facility activities programs that incorporate residents' interests, hobbies and cultural preferences are intregal in maintaining and/or improving residents' physical, mental, and psychosocial well-being and independence. The findings include: On 11/13/2023 at 11:03 a.m., Resident #73 was observed lying in bed with a hospital gown on. Her eyes were closed. She did not open her eyes or respond when her name was called. The room was dark. The television was not on and no music was playing from any device in her room. The room was not homelike as evidenced by no personal belongings visible anywhere in the room and the walls were bare. There was no Activities calendar in the resident's room. During the lunch meal service 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 before2023-11-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two (Residents #53 and #20) of three residents sampled for review of respiratory care, from a total sample of 41 residents, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The findings include: 1. On 11/13/23 at 2:45 p.m., Resident #53 was observed in her room. She was sitting up in a wheelchair receiving oxygen via a nasal cannula. A dark blue oxygen concentrator was positioned behind the resident next to her bed. The oxygen flow rate was set at 3 liters per minute (LPM). The resident was asked what the flow rate should be set at and she replied that the flow rate should be 2 LPM. (Photographic evidence obtained) On 11/15/2023 at 12:02 p.m., Resident #53's oxygen flow was observed to be set at 3 LPM. On 11/15/2023 at 4:25 p.m., Resident #53's oxygen flow rate was observed to be set at 3 LPM. (Photographic…
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 · D2023-11-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that two (Residents #41 and #17) of five residents sampled for medication review, from a total of 41 residents sampled, were free from unnecessary drugs. An unnecessary drug includes any drug used without adequate monitoring. The findings include: 1. A review of Resident #41's medical record revealed and admission to the facility on 7/18/2018. Her most recent readmission was on 8/18/2023. Her diagnoses included acute kidney failure; chronic systolic (congestive) heart failure; delusional disorder; atherosclerotic heart disease of native coronary artery; visual hallucinations; Parkinson's disease; unspecified dementia; type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). A review of the resident's active physician's orders revealed she was receiving Seroquel (antipsychotic) 50 mg (milligrams) daily; Namenda XR (cognition-enhancing medication) 14 mg daily; Buspar (anxiolytic) 5 mg twice a day; Novolog U-100…
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 before2023-11-16 · 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 less than 5% based on 32 opportunities for error with two errors identified, resulting in an error rate of 6.25 %. The errors affected two (Residents #454 and Resident # 86) of seven residents observed during medication administration, from a total of 41 residents in the sample. Failure to administer medications correctly, as ordered, could result in side effects including serious harm to a resident. The findings include: During medication administration observation on 11/14/23 at 12:34 p.m., Licensed Practical Nurse (LPN) Q was observed administering insulin to Resident #454. LPN Q obtained a blood glucose reading of 167. After reviewing the resident's sliding scale order, LPN Q stated the resident needed 2 units of NovoLog insulin. He obtained a NovoLog kwik pen and dialed the pen to 2 units. He administered the insulin in the resident's lower abdomen. In an interview with LPN Q on 11/14/23 at 12:45 p.m., he was asked how he ensured that there were no air bubbles…
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 before2023-11-16 · 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 a policy and procedure review, the facility failed to secure/store medications in locked compartments to limit unauthorized access to medications for two (Residents #35 and #57) of 41 sampled residents. Failure to ensure medications are secure and/or inaccessible could result in residents ingesting medications and suffering significant adverse consequences. The findings include: 1. On 11/13/23 at 12:26 p.m., Resident #35 was observed resting in bed. Bottles of over-the-counter Systane ultra dry eye relief and Systane complete dry eye relief were observed on the resident's bedside table. (Photographic evidence obtained) When he was asked whether the facility had evaluated him to self-administer medication, Resident #35 stated he liked to administer the eye drops at night to help reduce his dry eyes. On 11/15/23 at 10:36 a.m., Resident #35's eye drops were still observed at bedside. A review of Resident #35's active physician's orders revealed no orders for the Systane eye drops and no assessment for self-administration of medication. In 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 · D2023-09-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, interviews, and facility policy review, the facility failed to ensure that alleged violations involving neglect, and misappropriation of resident property, were reported no later than 24 hours to the State Survey Agency for two (Residents #1 and #2) of 4 residents reviewed for reportable incidents. The findings include: 1. A review of the facility's adverse incidence report revealed that Resident #1 had an incident on 8/8/2023. A review of the clinical record for Resident #1 revealed an admission date of 3/14/23, with re- entries on 7/3/23, 7/31/23, 08/16/23, 8/27/23, and discharged on 8/29/23. Her diagnoses included Diabetes Mellitus, Cardiovascular accident, chronic kidney disease, seizure disorder and bipolar disorder. Physician's orders for Resident #1 dated 8/1/23 revealed orders for insulin Levemir 100 units/milliliter (ml) inject 11 units subcutaneous two times a day (BID) and Humalog 100 units/inject 6 units three times a day and sliding scale during meals. On 8/3/23 there was 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 · Ecited before2022-01-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to administer oxygen at the ordered flow rate for one resident (Resident #45), and administered oxygen without a physician's order for two (Residents #92 and #8) of twenty-two residents on oxygen therapy, from a total sample of 40 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. A review of Resident #'45's clinical record revealed he was to the facility on 5/9/2021 with a diagnoses that included: chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was independent with most activities of daily living. A review of the quarterly mininum data set (MDS) assessment dated [DATE] revealed Resident #45 had a brief interview for mental status (BIMS) score score of 15, indicating cognitively intact. Further review of Resident #1's clinical record revealed a physican's order…
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 · D2022-01-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy and procedure review, the facility failed to implement a pressure ulcer/skin prevention person-centered care plan for one (Resident #33) of seven residents reviewed for care plans, from a total sample of 40 residents. Failure to implement the care plan puts the resident at risk of not receiving appropriate interventions and could potentiate medical or physical complications. The findings include: On 1/24/22 at 1:19 PM, Resident #33 was observed lying in her bed in a supine position. The bed was in the low position with a fall mat at the bedside. Heel boots were observed at the bedside chair. (Photographic evidence obtained) In an interview on 1/24/22 at 1:20 PM, Resident #33 stated that her toe was hurting. The resident's second toe on her right foot was observed to be reddened. Her feet were not elevated, and her bilateral heels were reddened. A review of the clinical record revealed that Resident #33 was admitted to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to provide assistance with bathing/showers for two (Residents #85 and #117) of three residents reviewed for activities of daily living (ADLs), out of a total sample of 40 residents. The findings include: 1. A review of Resident #85's medical record revealed an admission date of 10/4/2021. Medical diagnoses included metabolic encephalopathy, acute kidney failure, hemiplegia, unspecified affecting right dominant side and weakness. A quarterly minimum data set (MDS) assessment, dated 11/10/21, indicated a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. The resident was documented as needing extensive assistance with bed mobility and physical help with bathing. On 1/24/22 at 2:12 PM, an interview was conducted with Resident #85. She stated that the facility did not have enough staff to care for residents. She went on to say that she did not have a bed bath last week. When she was asked what day, she is scheduled to be bathed, she replied, On Monday 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 · D2022-01-27 · 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 record review, the facility failed to appropriately address a resident's change in condition by failing to 1) comprehensively assess a resident's behavioral change in condition, and 2) promptly notify the resident's health care provider, and 3) implement person-centered interventions to address the change in condition for one (Resident #23) of three residents reviewed for change in condition, from a total sample of 40 residents. The findings include: A review of Resident #23's medical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of chronic kidney disease. Secondary medical diagnoses included dementia with depression, hypertension, and dyslipidemia. The resident required extensive to total assistance with activities of daily living, including transfers. A quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 3 out of a possible 15 points, indicating severely impaired…
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 before2022-01-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide adequate assistance to prevent accidents for one (Resident #87) of three residents reviewed for accidents, and failed to appropriately monitor the neurological status for two (Residents #280 and #33) of three residents reviewed for falls, from a total sample of 40 residents. The findings include: 1. A review of Resident #87's medical record revealed a readmission date of 11/11/21 with diagnoses that included history of falls, fracture of the ulna, and laceration of the head. A minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3 out of a possible 15 points, indicating severely impaired cognition. The resident required limited to extensive assistance with activities of daily living and was occasionally incontinent of urine and frequently incontinent of bowel. Review of the nursing progress notes revealed an entry dated 11/11/21 12:31 a.m. authored 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 · D2022-01-27 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview and record reviews, the facility failed to follow physician's orders for one (Resident #2) of three residents receiving enteral feedings, from a total sample of 40 residents. The findings include: On 1/25/22 at 3:25 PM, Resident #2 was observed lying in bed with his eyes closed. He was receiving an enteral tube feeding of Glucerna 1.5, set at 50 ml (milliliters) per hour. (Photographic evidence was obtained) A review of the clinical record revealed that Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: acute kidney failure, polyneuropathy, gastrostomy status and dysphagia, oropharyngeal phase. A review of the January 2022 Physician's Order Sheets revealed an order dated 1/10/22 for Glucerna 1.5 Liquid 70 ml/hr. Enteral Tube Continuous for water flush 180-ml every 4 hr. 50 ml/hr. (Copy obtained) A review of the resident's care plan with start date of 12/27/21 revealed the resident has a feeding tube necessary for nutritional…
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 before2022-01-27 · 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, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were two errors and a total of twenty-six opportunities, resulting in an error rate of 7.69%. The finding include: 1. On 1/26/22 at 9:22 AM, an observation of medication administration observation was conducted for Resident #28 with Employee J, Registered Nurse (RN). Resident #28 had a physician's order for hydrochlorothiazide (used to treat high blood pressure), 25 mg (milligram) tablet, once daily by mouth. Employee J, RN reviewed the orders as he popped the medication in the medication cup. There were two tablets for hydrochlorothiazide 12.5 mg in the bag. Employee J, RN picked out one tablet of hydrochlorothiazide and placed it back in the cart and popped the other one in the medication cup. He proceeded to administered 1 tablet of hydrochlorothiazide 12.5 mg to Resident #28. On 1/26/22 at 9:30 AM, during an interview with Employee J, RN, he acknowledged only 1 tablet of hydrochlorothiazide…
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 before2022-01-27 · 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 observations, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for one resident (Resident #31) in a total sample of 40 residents. The finding include: On 1/24/22 at 12:53 PM, Resident #31 was observed lying in bed. There was a compound cream equal parts 1:1 zinc/bacitracin/nystatin/cream, observed at the bedside. (Photographic evidence obtained) A review of physician orders for Resident #31 revealed active orders to: Cleanse left and right foot with normal saline pat dry apply xeroform then calcium alginate the 4x4 gauze wrap with kerlix at bedtime (Qhs). Compound cream equal parts 1:1 zinc/bacitracin/ nystatin/cream, apply to bilateral inner thighs buttocks three times a day. On 1/25/22 at 1:40 PM, a second observation of Resident #31 was made. She was observed lying in bed with a compound cream equal parts 1:1 zinc/bacitracin/nystatin/cream, observed at the bedside. (Photographic evidence obtained) On 1/27/22 1:31 PM, the Director of Nursing (DON) went to Resident #31's room and confirmed that…
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
$17,777 in federal fines across 2 penalties.
- $5,975 — penalty dated 2023-11-16
- $11,802 — penalty dated 2023-11-16
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to MARQUIS HEALTH SERVICES — 87 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 3 of 5 | 4.3 | -1.3 vs chain |
The other 86 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 86; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| QUINTO NEXGEN LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| SKILLED VENTURE LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| UKR NEXGEN LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| NFR 2020 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| RSBRMK HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| SK NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| TRYKO NEXGEN HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| UAK 2020 IRRV TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| YK NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| YR NEXGEN TR | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2024 |
| KAHANOW, AVIVA | Individual | INDIRECT OWNERSHIP INTEREST | since 05/01/2024 |
| ROKEACH, FRAIDE | Individual | INDIRECT OWNERSHIP INTEREST | since 05/01/2024 |
| ISRAEL DISCOUNT BANK OF NEW YORK - IDB BANK OF YORK | Organization | 5% OR GREATER SECURITY INTEREST | since 05/01/2024 |
| DELUCA, MARISA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| HARMAN, DINA | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| PETERS, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| VIROJA, YOGESH | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| POSEN, MINDEE | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 05/01/2024 |
| HEALTHCARE SERVICES GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| RELIANT PRO REHAB, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| FLAGLER, OSHER | Individual | TRUSTEE OF THE SNF | since 05/01/2024 |
| LEVOVITZ, TZVI | Individual | TRUSTEE OF THE SNF | since 05/01/2024 |
| ROKOWSKY, YITZCHOK | Individual | TRUSTEE OF THE SNF | since 05/01/2024 |
| CEDARBRIDGE FINANCIAL SERVICES LLC | Organization | ADP OF THE SNF | since 05/01/2024 |
| CLINICAL CARE CONSULTANTS LLC | Organization | ADP OF THE SNF | since 05/01/2024 |
| MARQUIS HEALTH CONSULTING SERVICES LLC | Organization | ADP OF THE SNF | since 05/01/2024 |
| RIVERSIDE REAL PROPERTY LLC | Organization | ADP OF THE SNF | since 02/24/2025 |
| ZIMMET HEALTHCARE SERVICES GROUP LLC | Organization | ADP OF THE SNF | since 05/01/2024 |
| NARVEL, RAVISH | Individual | ADP OF THE SNF | since 05/01/2024 |
CMS files one row per role, so the 47 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
18 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 $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 105358. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, 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 →
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