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Riverwood Center

2802 Parental Home Road, Jacksonville, FL 32216 · For profit - Limited Liability company · 240 certified beds · (904) 721-0088 Medicare & Medicaid certified

Call the home — (904) 721-0088 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$34,778 in federal fines
Insights

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

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $34,778 in federal fines (most recent 2025-01-09)
  • its independent health-inspection rating is low (2/5)
  • about 29% of its spending goes to commonly-owned related companies

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4131 University Blvd S · (904) 274-8813 · Call to confirm hours
Pharmacy
5972 University Blvd W · (904) 419-5670 · Call to confirm hours
Grocery
7407 Goodnow Rd · (904) 635-6661 · Call to confirm hours
Park
2905 Parental Home Rd · Typically dawn to dusk
Place of worship

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 5 of 5
Short-stay residentsrehab / post-hospital 1 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 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.2%8.7%15.4%better
Long-stay residents who lose too much weight4.8%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms5.6%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened6.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.6%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.5%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control22.6%10.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table24.5%8.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine99.2%94.7%79.4%better
Short-stay residents rehospitalized after admission24.7%26.1%22.6%typical
Short-stay residents with an outpatient ER visit7.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.482.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.671.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

27.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

27.1%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
33.3%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 33.3% 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 87 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF27.1%CMS range 17.8–42.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.1–14.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge33.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge36.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.6–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.38
RN hours/ resident / day
0.90
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.28
RN hoursweekends
47.1%
Total nursing turnover
20.0%
RN turnover

How full it usually is: this home is certified for 240 beds and averages 218.0 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.10 hrs/resident/day on weekends vs 3.46 on weekdays — 10% thinner on weekends. RN hours go from 0.43 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% 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

8
deficiencies at the latest standard inspection (2025-01-09)
7
at the previous standard inspection (2023-02-02)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Actual harm · G2025-01-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 restorative nursing therapy to ensure that a resident's abilities in activities of daily living did not diminish for two (Residents #193 and #56) of two residents reviewed for the dining restorative program, from a total of 11 residents participating in the dining restorative program, in a total survey sample of 56 residents. The 11 residents on the dining restorative program were at risk of further decline. Resident #193 suffered a significant weight loss. The findings include: 1. During the dining observation on 01/06/25 at 11:50 AM, Resident #193 was observed seated at the dining table in the Caring Way unit. She was served a mechanical soft meal on a regular plate. She consumed 25% of her meal and then scooped the remaining food from her plate onto a paper napkin that was provided with the meal tray. Resident #137, who was seated beside her, was observed eating the food from the napkin and eventually he tried to eat the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure that one (Resident #50) of 52 sampled residents currently residing in the facility, had access to his call light. The findings include: On 01/06/2025 at 12:05 PM, Resident #50 was observed seated in his wheelchair in his room at the foot of his bed facing the entrance to the room. He was wearing a short sleeved tee shirt, pants and non-skid socks. His right arm, wrist and fingers were contracted. He indicated he did not have any concerns. The call light was observed lying on top of the bed near the head of bed next to the pillow and out of reach of the resident. (Photographic evidence obtained) The resident was served lunch at 1:15 PM in his room, but his call light was not placed within his reach. On 01/07/2025 at 11:28 AM, Resident #50 was observed in his room. He was seated in his wheelchair at the foot of his bed. The call light was observed lying on top of the bed near the head of the bed next to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy and procedure review, the facility failed to honor the personal privacy of one resident (#81) reviewed for personal privacy from a total survey sample of 56 residents. The findings include: On 01/06/25 at 1:30 PM, Resident #81 was observed in her semi-private room. She had no privacy curtain. On 01/06/25 at 2:30 PM, the resident's room was observed. There was no privacy curtain in place for this resident. On 01/07/25 at 10:17 AM, the resident was observed standing inside her doorway looking out into the corridor. There was no privacy curtain in place for this resident's area of the room near the window. A record review revealed that Resident #81 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, neurological disorder due to known physiological condition with behavioral disturbance, mood disorder due to known physiological condition, and major depressive disorder. A review of athe resident's care plan revealed the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy and procedure review, the facility failed to implement the comprehensive care plan to meet the resident's medical needs for one (Resident #43) of one resident reviewed for transmission based precautions from a total of 56 residents in the survey sample. Specifically, isolation precautions were not followed as indicated in the care plan. The findings include: On 01/06/25 during a 12:33 PM interview, Resident #43 stated she had scabies but wanted to be out of isolation, as she was not being treated. No precautions sign or PPE (personal protective equipment) were on her door. (Photographic evidence obtained) On 01/07/25 at 9:00 AM, no precautions sign or PPE were observed on the resident's door. On 01/08/25 at 9:30 AM, no precautions sign or PPE were observed on the resident's door. A review of the resident's medical record revealed the following physician's orders: 01/08/25 - Permethrin External cream 5%, apply all over head to toe topically every night…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #47) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 56 residents. The findings include: On 01/06/25 at 11:22 AM, Resident #47 was observed resting in bed with elongated, jagged fingernails on both hands. She was asked if the staff trimmed her fingernails and she replied, One nurse cut my nails once since I've been here. She was asked if she preferred her fingernails long. She stated, I prefer them short. She was asked how her fingernails had been maintained since she was admitted . She replied, Usually when I'm doing something they just break off down to the quick and hurt. The resident was observed with tremors of both hands. (Photographic evidence obtained) A review of Resident #47's medical record revealed she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, COPD (chronic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and staff interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one (Resident #18) out of four residents observed during medication administration, from a total survey sample of 56 residents. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents. The findings include: During medication administration observation on 1/7/25 at 9:40 AM, Licensed Practical Nurse (LPN) M was preparing medication for Resident #18. After reviewing the medication administration record (MAR), she stated she did not have the Fluoxetine that was ordered for Resident #18. She checked the MAR and identified that the medication had been ordered from the pharmacy on 12/29/24. She stated it should arrive later today. She then stated she would place an order for it again now, just in case, which she did. A review of Resident #18's physician's orders revealed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, staff interviews, and policy and procedure reviews, the facility failed to ensure a medication error rate of less than 5% based on three errors out of 26 opportunities for error. The three errors (failure to administer medications and crushing enteric coated medication) resulted in an error rate of 11.54%. Two (Residents #18 and #51) of four residents observed during medication administration from a total survey sample of 56 residents were affected. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents. The findings include: 1. During medication administration observation on 1/7/25 at 9:40 AM, Licensed Practical Nurse (LPN) M was preparing the medication for Resident #18. After reviewing the medication administration record (MAR), she stated she did not have the Fluoxetine that was ordered for Resident #18. She checked the MAR and identified that the medication had been ordered from the pharmacy on 12/29/24. She stated it should arrive later today. She then stated she would place 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy and procedure review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Resident #84) of two residents reviewed for dental care, from a total survey sample of 56 residents. The findings include: On 01/06/25 at 11:59 AM, Resident #84 was observed to be pleasantly confused. Even standing several feet away from her, she had noticeably foul-smelling breath. On 01/07/25 at 10:30 AM, Resident #84 was observed sitting up in a recliner in her room. Even standing several feet away from her, she had noticeably foul-smelling breath. On 01/07/25 at 3:30 PM, Resident #84 was observed and continued to have noticeably foul smelling breath. On 01/08/25 at 11:23 AM, a record review conducted for Resident #84 revealed an admission date of 12/19/2020 and diagnoses including dysphagia (difficulty swallowing), cognitive/communication deficit, and GERD (gastroesophageal reflux disease). A review of the resident's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, record review, interviews, and facility policy review, the facility failed to ensure that residents unable to carry out activities of daily living (ADLs), received necessary care and services to maintain proper grooming and personal hygiene, by failing to provide nail care for two (Residents #8 and #11) of four residents reviewed for ADLs, from a total sample of 16 residents. The findings include: 1. During an interview with Resident #8 on 2/12/24 at 10:10 AM, his left hand was observed to be contracted around a washcloth. He explained that without the washcloth, his fingernails would dig into his palm. The resident's fingernails on both hands were soiled with dark brown substance resembling feces around the cuticles and under each nail. When asked if he was receiving any assistance with handwashing or nail care, he replied, No, I am not. A record review for Resident #8 revealed he was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of medically complex…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure wound care was provided as ordered for two (Residents #2 and #3) of two residents reviewed for wound care, from a total sample of 16 residents. The finding include: 1. On 2/12/24 at 10:40 AM, Resident #2 was observed lying in bed on his left side. His eyes were closed and did not answer to his name being called, resp 16/minute. His right foot was observed to be wrapped in gauze and dated 2/10/24. The bottom of his right foot which was observed wrapped in gauze, which was colored, and dirt was on both the exposed foot (heel) and the gauze. A record review for Resident #2 revealed an admission date of 12/5/23, with diagnoses of congestive heart failure, insomnia, unspecified psychosis, dementia, major depressive disorder, mixed anxiety disorder. A review of 5-day…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, interviews, and facility policy review, the facility failed to practice proper infection control measures by 1) failing to wear required personal protective equipment (PPE) for one (Resident #12) of one resident reviewed for transmission base precautions, and 2) failing to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound care dressing change for one (Resident #2) of one resident observed during wound care, from a total sample of 16 residents. The findings include: 1. On 2/12/24 at 11:44 AM, Employee D, Certified Nursing Assistant (CNA) was observed entering Resident #12's room without donning personal protective equipment (PPE). The door for Resident #12's room was observed to contain a PPE hanger with pockets that were observed to contain a box of gloves, a package of disposable blue gowns, N95 face masks, and face shields and a sign stating, Contact Precautions. The sign was observed to say: Put on gloves before room entry. Discard gloves before room exit. Put gown…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2023-08-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, record review, and review of the facility's policy, the facility failed to provide appropriate and timely assistance for one (Resident #5) of five residents reviewed for activities of daily living (ADLs), who required extensive assistance with toileting. The findings include: A review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, personal history of TIA (Transient ischemic attack) and cerebral infarction, mood disorder due to known physiological condition, muscle weakness and anxiety disorder. A review of the admissions minimum data set (MDS) assessment, dated 7/12/23, revealed a brief interview for metal status (BIMS) score of 3 out of a possible 15, indicating severely impaired cognition. Resident #5 required total dependence with transfers, locomotion on/off unit and personal hygiene, extensive assistance with bed mobility, eating and toilet use. He was frequently incontinent of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-02 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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, record review, and policy and procedure review, the facility failed to ensure that resident meals were served at a safe and appetizing temperature, for five (Residents #478, #467, #104, #31, and #184) out of 55 sampled residents. Failure to provide palatable, attractive, and appetizing food in accordance with professional standards for food service, can decrease the amount of food all residents eat and drink. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a facility tour on 1/30/23 at 12:50 PM, Resident #468, who had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition), reported, The food is always cold. The food sits in the hallway for 30 minutes before being served. On 2/1/23 at 2:00 PM, Resident #467, with a BIMS score of 10 out of a possible 15 points (moderate cogntive impairment) reported, Today the food was cold all…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, staff and resident interviews, medical record review, and facility policy review, the facility failed to assist five (Residents #115, #65, #37, #98, and #70) of 55 sampled residents, reviewed for activities of daily living (ADLs), necessary to maintain grooming and personal hygiene for dependent residents. The findings include: 1. On 01/30/2023 at 12:10 PM, Resident #115 was observed in her room, sitting up in a wheelchair, dressed in day clothing. Her fingernails were elongated with brown debris under each nail. On 01/31/2023 at 10:02 AM, Resident #115 was observed in her room, sitting up in a wheelchair, dressed in day clothing. Her fingernails were elongated with brown debris under each nail. On 02/01/2023 at 8:55 AM, Resident #115 was observed in her room, awake in bed. Her fingernails were elongated with brown debris under each nail. On 02/01/2023 at 2:50 PM, Resident #115 was in her room, awake in bed. Her fingernails were elongated with brown debris under each nail. The resident 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, by failing to 1) Carry out physician's orders for consultations for Resident #30, and 2) Promptly identify and intervene for a change in condition (dehydration), report low blood pressures (hypotension) to the physician, consult the physician about low blood pressures prior to the administration of blood pressure medications for a resident with hypotension, and follow physician's orders for laboratory tests, for Resident #517, two residents reviewed from a total sample of 55 residents. The findings include: 1. On 1/31/22 at 10:00 AM, Resident #30 was observed lying in bed. He stated he had spoken to his physician multiple times related to his pain and vision. He had pain in his left lower back that radiated to his left foot. He stated when 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-02 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, medical record review, and policy and procedure review, the facility failed to ensure that two (Residents #37 and #74) of a total sample of 55 residents were provided with foot care consistent with professional standards of practice, including assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists. The findings include: 1. On 01/31/23 at 10:00 AM, Resident #37 was observed lying in bed, awake and conversant. The resident stated she had not seen a podiatrist. She pulled back her covers and both feet were observed to have significantly thickened toenails, which were elongated and curled. She stated her left great toe hurt. She was asked when she had last seen a podiatrist. She stated, I don't know, but I haven't seen one since I've been here. She was asked if staff trimmed or cleaned her toenails. She stated, No. I don't think they will, because I'm a diabetic. She was asked if she had asked staff for a podiatry appointment. She replied, Yes, I've asked more than once. I haven't…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, and facility policy review, the facility did not ensure the resident environment remained as free of accident hazards as is possible for one (Resident #106) of a total sample of 55 residents. The facility, which is responsible for resident safety, had no protocol for verifying the safety of individual resident refrigerators and/or maintaining safe temperatures inside to ensure foodborne illness did not result from temperatures that were too warm to keep foods properly cooled. The findings include: On 1/30/23 at 12:15 PM, Resident #106 was observed lying in bed, dressed in day clothes. A personal refrigerator was observed in her room beside her bed. No temperature log was observed in the area. The resident was asked what she kept inside the refrigerator. She stated, Usually leftovers if I get some take out food. She was asked permission to look inside the refrigerator. She agreed. Three coffee creamers were observed, and a thermometer which read 48 degrees. On 1/31/23 at 10:49 AM, Resident #106 was not observed in her room. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one resident (#35) who required blood pressure and pain medication, out of four residents reviewed for unnecessary medication, from a total sample of 55 residents. The findings include: A medical record review revealed that Resident #35 was admitted to the facility on [DATE] with a primary diagnosis of pneumonia. Secondary diagnoses included anxiety and pulmonary hypertension. A review of a Physician's Order, dated 3/4/22, revealed Tramadol 50 milligrams (mg) every 6 hours for non-acute pain, Lisinopril 2.5 mg, give 2 tablets one time a day for hypertension (high blood pressure). A review of the electronic Medication Administration Record (eMAR) for January 2023, revealed that on 1/30/23 and 1/31/23 lisinopril was not administered. The eMAR notes indicated that the drug…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and facility policy review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse. The findings include: On 2/2/23 at 9:20 AM, Licensed Practical Nurse (LPN) N was observed retrieving a Clonidine 0.1 mg (milligram) tablet from the Emergency Medication Supply Machine (Medbank). The Medbank was observed located in the hallway of the Beachside Unit. The Medbank was observed to be self-standing in the common area hallway, not enclosed or within a medication room. No secondary locking system was observed. The nurse was asked if narcotic medications were also contained in the machine. She stated, Yes, all the back-up medications are kept there, including narcotics. (Photographic evidence obtained) A list of all current medications kept in the Medbank was requested, as well as the facility's policy for storage of controlled narcotic medications. A review of the policy…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-06-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) Failing to maintain the dishwasher at appropriate temperatures during the wash and final rinse cycles, 2) Failing to ensure kitchen employees wore face coverings and gloves appropriately, and 3) Failing to ensure three of three nourishment rooms were clean and stored/labeled food appropriately. The facility census was 154. All residents receiving food from the kitchen and/or nourishment rooms had the potential to be affected by this deficient practice. The findings include: 1. On 6/15/2021 at 10:13 AM, during an observation of the dish room, the facility's dishwasher machine was observed to be a low temperature, chemical machine. (Photographic evidence obtained) The dishwasher label read: Wash tank minimum temperature of 140°F, Pumped rinse tank minimum temperature of 120°F; Final rinse minimum temperature 120°F. The dishwasher was in use at the time of the observation; employees were cleaning dishes from the…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to maintain a clean living environment for one (Resident #251) of five residents receiving enteral feedings through a gastrostomy tube (g-tube), from a total of 54 sampled residents. Food product was splattered on the wall adjacent to the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand beside the resident's bed. Failure to provide a clean living environment can present the potential for infection and illness for the residents. The findings include: Resident #251 was observed on 06/14/2021 at 12:35 PM lying in bed with her eyes closed. She did not respond to requests to enter the room. An enteral feeding pump was observed next to her bed. The pump was not on. Enteral feeding product was splattered on the wall beside the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand beside the bed. (Photographic evidence obtained) A review of Resident #251's clinical record revealed an active…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to develop a baseline care plan for catheter care for one (Resident #252) of six newly admitted residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling Foley catheter and a urinary tract infection (UTI). Failure to develop a plan of care for catheter care could potentially exacerbate the urinary tract infection. The findings include: Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. He was attempting to get out of bed by himself. Both of his feet were on the floor. His catheter bag was not contained in a dignity bag but was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained) During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to coordinate hospice services for one (Resident #57) of eight residents receiving hospice services, from a total sample of 54 residents. The findings include: A record review for Resident #57 revealed a [AGE] year old female admitted on [DATE] with diagnoses including dementia, chronic kidney disease, asthma, rhabdomyolysis, and overactive bladder. She was alert with confusion, required limited assistance with activites of daily living (ADLs), and was ambulatory without assistance. She was ordered hospice services on 10/6/20 due to a decline in condition. A review of the medical record found no hospice notes or plan of care after February 2021. An interview was conducted with the Unit Clerk on 6/17/21 at 9:05 AM. She was asked where the most recent hospice notes for Resident #57 were located. She stated this particular hospice was not good about putting notes in the charts. She said she would look in medical records. After looking in the files,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, by failing to ensure medications were not left at residents' bedsides for one (Resident #47) of a total of 54 residents in the sample. The findings include: On 6/15/21 at 10:30 AM during an interview with Resident #47, a bottle of Systane eye drops, without a pharmacy label, and a plastic cup with an orange gel substance and spoon in it were observed on the resident's night table. The resident was asked if she was able to self-administer the eye drops on the table. She said no. She was asked if she knew what was in the cup with the orange substance in it, and she said, probably Metamucil. I told the nurse to leave it and I would take it later. An interview was conducted with the Employee M, Agency Nurse, on 6/15/21 at 10:40 AM. She was asked if she had left medication and eye drops at Resident #47's beside. She stated she left the resident's Metamucil on the night table, as the resident didn't want it at that time, and she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, clinical record reviews and staff interviews, the facility failed to provide urinary catheter care for one (Resident #252) of six sampled residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling urinary catheter and a urinary tract infection (UTI). Failure to provide catheter care could potentially exacerbate the urinary tract infection. The findings include: Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. His catheter bag was was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained) During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if needed. She confirmed she had not provided catheter care since his admission. She stated the staff would wipe the tubing and the bag off if they became soiled. The catheter bag was hung on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 record reviews, staff and resident interviews and observations, the facility failed to ensure that residents requiring respiratory care, received appropriate care, consistent with professional standards of practice, by failing to follow physician's orders for the administration for oxygen for two (Residents #102 and #131) of two residents sampled for oxygen administration from a total sample of 54 residents. The findings include: 1. On 6/15/21 at 10:27 AM, Resident #131 was observed coming out of the bathroom. Oxygen tubing was observed on the bed, the oxygen concentrator was on and the oxygen flow rate was set at 3.5 liters per minute (LPM). The resident was was asked if she knew how much oxygen flow she was ordered, and she replied 2 liters. When asked who set the flow rate, she said the device was set for 2 liters, so she didn't have to do anything except put the oxygen cannula back on. An interview was conducted with Employee K, Licensed Practical Nurse (LPN), on 6/15/21 at 10:45 AM. She was asked…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure that medications were properly stored/disposed of safely for two (Residents #138 and #61) of six residents observed during medication administration. The findings include: 1. On 6/15/21 at 4:38 PM, medication administration was observed with Employee A, Registered Nurse (RN), for Resident #138. The nurse pulled two tablets of olanzapine (Zyprexa - antipsychotic), 7.5 milligrams (mg) from a blister pack. After review of Resident #138's Medication Administration Record (MAR), she noted that the order had changed from 7.5 mg to 10.0 mg. She took the two tablets of 7.5 mg olanzapine and discarded them in the trash can. In an interview with Employee A on 6/15/21 at 5:00 PM, she was asked what the facility's protocol was for medication destruction. She stated that there was a destroyer liquid in the medication room. She admitted that medication should not be discarded in the trash can and stated she forgot. 2. On 6/16/21 at 9:03 AM, Employee B, Licensed Practical Nurse (LPN), was observed prepping…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

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

Fines & penalties

$34,778 in federal fines across 1 penalty.

  • $34,778 — penalty dated 2025-01-09

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 ASTON HEALTH — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 3 of 54.1-1.1 vs chain
The other 37 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Crescent Health And Rehabilitation CenterSarasota, FL 1 of 5Kensington Gardens Rehab And Nursing CenterClearwater, FL 1 of 5Nursing & Rehabilitation Center Of New Port RicheyNew Port Richey, FL 1 of 5Oak Haven Rehab And Nursing CenterAuburndale, FL 1 of 5Vero Beach Care CenterVero Beach, FL 2 of 5Baya Pointe Nursing And Rehabilitation CenterLake City, FL 2 of 5Capri Health And Rehabilitation CenterVenice, FL 2 of 5Creekside Health And Rehabilitation CenterSarasota, FL 2 of 5Fairway Oaks CenterTampa, FL 2 of 5Flagler Health And Rehabilitation CenterBunnell, FL 2 of 5Haines City Rehabilitation And Nursing CenterHaines City, FL 2 of 5Highlands Lake CenterLakeland, FL 2 of 5Indian River CenterWest Melbourne, FL 2 of 5North Port Rehabilitation And Nursing CenterNorth Port, FL 2 of 5Pensacola Nursing & Rehabilitation CenterPensacola, FL 2 of 5Sandgate Gardens Rehab And Nursing CenterFort Pierce, FL 2 of 5Sea Breeze Rehab And Nursing CenterVero Beach, FL 2 of 5Tierra Pines CenterLargo, FL 2 of 5Viera Del Mar Health And Rehabilitation CenterViera, FL 2 of 5Winter Garden Rehabilitation And Nursing CenterWinter Garden, FL 3 of 5Cedarbrook Health And Rehabilitation CenterFort Myers, FL 3 of 5Coquina CenterOrmond Beach, FL 3 of 5Eagleridge Health And Rehabilitation CenterFort Myers, FL 3 of 5Fouraker Hills Rehab And Nursing CenterJacksonville, FL 3 of 5Hillside Health And Rehabilitation CenterZephyrhills, FL 3 of 5Oakpark Health And Rehabilitation CenterPalm Harbor, FL 4 of 5Bridgeview CenterOrmond Beach, FL 4 of 5Coastal Health And Rehabilitation CenterDaytona Beach, FL 4 of 5Debary Health And Rehabilitation CenterDebary, FL 4 of 5Fernandina Beach Rehabilitation And Nursing CenterFernandina Beach, FL 4 of 5Island Lake CenterLongwood, FL 4 of 5Meadowpark Health And Rehabilitation CenterDunedin, FL 4 of 5Parkside Health And Rehabilitation CenterDeland, FL 4 of 5Ruleme CenterEustis, FL 4 of 5Seaside Health And Rehabilitation CenterDaytona Beach, FL 5 of 5Bayview CenterEustis, FL 5 of 5Osprey Point Nursing CenterBushnell, FL

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
KLEIN, SAMUELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST75%since 01/01/2021
KALMUS, GREGORYIndividualW-2 MANAGING EMPLOYEEsince 07/21/2020

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.

$22.0M
Net patient revenuemost recent cost report
+33.4%
Operating marginrevenue minus expenses
$4.2M
Related-party expense29% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 8%Other / private 23%

This home reported $4.2M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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.

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

$189per resident / day
operating cost
$5,743per month
≈ monthly operating cost
$284per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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