Westside Oaks Rehabilitation & Nursing Center

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

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.

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.

Met the expected recovery: 61.8% 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 55 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% 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.

Staffing

How full it usually is: this home is certified for 180 beds and averages 171.8 residents a day — about 95% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 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 3.01 hrs/resident/day on weekends vs 3.37 on weekdays — 11% thinner on weekends. RN hours go from 0.53 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

24 citations, most serious first. The 18 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · Lcited before2026-04-01 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with residents, staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including adequate supervision and sufficient safeguards, were in place to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1 sustaining second-degree facial burns and respiratory distress after his nasal cannula ignited while he smoked in his room, requiring emergency transfer to a local acute care hospital and subsequent transfer to a burn…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2026-04-01 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, staff interviews, a review of the facility's policies titled Quality Assessment and Performance Improvement (QAPI) Policy and Risk Management, and a review of QAPI meeting documentation, the facility failed to have an effective QAPI process that used adverse event data and safety information related to smoking and oxygen use, to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of smoking in his room while using oxygen, was again found smoking in his room while using oxygen. His nasal cannula ignited and he sustained second-degree facial burns and respiratory distress requiring emergent transport to an acute care hospital burn unit for treatment. Resident #1 and three other residents (#2, #3 and #4) were known to keep cigarettes and lighters on their person or in their rooms, and two of the four (Residents #1 and #2) were oxygen-dependent and were…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2026-04-01 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, resident and staff interviews, and a review of the facility's policies titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and Smoking/Vaping, the facility failed to protect the residents' right to be free from neglect/deprivation of services by Certified Nursing Assistants (CNAs) A, B, D, Registered Nurse (RN) E and the Director of Nursing (DON). The facility failed to ensure sufficient safeguards and supervision to protect the residents' right to be free from neglect, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, resident and staff interviews, and a review of the facility policy titled Smoking/Vaping, the facility failed to ensure residents received adequate supervision and sufficient safeguards to prevent avoidable accidents, by failing to ensure that CNAs A, B, D, RN E and the DON implemented the facility's Smoking/Vaping policy to prevent four oxygen dependent residents (#1, #2, #3 and #4) out of four residents reviewed for smoking, from storing cigarettes and lighters in their rooms, and to prevent two oxygen-dependent residents (#1 and #2) from smoking in their rooms while oxygen was in use. This failure resulted in Resident #1 sustaining second-degree facial burns and respiratory distress after his nasal cannula ignited while he smoked in his room, requiring emergency transfer to a local acute care hospital and subsequent transfer to a burn unit for treatment.Resident #1 was identified on 9/25/24 as unsafely smoking in his room while receiving oxygen. Two nursing…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, the facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to protect Resident #1's right to be free from neglect, by failing to ensure adequate supervision and safeguards to prevent the resident, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming his incontinence pad, choking and dying. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed. The Medical Examiner discovered during an autopsy that Resident #1 was full 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-07-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond 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 a review of facility and resident records, facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), and interviews with staff and outside medical professionals, the facility failed to conduct a thorough investigation to rule out abuse or neglect after one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed incontinence briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the Unit Manager (UM) and Nurse Practitioner (NP), no interviews were obtained and there was no evidence verifying that a thorough record review was conducted. Only written statements, which…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-02 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, facility job descriptions, policies and procedures, and interviews with staff and medical professionals, the facility's Administration failed to provide oversight of the facility in a manner that ensured necessary interventions, including supervision, were in place for Resident #1's safety when he had a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), and consistently chewed/consumed his briefs and disposable incontinence pads. On June 20, 2025 at 1:49 PM, Resident #1 was found in his bed unresponsive with feces and bits of blue plastic resembling incontinence pad pieces in his mouth. Resuscitation efforts were initiated, and he was transported to the hospital by Emergency Medical Services (EMS), but resuscitation efforts failed, and the resident expired. Despite numerous staff members' awareness of the resident's behaviors, neither the Administrator nor the Medical Director…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-02 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility and resident records, staff interviews, and review of the Quality Assurance and Performance Improvement (QAPI) plan, the facility failed to have an effective QAPI process that used adverse event data to identify a Root Cause Analysis (RCA) and develop relevant performance improvement activities to prevent similar future events. Resident #1, with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), who chewed and consumed briefs and disposable incontinence pads, was found unresponsive with feces and bits of blue plastic resembling incontinence pads in his mouth. As a result of the incident, Resident #1 died. Despite direct observation of the event by CNAs A, B, C, the unit manager (UM) and nurse practitioner (NP), the facility failed to thoroughly investigate in order to identify an RCA and develop measures needed to ensure the safety and protection of other residents at risk. This had the potential…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-01 · tag F0609 — failed to report abuse allegations — isolated
  Timely 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 a review of facility documents, resident and staff interviews, and a review of the facility's policy titled Adverse Incident Reporting, the facility failed to ensure the timely reporting of an adverse incident for one (Resident #1) of four residents reviewed. The facility failed to report an adverse incident that occurred on 2/27/26 in which Resident #1 sustained second degree facial burns and respiratory distress after smoking in his room while on oxygen, requiring his transfer to an acute care facility burn unit for treatment.The findings include: An interview was conducted with Resident #1 on 3/30/26 at 9:51 AM. He was observed lying in bed, awake, wearing his nasal cannula with oxygen flowing. When he was asked about his 2/27/26 incident, he stated he smoked a cigarette in his room while wearing oxygen via nasal cannula, the cannula ignited, and he sustained burns to his face that required transport to the hospital. A review of Resident #1's record revealed that he was admitted to the facility 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-05 · tag F0645 — pattern
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide accurate Preadmission Screening and Resident Reviews (PASRRs) for seven (Residents #23, #62, #63, #65, #76, #101, and #167) of eight residents sampled for PASRRs and identified with a mental disorder (MD) and/or intellectual disability (ID), and failed to ensure that the residents were properly evaluated and received care and services in a setting appropriate for their needs. The findings include:1.A review of Resident #23's medical record revealed an admission date of 5/8/2025 with the latest readmission on [DATE]. His diagnoses included generalized anxiety disorder (5/12/2025), schizophrenia (5/08/2025), brief psychotic disorder (5/12/2025), major depressive disorder (5/12/2025), and alcohol abuse (5/8/2025).A review of the resident's active care plan revealed focus areas including:7/8/2025: [Resident #23] has potential for impaired or inappropriate behaviors r/t Dementia: AEB (as evidenced by) refusing blood pressure, cognitive loss,…

  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 · Ecited before2026-03-05 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 reviews, and a review of facility policies and procedures, the facility failed to ensure that eight (Residents #5, #34, #11, #166, #91, #19, #82, and #159) of 73 sampled residents received appropriate ADL (activities of daily living) care necessary to maintain good grooming, by failing to ensure fingernails were clean/trimmed/clipped, hair was shampooed, and/or facial hair was removed. The findings include: 1.An interview was conducted on 3/2/2026 at 9:20 AM with Resident #5. He was observed sitting up in bed watching TV. The resident's hair was oily and disheveled. The resident stated he did not know the last time he received a shower or complete bed bath. He raised his hand to show his nails which were visibly stained, uneven and jagged. He stated he was receiving Hospice services and that in the past, they bathed him; however, they had not done so for quite some time. He stated he would like to get a real shower. I'm so nasty. I feel like my skin is crawling. 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 · E2026-03-05 · tag F0850 — failed to provide social-work services — pattern
  Hire a qualified full-time social worker in a facility with more than 120 beds.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of staff records, and interviews conducted with the Administrator, the facility, which is licensed for 180 beds, failed to ensure the full-time social worker was qualified, and failed to verify educational requirements were met, with the potential to negatively impact the overall health, safety, and quality of life to all 172-residents present during the recertification survey.The findings include:On 3/05/2025 at 1:37 PM, a personnel record review was conducted for the Social Services Director (SSD) that revealed she did not have a bachelor's degree in social work, or a similar human services field.During an interview with the Administrator on 03/05/2026 at 1:49 PM, she reported having problems with the SSD's performance, and after she was promoted, a request for a copy of her master's degree in social work, transcripts, and her social worker license was made, but was never provided. The Administrator further reported that she asked the SSD to go home and get her degree and credentials during the recertification survey, and at the time of exit from the survey after…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one (Resident #82) of 73 residents in the total survey sample was provided with adequate and comfortable lighting at his bedside. Inadequate lighting can result in an increased risk for falls/accidents as well as potential psychological distress (anxiety/depression). The findings include: On 03/03/26 at10:27 AM, Resident #82 was observed resting in bed. The resident, in room [ROOM NUMBER] Bed D, shared a room with three other residents. His area of the room was observed to be dark without a light source. (photographic evidence obtained) Resident #82 stated he did not know why he did not have a light in his area of the room and it bothered him that it was so dark. Resident #82's roommate in Bed C stated he used to be in Bed D but had asked to move to Bed C so that he would have a working light fixture over the bed. room [ROOM NUMBER] Beds A, B and C were equipped with light fixtures on the wall at the head of the bed. The light…

  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 · D2026-03-05 · 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 observations, interviews and record reviews, the facility failed to ensure residents requiring respiratory care received such care, consistent with professional standards of practice, by failing to ensure that two (Residents #54 and #49) of two residents reviewed for respiratory care, received oxygen at the flow rate prescribed by their physicians.The findings include: 1. On 3/3/2026 at 9:30 AM, Resident #54's oxygen concentrator flow rate was observed to be set at 2.5 l/min (liters per minute). On 3/4/2026 at 9:00 AM, Resident #54's oxygen concentrator flow rate was observed to be set at 2.5l/min. During an interview on 3/4/2026 at 9:05 AM, Registered Nurse (RN) D stated, I check my oxygen concentrators when I arrive to check the settings. When asked if a resident had orders for oxygen at 2 liters per minute via nasal cannula, how that oxygen should be delivered, RN D stated, It should be at 2 liters a minute via nasal cannula. RN D was asked if she knew what Resident #54's oxygen flow rate should be…

  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 · D2026-03-05 · tag F0914 — isolated
  Provide bedrooms that don't allow residents to see each other when privacy is 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 1) Ensure privacy curtains were provided to five (Residents #192, #116, #5, #82 and #105) of 30 residents sampled for privacy curtains, and 2) Ensure privacy curtains were not stained for two (Rooms 9B and 9D) of 32 privacy curtains observed.The findings include:On 03/03/26 at 10:36 AM, Resident #82 was observed in his bedroom, which lacked a privacy curtain track and privacy curtain. (Photographic evidence obtained)On 03/03/26 at 2:19 PM, resident room [ROOM NUMBER], beds 9B and 9D's curtains were observed to be heavily stained. Bed 9D had black scratch marks covering the lower portion of the privacy curtain. Bed 9B had large dark spots covering the upper right portion of the privacy curtain. (Photographic evidence obtained) On 03/04/26 at 9:51 AM, another observation was made of bed 9D with black scratch marks covering the lower portion of the privacy curtain and bed 9B with large dark spots covering the upper right portion of 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure a call light or hand bell was within reach for three (Residents #13, #43 and #149) of 73 sampled residents. The findings include:1.On 03/02/26 at 2:12 PM, Resident #13 was observed lying in bed with his eyes closed. A hand bell was observed on top of the light above the head of the bed. It was not within the resident's reach and was approximately 3.5 feet above the resident's bed. (Photographic evidence obtained). The resident did not respond to questions related to the call light or hand bell. The resident's roommate stated Resident #13 could not talk and that the resident was provided with a hand bell because his call light was not working.On 03/02/26 at 3:30 PM, the Director of Nursing (DON) was interviewed and was accompanied to Resident #13's room. He was asked if the resident was physically capable of reaching the hand bell above the light. The DON reported that the hand bell was provided to the resident because the call light was not working. The DON stated the resident was bedbound and would not…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-05 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make 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 environment for two (Residents #17 and #79) of 172 residents currently living in the facility, by failing to keep sharp, potentially dangerous items out of resident rooms. The findings include: 1.During a tour of the facility on 3/2/2026 at 12:26 PM, resident room [ROOM NUMBER] on the secured Memory Care Unit located on the bottom floor of the facility was observed. In the room was a wooden dresser located near a window at the foot of Bed B (Resident #97) and Bed C (Resident #17). An open drawer revealed a clear plastic bag containing several blue razors and large nail clippers. (Photographic evidence obtained) A follow-up tour was made on 3/4/2026 at 4:04 PM. The clear plastic bag containing the blue razors and large nail clippers remained in the top drawer. Resident #17 was seated in his wheelchair near the end of the bed near the wooden dresser. He confirmed the dresser was his. He also confirmed the bag of razors 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · 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 a review of facility and resident records, a review of the facility's policy and procedure titled Care Plan-Comprehensive, and interviews with staff and medical professionals, the facility failed to develop and implement a comprehensive person-centered care plan detailing a focused problem area and specific interventions needed to protect one (Resident #1) of one resident with a known history of pica (an eating disorder characterized by a compulsive and recurrent consumption of non-nutritive and non-food items), from consuming incontinence pads. This affected one (Resident #1) of three residents reviewed for behavioral issues, from a total of 52 residents with behavioral care plans.The findings include:A review of a facility report authored by the Director of Nursing (DON) on 6/27/25, revealed that on 6/20/25 at 1:49 PM, Resident #1 was observed unresponsive in bed by a certified nursing assistant (CNA). The CNA called the Unit Manager (UM) immediately and upon entering the room, the UM observed brown…

  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

“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.

Fines & penalties

$96,892 in federal fines across 1 penalty.

• $96,892 — penalty dated 2025-07-02

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 BENJAMIN LANDA — 48 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 →

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

11 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.

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $4.5M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in FL