Kissimmee Health And Rehabilitation Center
320 N Mitchell St, Kissimmee, FL 34741 · For profit - Limited Liability company · 59 certified beds · (407) 847-7200 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- about 26% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 fell from 3 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.4% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.8% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.0% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 5.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.1% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.6% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.4% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.81 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.53 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
39.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.5% 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 40 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 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 39.0%CMS range 23.7–55.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.9–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 32.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 35.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.2%CMS range 4.2–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 59 beds and averages 56.5 residents a day — about 96% occupied, or roughly 2 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.98 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.19 hrs/resident/day on weekends vs 3.59 on weekdays — 11% thinner on weekends. RN hours go from 1.02 to 0.90 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 24% is below 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 unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-05-28 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected prognosis of life for 1 of 1 resident reviewed for hospice services, (#11) and failed to accurately reflect a treatment for skin impairment for 1 of 1 resident reviewed for skin conditions, (#54), out of a total sample of 23 residents.Findings: 1. Review of resident #11's medical record revealed he was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. His diagnoses included Alzheimer's disease, dementia, and heart disease.Review of the medical record for resident #11 revealed a certification form dated 3/10/26 from hospice. The document included a verbal certification given by the physician that read, Based on the information available, I believe that the patient has a life expectancy of 6 (six) months or less if the disease takes its natural course. Review of resident #11's quarterly MDS assessment with Assessment Reference Date (ARD) of 3/19/26,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to resubmit an accurate Preadmission Screening and Resident Review (PASRR) upon admission and after a change in condition for a resident diagnosed with Serious Mental Illnesses (SMI) and Intellectual Disability (ID) for 1 of 1 residents reviewed for PASARR, out of a total sample of 23 residents, (#46).Findings:Review of resident #46's medical record revealed she was admitted to the facility on [DATE] with diagnoses including mood disorder, psychotic disorder, and intellectual disability. Review of resident #46's annual Minimum Data Set (MDS) with Assessment Reference Date 3/20/26 revealed she had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment revealed a Mood Interview was conducted and resident #46 reported feeling down, depressed, or hopeless 7 to 11 days during the lookback period. She also indicated she sometimes felt isolated. The assessment noted no rejection of care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan for 1 out of 23 residents reviewed for care plans, of a total sample of 23 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, diabetes, and stroke.The Minimum Data Set (MDS) assessment dated [DATE] revealed resident #3 had a Brief Interview for Mental Status of 15 out of 15, which meant he was cognitively intact.Review of the facility's incident log showed the resident fell on [DATE], and again on 12/24/25.An Agency for Health Care Administration Transfer form dated 12/24/26 indicated resident #3 had an unwitnessed fall, hit his head, and was transferred to the hospital. Review of a Physician's progress note dated 2/17/26 revealed the resident had a cervical spine fracture, he refused surgery, and the doctor ordered a neck brace to be worn at all times. A cervical spine fracture is a break to one of the neck bones. Often a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate assessment, treatment, and implement ordered interventions for 1 of 1 resident reviewed for skin conditions, out of a total sample of 23 residents, (#54). Findings: Review of resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, human immunodeficiency virus (HIV), major depressive disorder, heart disease, and type 2 diabetes. Review of resident #54's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/14/26 revealed a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment showed resident #54's speech was clear with distinct intelligible words, he made himself understood, and usually understood others, missing some part or intent of message but comprehending most conversations. The MDS assessment indicated resident #54 did not reject evaluation or care needed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observation, interview, and record review, the facility failed to provide pharmaceutical services related to accurate interpretation of a physician order, and inaccurate administration and documentation of medications for 1 of 4 residents reviewed for medication pass, (#47); and failed to appropriately dispose of medications, (#67), for 1 of 4 residents reviewed for medication pass, out of a total sample of 23 residents.Findings:1. On 5/26/2026 at 10:06 AM, Registered Nurse (RN) E stated she was administering the 9:00 AM medications, which could be given one hour before or one hour after the scheduled administration time. She prepared the following medications for resident #47: Aspirin 81 milligrams (mg), Cranberry 450 mg, Iron 325 mg, Acetaminophen 500 mg, Memantine 5 mg, Isosorbide 30 mg, Donepezil 5 mg, Amlodipine 5 mg, and Hydralazine 10 mg. At 10:16 AM, RN E entered resident #47's room and administered the medications.Review of resident #47's Medication Administration Record (MAR) revealed 9:00 AM medications included: Aspiring 81, Cholecalciferol 5000 international…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene during medication administration in accordance with infection control standards to prevent the spread of infection for 1 of 4 nurses reviewed for medication administration, (Registered Nurse E). Findings:On 5/26/26 at 10:02 AM, Registered Nurse (RN) E entered resident #47's room, obtained a pair of gloves, donned the gloves, took the resident's blood pressure, then removed the gloves and exited the room without performing hand hygiene. At 10:06 AM, RN E obtained 3 medication cups and prepared oral medications without performing hand hygiene. After preparing the medications, RN E entered the resident's room at 10:16 AM and administered the medications. At 10:19 AM, when asked about when hand hygiene was expected to be performed, RN E stated it should be done before and after medication administration. She said, I guess I skipped points. RN E explained hand hygiene was important for patient safety and prevention of infection. She acknowledged she should have performed hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-29 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interviews, the facility failed to post a complete Nurse Staffing report in a place readily accessible to residents, staff, and visitors. Findings: On 5/27/25 at 2:30 PM, the Nurse Staffing sheet was posted on the wall in the hall leading from the lobby to the resident rooms. It was about six feet from the floor and out of view of the residents. Review of the posting revealed it did not include the facility census as required. On 5/28/25 at 2:00 PM, a facility visitor stated she was not aware of the facility staff posting on the wall. The visitor looked at it and acknowledged she could not read it because the typing was too small. On 5/29/25 at 12:14 PM, the Staffing Coordinator stated she was responsible for creating the staffing document that was posted in the lobby. She looked at the posting where it hung on the wall and acknowledged it could not be seen by anyone sitting in a wheelchair. She said there was another one posted outside her office door. When she looked at it, she agreed the words were too small for anyone in a wheelchair to read. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-29 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 qualified staff had the appropriate competencies and skill sets to carry out management and oversight of the food and nutrition services as demonstrated by numerous irregularities including labeling/dating food, training to staff on food safety and preparation, and logs for the dish machine, which had the potential to affect all 53 of 53 residents residing and eating at the facility. Findings: On 5/27/25 at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), multiple food items in the walk-in refrigerator, freezer and dry storage room had unlabeled, undated, expired, and improperly stored food items. The CDM did not provide required oversight of staff to monitor or address issues including food items left unlabeled, and undated or expired foods. The CDM did not provide to staff readily available policies and procedures for food labeling, storage and the expiration date policy. Instead, staff were directed to discard prepared foods after three days and was not aware 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.
- Potential for harm · Fcited before2025-05-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to label and date stored food in accordance with professional standards for food safety, failed to ensure the dish machine was operated at proper temperatures and sanitizer was dispensed at proper concentrations, and failed to ensure nutritional supplements and residents' food brought in from family were dated and discarded when expired to prevent foodborne illness. These deficiencies had the potential to affect all the 53 residents residing and eating at the facility. Findings: 1. On 5/27/25 at 9:38 AM, during the initial kitchen tour with the Certified Dietary Manager, (CDM) multiple food items in the walk-in refrigerator were dated with a 30-day span between when they were received/opened and when they were to be discarded. For example, a large, clear bin of diced tomatoes were dated 5/25-6/25, approximately 25 cucumbers which had small, soft, dent spots in them which indicted spoilage, were dated 5/19-6/19, a plastic container of blueberries, which the CDM stated were previously frozen, were smashed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-29 · tag F0867 — failed to act on quality-improvement findings — patternSet 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
Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan dated 1/18/24, revealed it was designed to be ongoing and comprehensive. The plan detailed the facility used a systematic approach to determine when in-depth analysis was needed to fully understand the problem, its causes and implications of change. The facility used a thorough and highly organized/structured approach to determine the root cause of identified problems. The plan indicated the facility would utilize a variety of tools to describe the current process used and identify any area of breakdown or weakness in the current process. The document described each Performance Improvement Project (PIP) subcommittee would provide the QAA committee with a summary report, analysis of activities, and recommendations. The facility had a deficiency cited at F812 during 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.
Show the remaining 15 citations
- Potential for harm · D2025-05-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement appropriate dietary recommendations to treat significant weight loss for 2 out of 3 residents reviewed for nutrition, of a total sample of 31 residents, (#43, and #25). Findings: 1. Resident #43 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses that included acute and chronic respiratory failure; partial paralysis following stroke, affecting the left dominant side; type 2 diabetes mellitus, trouble swallowing, unspecified dementia, moderate protein calorie malnutrition, colostomy status and gastrostomy (feeding tube) status. A colostomy is a temporary, or permanent surgical opening in the abdomen to drain stool from the body, (retrieved on www.hopkinsmedicine.org on 6/11/25). Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 5/06/25 revealed resident # 43 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 of 7 residents reviewed for medication administration, of a total sample of 31 residents, (#10). Findings: Resident #10 was readmitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, emphysema, Alzheimer's disease, dementia, sensorineural hearing loss and dry eye syndrome. A review of the quarterly Minimum Data Set assessment with reference date 4/04/25 revealed resident #10 had moderately impaired cognition. The assessment revealed the resident had no behaviors, nor rejection of care during the lookback period. Review of physician's orders revealed resident #10 was scheduled to receive one drop of Refresh Liquigel Ophthalmic Gel 1% (Carboxymethylcellulose Sodium (Ophthalmic)) in both eyes, four times a day for dry eyes and one drop of Latanoprost Ophthalmic Solution 0.005% in both eyes at bedtime for glaucoma. On 5/28/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-30 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their grievance process related to expressed concerns for care for 2 of 3 residents reviewed for grievances, of a total sample of 8 residents, (#2 and #4). Findings: 1. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included stroke, dementia, and urinary tract infection. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated moderate cognitive impairment. Review of resident #2's medical record showed her son was her responsible party. On 4/29/24 at 4:28 PM, during a telephone interview, resident #2's son stated he found out his mother sustained a fall in the facility when he visited her in the hospital on 4/06/24. He explained he saw a bruise on her left leg and wanted to know the details of her fall. He mentioned his mother mentioned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-29 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 nurses monitored complication risks for 1 of 1 resident reviewed for Dialysis, of a total sample of 27 residents, (#5). Finding: Review of the medical record revealed resident #5, an [AGE] year old female was admitted to the facility on [DATE]. Her diagnoses included end stage renal (kidney) disease, dependence on renal dialysis, chronic respiratory failure, hypoxemia (low blood oxygen), congestive heart failure (heart pumping dysfunction), cardiomyopathy (heart muscle disease), Chronic Obstructive Respiratory Disease (COPD), anemia, type 2 diabetes mellitus, malnutrition, major depressive disorder, and acquired absence of both legs above the knee. After re-hospitalization, on 2/18/24 she was readmitted back to the facility with additional diagnoses that included pleural effusion (fluid in the lung space) and acute cystitis (bladder inflammation). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food was stored in a safe and sanitary manner in the kitchen's walk in refrigerator and 1 of 1 nourishment room and failed to ensure 2 of 3 employees observed followed appropriate hygienic practices in food preparation areas. Findings: 1. An initial visit to the kitchen on 2/26/24 at 9:06 AM revealed a tray of refried beans and a tray of ravioli with tomato sauce in the walk-in refrigerator were covered with a plastic wrap but were not labeled or dated. The Certified Dietary Manager (CDM) stated they had to be from the weekend and acknowledged all leftovers in the refrigerator had to be properly labeled and dated. 2. On 2/29/24 at 5:56 PM, observation of a refrigerator located in the nourishment room with Certified Nursing Assistant (CNA) D revealed two Styrofoam cups with leftover shakes. One cup had a room number and 2/26 written and the other cup had 2/29 written but did not have a resident's name and room number. CNA D discarded both cups and stated they should not use food in the refrigerator 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.
- Potential for harm · Ecited before2024-02-29 · tag F0867 — failed to act on quality-improvement findings — patternSet 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
Based on interview, and record review, the facility failed to fully implement and monitor Performance Improvement Plans (PIPs) for identified resident care deficits. Finding: In an interview on 2/29/24 at 2:48 PM, the Director of Nursing (DON) said nurses were expected to monitor residents who received dialysis for complications and notify the doctor if there were concerns. She explained, she had been working at the facility for less than a week and said the previous DON was, working with dialysis for the check site bleeding. On 2/29/24 at 3:20 PM, the DON stated she had a PIP related to dialysis residents with fluid restrictions. She provided documents she referred to as a PIP with logs titled Dialysis Audit Tool with handwritten entries dated from 1/19/2024 to 2/19/2024 and a blank form titled, Dialysis Communication Tool. She explained that the former DON had developed a new form and implemented the project two months prior. On 2/27/24 at 3:50 PM, a review of the Dialysis Book kept at the nurse's station revealed it contained blank and completed forms titled, Dialysis Transfer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-29 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to provide evidence of the Infection Preventionist's (IP) qualifications for 1 out of 1 staff reviewed for specialized training in infection prevention and control. Findings: Review of the infection prevention and control module certificates provided by the Nursing Home Administrator and the Infection Preventionist (IP) indicated that only six modules were completed by the IP on September 25, 2021. There was no evidence presented to confirm completion of the Infection Prevention Training Course by the IP. On 2/29/24 at 4:17 PM, the Infection Preventionist (IP) stated she had been the IP at the facility for three years. She acknowledged she completed the CDC (Center for Disease Control) Infection Prevention and Control training course in 2021. The IP verified she was unable to provide proof of completion for the infection prevention training course and could only present evidence of having completed six modules on September 25, 2021. The facility's Infection Control Preventionist job description/job requirements read,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 observation, interview, and record review, the facility failed to ensure 1 of 1 resident with physical limitations reviewed for Environment was provided call light device access, of a total sample of 27 residents, (#5). Finding: Review of the medical record revealed resident #5, an [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included end stage renal (kidney) disease, dependence on renal dialysis, congestive heart failure (heart pumping dysfunction), Chronic Obstructive Pulmonary Disease (COPD), and acquired absence of both legs above the knee. After re-hospitalization, on 2/18/24 she was readmitted back to the facility with additional diagnoses that included pleural effusion (fluid in the lung space) and acute cystitis (bladder inflammation). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) 11/19/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 honor resident's rights to choose their preferred morning wake-up time for 1 of 6 residents reviewed for choices out of a total sample of 27 residents, (#22). Findings: Review of the medical record revealed resident #22 was admitted to the facility on [DATE]. Her diagnosis included Alzheimer's Disease, dementia, major depressive disorder, and adjustment disorder. Resident #22's Annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/23/23 revealed the resident was the primary respondent for daily and activity preferences, and it was very important to her to choose her daily preferences such as her own bedtime. The resident's Quarterly MDS assessment with ARD of 11/17/23 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact. The assessment noted the resident was totally dependent on staff for transfers and required maximal assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide personal fund quarterly statements to 1 out of 1 resident reviewed for personal funds out of a total sample of 27 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] from the hospital. His diagnosis included unspecified convulsions, hemiplegia, and hemiparesis following cerebral infarction, depression, and anxiety disorder. The most recent annual Minimum Data Set (MDS) with an assessment reference date of 12/29/23 revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. On 2/26/24 at 11:05 AM, resident #44 stated the facility held funds on his behalf but he had not received information regarding the balance in his account. He said he had never received financial statements from the facility. He explained he wanted to order some take out food but was uncertain about the balance in his facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to clarify code status related to a Do Not Resuscitate Order (DNRO) for 1 of 2 residents reviewed for Advance Directives of a total sample of 27 residents, (#57) Findings: Review of resident #57's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included chronic obstructive pulmonary disease. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on [DATE] revealed resident #57 required a surrogate for decision making. The form showed resident #57 was alert, disoriented but could follow simple instructions. Section H. Advance Directives was answered YES for DNR (Do Not Resuscitate). The form instructed the transferring facility to attach any relevant documentation. Review of hospital documentation revealed physician notes dated 2/6, 2/12, 2/13, 2/14, and [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide Advance Beneficiary Notification of Non-Coverage to 2 out of 3 residents reviewed for skilled nursing facility beneficiary notices out of a total of 27 sampled residents, (#7 and #48). Findings: 1. Resident #7 was admitted to the facility on [DATE] from the hospital. Her diagnosis included chronic obstructive pulmonary disease, type II diabetes, dementia, depression, and anxiety disorder. Review of resident #7's Census Line revealed the resident's Medicare Part A skilled nursing care began on 12/4/23 with the last covered day of Part A service on 1/22/24. She remained in the Long-Term Care facility with Medicaid Pending as her primary payer source effective 1/23/24. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification revealed resident #7 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A service but did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). 2.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders to prevent gastrostomy tube feeding complications and adequate hydration for 1 of 1 resident reviewed for gastric tube feeding out of a total sample of 27 residents, (#212). Findings: Review of the medical record revealed resident #212 was admitted to the facility on [DATE] from the hospital. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction, dementia, obesity, dysphagia, gastrostomy status, unspecified protein-calorie malnutrition, and persistent mood disorders. Resident #212's Minimum Data Set (MDS) admission assessment with an assessment reference date of 2/18/24 revealed the resident scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she had moderately impaired cognition. The assessment also noted the resident had a feeding tube on admission that provided 51 percent or more of her total caloric intake and 501 cubic centimeters (cc) or more of her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the Consultant Pharmacist's recommendations were acted upon in a timely manner for 3 of 5 residents reviewed for unnecessary medications of a total sample of 27 residents, (#1, #28, #45). Findings: 1. Resident #1, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included multiple sclerosis, diabetes type 2, schizophrenia, bipolar disorder, pseudobulbar effect, major depressive disorder, and generalized anxiety. Review of the resident's Pharmacist recommendations revealed the following: on 8/16/23 the resident had an order for Austedo IR 18 milligram (mg) daily. The recommendation was for the physician to consider changing the medication to twice daily. The rationale documented for the recommendation was, Per manufacturer, doses greater than or equal to 12 mg/day should be administered in two divided doses. The prescriber's response dated 9/01/23 indicated the prescriber…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to clarify an order for Voltaren gel 1%, that did not have directions for required amount of medication to be used for 2 of 5 residents reviewed for unnecessary medications of a total sample of 27 residents, (#23, #213). Findings: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses to include myocardial infarction, depression, anxiety, chronic pain, and chronic kidney disease. Review of the resident's physician orders dated 2/12/24, revealed orders for Voltaren external gel 1%, apply to bilateral knees topically two times a day for pain. On 2/14/24 an order for Voltaren external gel 1%, apply to bilateral feet typically every 8 hours as needed for pain (with no stop date) and an order on 2/15/24, for Voltaren external gel 1% (topical) apply to bilateral feet topically two times a day for pain for 7 days. The orders had no direction for the amount of gel to apply. 2. Resident #213 was admitted to the facility on [DATE] with diagnoses to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.6 | +1.4 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 5 of 5 | 2.2 | +2.8 vs chain |
| Quality measures | 3 of 5 | 3.4 | -0.4 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MARQUEZ, SIMON | Individual | W-2 MANAGING EMPLOYEE | since 11/03/2020 |
| GORELICK, BATYA | Individual | CORPORATE OFFICER | since 05/01/2021 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 26% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105379. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, 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 →
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