Kissimmee Nursing & Rehabilitation Center
2511 John Young Parkway North, Kissimmee, FL 34741 · For profit - Limited Liability company · 120 certified beds · (407) 931-3336 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — 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
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 | 9.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.8% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.9% | 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 | 8.6% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.1% | 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 | 3.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.1% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.5% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.1% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.1% | 9.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.87 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.62 | 1.15 | 1.80 | typical |
‡ 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.
29.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.8% 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 32 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 29.1%CMS range 18.1–45.1 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.9–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 43.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 43.8% | 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 | 37.5% | 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 | 95.9% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 4.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.2% | 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 | 9.1%CMS range 6.2–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 120 beds and averages 112.4 residents a day — about 94% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.26 hrs/resident/day on weekends vs 3.76 on weekdays — 13% thinner on weekends. RN hours go from 1.00 to 0.81 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% 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 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 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2021-10-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services to prevent development of a pressure ulcer and promote healing of a newly identified area of skin breakdown for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 40 residents, (#96). The facility's failure to implement preventative interventions consistent with the resident's risk for skin breakdown, and failure to initiate treatment according to accepted standards of practice resulted in actual harm, development of a stage 3 sacral pressure ulcer. Findings: Resident #96 was admitted to the facility from an acute care hospital on 6/12/21 and was readmitted on [DATE] with diagnoses of weakness, partial paralysis after a stroke, and dementia. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 9/19/21 revealed resident #96 had a Brief Interview for Mental Status score of 15 indicating he was cognitively intact. He required extensive assistance of two people for bed…
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 · D2025-02-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 promote dignity in dining for 1 of 4 residents reviewed for dignity, of a total sample of 59 residents, (#51). Findings: Review of resident #51's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and anxiety. Review of resident #51's Minimum Data Set quarterly assessment with Assessment Reference Date of 12/6/24 revealed a Brief Interview for Mental Status score of 3 out of 15, which indicated severe cognitive impairment. On 2/26/25 at 3:23 PM, Certified Nursing Assistant (CNA) H explained the interventions in place to assist resident #51. During the conversation, CNA H described resident #51 by saying, she is a feeder. CNA H affirmed that was the term used to refer to the residents who required assistance eating. CNA H asked, Should we not call them like that? Later, on 2/27/25 at 1:59 PM, CNA H repeated, She is a feeder while pointing to the eating…
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 · D2025-02-28 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 notify emergency contact and Power of Attorney of changes in medication for 1 of 1 residents reviewed for notification of emergency contact, of a total sample of 59 residents, (#20). Findings: Resident #20 was admitted to the facility on [DATE] with diagnoses including epilepsy (seizures), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, dementia type 2 diabetes, altered mental status, adjustment disorder with mixed anxiety and depressed mood, and personal history of traumatic brain injury. The admission Record contained essential information including resident #1's selected emergency contacts with their associated telephone numbers. The document listed the resident's son as emergency contact #1 and the healthcare Power of Attorney. Resident #1's daughter was emergency contact #2. The hospital transfer form dated 1/23/25 revealed that resident #20 required a surrogate when making healthcare decisions…
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 · D2025-02-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was evaluated for safe self-administration of medications for 1 of 2 residents reviewed for choices, of a total sample of 59 residents, (#5). Findings: Review of resident #5's medical record revealed she was initially admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 2/03/25. Her diagnoses included coronary artery disease, lymphedema, and chronic pain syndrome. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 12/31/24 revealed resident #5 had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The MDS assessment noted rejection of care necessary to obtain goals for her health and well-being occurred 4 to 6 days, but less than daily, during the look-back period. On 2/27/25 at 11:06 AM, resident #5 was observed in bed with a medication cup containing various pills on her bedside table, along with 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 · D2025-02-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report allegations of abuse and neglect to the State Agency (SA) and protect the resident during the investigation for 1 of 2 residents reviewed for abuse, of a total sample of 59 residents, (#56). Findings: Review of resident #56's medical records revealed she was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 1/01/25. Her diagnoses included paraplegia (paralysis that affects the lower half of the body), anemia, psoriasis (skin disorder), major depressive disorder, and coronary artery disease. Review of resident #56's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 12/02/24 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The MDS assessment noted her primary language was Spanish, and she wanted an interpreter to communicate with a doctor or health care staff. The Mood section revealed resident #56…
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 · D2025-02-28 · 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 the Minimum Data Set (MDS) assessment accurately reflected fall with major injury status for 1 of 4 residents reviewed for falls, of a total sample of 59 residents, (#109). Findings: Resident #109's medical record revealed he was initially admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/11/25. His diagnoses included osteomyelitis (bone infection), difficulty walking, and femur fracture. On 2/24/25 at 11:40 AM, resident #109 stated he fell coming out of the bathroom about 3 weeks ago, and broke his right femur; he said he was transported to the hospital but did not have surgery. Review of resident #109's MDS Discharge Assessment with an Assessment Reference Date (ARD) of 1/25/25 and a 5-day assessment with an ARD of 2/18/25 revealed that his fall status was incorrectly assessed. On 2/27/25 at 5:15 PM, MDS Transitional Nurse K explained he was responsible for completing this MDS. He acknowledged both MDS's did…
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 · D2025-02-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an individualized comprehensive care plan was implemented for 1 of 1 resident reviewed for seizure safety precautions, (#92); and for 1 of 2 residents reviewed for communication, (#56), of a total sample of 59 residents. Findings: 1. A review of the medical record revealed resident #92 was admitted to the facility on [DATE] with diagnoses that included hydrocephalus (fluid on the brain), epilepsy (seizure disorder), autistic disorder, speech disturbances, and mood disorders. The Minimum Data Set (MDS) Annual assessment with an assessment reference date (ARD) of 12/11/24 revealed resident #92 had a Brief Interview for Mental Status (BIMS) that could not be conducted as the resident was rarely or never understood. A review of the resident's medical record revealed current comprehensive care plans with a focus on seizure disorders related to epilepsy. Interventions included seizure medication as ordered and padding to side rails. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-28 · 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 and implement appropriate interventions including the provision of adequate supervision to prevent falls for 2 of 4 residents reviewed for falls, of a total sample of 59 residents, (#3 and #51). Findings: 1. Review of resident #3's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 8/14/24. Her diagnoses included senile degeneration of brain, type 2 diabetes, dementia, glaucoma, bilateral hearing loss, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/10/24 revealed resident #3's Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The MDS assessment showed resident #3's hearing was highly impaired, and her vision was impaired. She required supervision for eating, and substantial assistance from staff for toileting,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-28 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an ongoing program of activities to meet the needs and interests of 1 of 5 residents reviewed for activities, of a total sample of 59 residents, (#58). Findings: Resident #58 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, hypertension, and open-angle glaucoma with borderline findings. The Minimum Data Set (MDS) Annual assessment, with an assessment reference date of 1/14/25, revealed resident #58 had a Brief Interview for Mental Status of 12/15, which indicated mild cognitive impairment. The MDS revealed that resident #58 was visually impaired and required large print in newspapers and books but not regular print. A review of the resident's comprehensive care plan revealed the resident's activities should be compatible with physical and mental capabilities, such as large print holders, if the resident lacked hand strength and task segmentation. On 2/25/25 at 9:52 AM, Activity Aide R…
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 · D2025-02-28 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 interview, and record review, the facility failed to have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 sampled residents who receive hemodialysis, of a total sample of 59 residents, (#12). Findings: Review of resident #12's medical record revealed an admission date of 5/30/24. His Quarterly Minimum Data Set, dated [DATE] indicated a Brief Interview of Mental Status score of 5/15, which indicated moderate cognitive impairment. His diagnoses included: end stage renal disease, dependence on renal dialysis, and unspecified dementia with unspecified severity, without behavioral disturbance. Review of resident #12's medical record revealed physician's orders dated 4/16/24 for hemodialysis to occur on Monday, Wednesday, and Friday at Dialysis Center #1. Review of resident #12's medical record revealed no documentation of communication having occurred between staff from Dialysis Center #1 and the facility nursing staff from 1/01/25 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 · D2025-02-28 · 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 accurately document the administration of medications in the Medication Administration Record (MAR) for 1 of 3 residents reviewed for pain, of a total sample of 59 residents, (#18). Findings: Review of resident #18's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, Alzheimer's disease, dementia, and osteoarthritis of knee. Review of resident #18's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 5/15, which indicated he was cognitively impaired. The MDS assessment noted no rejection of evaluation or care necessary to obtain his goals for health and well-being. Review of resident #18's medical record revealed a care plan for acute/chronic pain related to disease process and general discomfort revised on 9/05/22. The interventions directed nurses to administer analgesia…
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 13 citations
- Potential for harm · D2025-02-28 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 interview, and record review, the facility failed to maintain effective communication between nursing staff and hospice to promote adequate treatment, monitoring, and continuity of care for 2 of 2 residents reviewed for hospice care and services, out of a total sample of 59 residents, (#3 and #469). Findings: 1. Review of resident #3's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 8/14/24. Her diagnoses included senile degeneration of brain, type 2 diabetes, dementia, glaucoma, bilateral hearing loss, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/10/24 revealed resident #3's Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The MDS assessment showed resident #3's was receiving hospice care. Review of resident #3's comprehensive care plan revealed a focus of hospice care related 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 · D2025-02-28 · 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 during the medication administration task, facility staff failed to disinfect the blood pressure monitor between residents for 1 out of 5 residents reviewed for medication administration, of a total sample of 59 residents, (#1). Findings: On 2/25/25 at 10:09 AM, during the Medication Administration task, it was observed that Registered Nurse (RN) D used a portable blood pressure monitoring device to take the blood pressure of resident #98. She then proceeded to the next resident #1 for medication administration. She did not disinfect the blood pressure monitor after using it for resident # 98, nor before using it on resident #1. RN D explained that she was stressed and had forgotten to clean the device between residents as she was supposed to. On 2/28/25 at 9:46 AM, the Infection Preventionist (IP) said that the purple top wipes were used to disinfect equipment for one minute and they always tried to follow the manufacturer's drying and contact times. She described that facility staff recently had an in-service concerning sanitizing…
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 · D2025-02-28 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to develop a comprehensive system to monitor antibiotic use in the facility from January 2025 through the time of the survey. Findings: Review of the Infection Control Report dated 1/01/25 to 1/31/25 included the Infection Surveillance Monthly Report dated 1/01/25 to 1/31/25 which revealed in the Summary by Infection Category that there was 1 Urinary Tract/Kidney infection that occurred with a resident, #23. Review of the Order Listing Report dated 01/01/25 to 01/31/2025 which included antibiotic medication classes revealed residents #99, #53, #87, and #20 were also receiving antibiotics in January 2025 for urinary tract/kidney infections. Review of resident #99's medical record revealed an order dated 1/07/25 for a urinalysis. The urinalysis lab report indicated a collection and report date of 01/09/25. There was no culture and sensitivity testing that followed the 1/09/25 urinalysis. A physician's order with a start date of 1/14/25 stated to give…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · 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 follow physician orders related to the monitoring of vital signs and medication administration for 1 of 5 residents reviewed for following physician orders, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for respite care for diagnoses that included, brain cancer, cachexia (wasting syndrome) and quadriplegia (paralysis below the neck). The resident also had a Percutaneous Endoscopic Gastrostomy (PEG) tube which is a tube that goes into the stomach to assist with feeding when oral intake isn't adequate. Resident #1 remained at the facility until 5/15/14 when he was discharged back to his home. According to The National Institute for Aging, respite care is a period of short-term relief for primary caregivers, which gives them time to rest (retrieved on 7/11/24 from www.nia.nih.gov). Review of resident #1's medical record revealed a physician's order dated 5/11/24 to administer Midodrine HCl 10 milligrams (mg) two times 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 · Ecited before2024-06-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to promote healing and prevent worsening of existing pressure ulcers for 3 of 13 residents reviewed for pressure ulcers, of a total sample of 20 residents, (#3, #9, and #17). Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), There are Stage 1 to 4 pressure ulcers, unstageable and suspected deep tissue injury (SDTI) .Stage 2 has partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed, without slough .Stage 3 has full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed . Stage 4 has full thickness tissue loss with exposed bone, tendon or muscle Unstageable depth is unknown and presents with full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue) .SDTI has depth unknown presenting as purple or maroon localized area of discolored intact skin or blood blister…
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 · E2023-08-10 · 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 maintain safe and sanitary conditions for food storage in 2 of 2 nutrition stations, (Specialized Subacute Unit and General and Restorative Unit). Findings: On 8/10/23 at 10:30 AM, during a tour of the Specialized Subacute Unit (SSU) nutrition station with the SSU Unit Manager (UM), the following concerns were identified: * The countertop sink was leaking underneath the cabinet into bath basin and overflowing pink colored water noted to be eroding cabinet. The cabinet had brownish/black substance noted in the corners. * The cabinet above the sink was disheveled with dirt/crumbs scattered as well as miscellaneous items inside the cabinet including staff's bag lunch with avocado, apple, orange, sunscreen, water bottle, phone cord, melting frozen water bottle thawing and pooling water on shelf, thickener packets, salt/pepper packets, mayo packets, staff empty plastic thermos drink holder. * The refrigerator included two half cheese sandwiches with no date/label, another empty staff drink thermos, resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 copy of a transfer/discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents reviewed for hospitalization of a total sample of 36 residents. (#6, #21) Findings: 1. Resident #6 was admitted to the facility on [DATE] from an acute care hospital. The resident had multiple readmissions to the facility, with her most recent readmission on [DATE]. Her diagnoses included myocardial infarction, takotsubo syndrome, atherosclerotic heart disease, hypertension, lymphedema, and malignant neoplasm of large intestine. Record review of the resident's clinical records revealed she was transferred to an acute care hospital on 5/08/23 to 5/11/23, 5/25/23 to 5/27/23, 5/31/23 to 6/06/23, 6/20/23 to 6/26/23, and on 7/16/23 to 7/17/23. Notification to the Ombudsman of the resident's hospital transfers could not be identified. 2. Resident #21 was admitted to the facility on [DATE], discharged to an acute…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate a baseline care plan to address infection and a peripherally inserted central catheter (PICC) line for 1 resident reviewed for antibiotic use of a total sample of 36 residents. (#78). Findings Resident #78, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included osteomyelitis, generalized muscle weakness, cystitis, diabetes type II, chronic obstructive pulmonary disease, and atrial fibrillation. The resident's physician orders dated 7/25/23 included, Meropenem 1000 milligram every 8 hours, with a stop date of 8/18/23, and change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Meropenem is an antibiotic that is used to treat severe infections of the skin and stomach. (retrieved on 8/18/23 from www.drugs.com). Review of the resident's Baseline Care plan dated 7/24/23 revealed the resident was on intravenous (IV) medications. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure an individualized activity program was provided to 1 of 1 resident reviewed for Activities from a total sample of 36 residents. (#313) Findings: Review of the medical record revealed resident #313 was admitted to the facility from an acute care hospital on 7/22/23. The resident had diagnoses that included major depressive disorder, single episode, moderate, multiple myeloma, seizures, type 2 diabetes mellitus, weakness, and pressure ulcers of the sacral region and the left heel. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date 7/29/23 noted the resident scored 12 out of 15 for the Brief Interview for Mental Status (BIMS) and did not require further cognitive assessment. The Resident Mood Interview showed the resident felt down, depressed, or hopeless, and he had trouble concentrating for 7 to 11 days. Medications noted the resident received antidepressants for 7 out of 7 days during the look back period. The Preferences for Routine and Activities showed that the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-10 · 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 ensure physician's orders and care plan interventions were implemented to meet the resident's needs for 1 resident reviewed for edema of a total sample of 36 residents. (#1) Findings: Resident # 1, a 91- year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, venous insufficiency, mononeuropathy of bilateral lower limbs, diabetes type II, and cardiac pacemaker. Physician's order dated 7/05/23 was for knee high light compression stocking to the left lower extremity, on in the AM, and off at nights as tolerated, for lymphedema of left lower extremity, with start date of 7/06/23. Lymphedema is swelling due to build-up of lymph fluid in the body. (retrieved on 8/18/23 from www.cdc.gov). On 8/07/23 at 11:15 AM, on 8/08/23 at 12:00 PM, and on 8/08/23 at 4:11 PM, resident #1, was sitting in her wheelchair at the entrance of her room, she had edema to 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 · D2023-08-10 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for antibiotic use of a total sample of 36 residents, (#78). Findings: Resident #78, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included osteomyelitis, generalized muscle weakness, cystitis, diabetes type II, chronic obstructive pulmonary disease, and atrial fibrillation. The resident's physician orders dated 7/25/23 included, Meropenem 1000 milligram every 8 hours, with a stop date of 8/18/23, and change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Meropenem is an antibiotic that is used to treat severe infections of the skin and stomach. (retrieved on 8/18/23 from www.drugs.com). On 8/08/23 at 11:46 AM, resident # 78 was lying in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · 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 1 monthly Medication Regimen Review (MRR) recommendation was reviewed timely by the physician, and failed to act timely on 1 monthly MRR with physician's orders for 2 of 5 residents reviewed for Unnecessary Medications out of a total sample of 36 residents. (#27, #313) Findings: 1. Review of the medical record revealed resident #27 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included hypertensive heart disease, chronic kidney disease, liver cirrhosis, anemia, ileostomy, stroke, muscle weakness, depression, and bipolar II disorder. The Order Summary Report noted the resident's medication orders included Magnesium Oxide 400 milligrams (MG) for low magnesium ordered 6/03/23, Lasix 20 MG for edema ordered 6/03/23, Omeprazole Delayed Release 20 MG for gastroesophageal reflux disease (GERD) ordered 6/03/23, Pantoprazole Sodium Delayed Release 40 MG for GERD ordered 6/09/23, Ondansetron HCI 4 MG for nausea…
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 · E2021-10-14 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 mechanically altered foods to meet the individual needs for 1 of 5 residents reviewed for nutrition, out of 40 sampled residents, (#52). Findings: Resident #52 was admitted to the facility from an acute care hospital on 9/20/19 with diagnoses including muscle weakness, diabetes, anemia. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 8/16/21 revealed resident #52 had a Brief Interview for Mental Status score of 14 indicating her cognition was intact. She required set up help only to eat her meals. The MDS assessment indicated she required a mechanically altered, therapeutic diet. Review of resident #52's medical record revealed a care plan for activities of daily living initiated on 10/10/19. The interventions noted the resident had a mechanically altered diet and was able to feed herself. A care plan for nutrition initiated on 9/27/19 revealed resident #52 had a nutritional problem related to altered food texture. The care plan directed staff to provide and serve diet…
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 HARBORVIEW HEALTH SYSTEMS — 22 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 | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 4 of 5 | 2.4 | +1.6 vs chain |
| Quality measures | 2 of 5 | 2.3 | -0.3 vs chain |
The other 21 homes this chain runs (chain average 1.9★, per CMS)
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 | Share | Since |
|---|---|---|---|---|
| HARBORVIEW KISSIMMEE HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 07/15/2024 |
| CHAPPEL, CHRISTOPHER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/15/2024 |
| VAUGHAN, CHRISTA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/15/2024 |
| LEIBOWITZ, CHAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/15/2024 |
| DAHAN, MICHELLE | Individual | TRUSTEE OF THE SNF | — | since 07/15/2024 |
| ENGLANDER, SHMUEL | Individual | TRUSTEE OF THE SNF | — | since 07/15/2024 |
| KLEIN, JOSEPH | Individual | TRUSTEE OF THE SNF | — | since 07/15/2024 |
| LEIBOWITZ, ELIYAHU | Individual | TRUSTEE OF THE SNF | — | since 07/15/2024 |
| SOKOLOFF, RIVKA | Individual | TRUSTEE OF THE SNF | — | since 07/15/2024 |
| CL 2022 IRRV TR | Organization | ADP OF THE SNF | — | since 09/24/2025 |
| DE 2021 IRRV TR | Organization | ADP OF THE SNF | — | since 09/24/2025 |
| FL 7 NURSING AND REHAB HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/24/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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 71% 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 $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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
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 106011. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-28, 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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