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Terrace Of Kissimmee, The

221 Park Place Blvd, Kissimmee, FL 34741 · For profit - Limited Liability company · 120 certified beds · (407) 935-0200 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20252 immediate-jeopardy citations$38,724 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • 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
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • 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
  • the CMS record shows $38,724 in federal fines (most recent 2024-10-24)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(407) 870-5050 · Call to confirm hours
Pharmacy
200 Park Place Blvd · (407) 344-9700 · Call to confirm hours
Grocery
1702 N Main St · (407) 343-7429 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2311 N Orange Blossom Trl · (407) 957-9077

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 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.1%8.7%15.4%typical
Long-stay residents who lose too much weight8.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.3%0.9%typical
Long-stay residents with a urinary tract infection1.8%0.7%2.0%typical
Long-stay residents with depressive symptoms2.2%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.6%2.5%3.3%better
Long-stay residents whose ability to walk worsened17.1%9.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication23.8%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers9.1%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control5.4%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 table14.3%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine91.9%94.7%79.4%better
Short-stay residents rehospitalized after admission21.3%26.1%22.6%typical
Short-stay residents with an outpatient ER visit7.9%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days4.872.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.211.151.80better

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

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

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

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

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

52.5% 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 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.5%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
54.5%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 54.5% 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 110 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.5%CMS range 42.6–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.5–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.2%CMS range 5.8–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.241.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.62
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.82
Total nurse hours/ resident / day
0.47
RN hoursweekends
42.6%
Total nursing turnover
55.2%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 115.5 residents a day — about 96% occupied, or roughly 4 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.44 hrs/resident/day on weekends vs 3.97 on weekdays — 13% thinner on weekends. RN hours go from 0.68 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

9
deficiencies at the latest standard inspection (2025-04-17)
1
at the previous standard inspection (2023-09-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to protect the resident's right to be free from neglect by failing to honor the resident's wishes for life saving measures, by failing to follow physician's order for Full Code and failing to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident with no vital signs. LPN C did not check the resident's code status nor provide CPR but instead informed the Weekend Supervisor Registered Nurse (RN) E of the situation at approximately 10:08 PM. RN E found resident #2 without any vital signs and failed to initiate CPR although he knew the resident had a physician order for Full Code. Both nurses failed to provide CPR, failed to call a code overhead for additional support, failed to call 911…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-10-24 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 honor the resident's/family's wishes and failed to follow the physician's order to provide basic life support (BLS) and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found unresponsive in bed, not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident had no vital signs. LPN C did not verify the resident's code status, or initiate CPR and instead asked Registered Nurse (RN) Supervisor E at approximately 10:08 PM to come to the resident's room. RN E evaluated resident #2 with no vital signs, disregarded the physician order for Full Code or Full Resuscitation status and did not initiate CPR. The facility's failure to ensure staff followed the resident/family's wishes and physician's order to initiate CPR resulted in Immediate Jeopardy…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-23 · tag F0641 — isolated
    Ensure 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) assessments accurately reflected health conditions for 1 of 3 residents reviewed for falls, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her diagnoses included seizures, disorders of bone density and structure, anxiety, muscle weakness, and dementia with mood disturbance. Review of resident #2's medical record revealed an Event Report dated 11/18/25 that documented a fall that resulted in bleeding from the nose and a skin tear above the right eyebrow. Review of the Observation Detail List Report dated 11/18/25 revealed resident #2 was transferred to the hospital due to the fall. Review of Section J - Health Conditions of resident #2's Discharge Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/18/25 revealed she had one fall with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-23 · tag F0849 — isolated
    Arrange 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 communicate with the hospice provider when a change in condition was identified to ensure collaboration on the provision of necessary care and services for 1 of 1 resident reviewed for hospice services, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her diagnoses included seizures, disorders of bone density and structure, anxiety, muscle weakness, and dementia with mood disturbance. Review of resident #2's Progress Notes revealed a nursing note dated 8/15/25 and a Social Services note dated 8/17/25, detailing the resident returned to the facility from the hospital on hospice services. Review of resident #2's comprehensive care plan revealed a hospice care plan initiated on 8/18/25 and revised on 11/24/25. The care plan included an approach that directed nursing staff to observe 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety by failing to label, date, and discard food after an acceptable time period and by failing to air-dry glasses, cups, and trays prior to their use in meal service, in one of one walk-in refrigerator/freezer, one of one dry storage room and one of one kitchen. Findings: On 4/14/25 at 9:45 AM, during the initial kitchen tour with the Consultant Certified Dietary Manager (CDM) S, there were multiple leftover/previously opened food items found unlabeled and undated in the walk-in refrigerator as listed: four packages of wrapped American Cheese slices, two packages of shredded cheese, a half-pan of what appeared to be chicken breasts floating in water, a 1/3 steamtable pan of rice, a 1/6 pan of what appeared to be egg salad, a 1/3 pan of what appeared to be au gratin potatoes, a 1/2 pan of jello and a deep pan of some kind of ground, cooked meat. In addition, there was a number of leftover food items, undated as to when they were prepared…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-17 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained for two of ten concerns identified during the survey, (F554, and F880). Findings: Review of the facility's undated policy, Quality Assurance and Performance Improvement (QAPI) Program, revealed the purpose of the QAPI Program was to establish data driven, facility wide processes to improve the quality of care, quality of life and clinical outcomes of their residents. The policy included Action Steps to support and enhance the QAPI Program. The document included, Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include: . State surveys and deficiencies . The facility had concerns related to infection control and self-administration/improper administration of medications which led to deficiencies at F880 in the last…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0554 — isolated
    Allow 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 proper administration of medications for one of one resident assessed for self administration of medications, of a total sample of 44 residents, (#94). Findings: Review of the medical record revealed resident #94 a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Parkinson's disease, peripheral neuropathy, mixed anxiety disorders, neuralgia. On 4/14/25 at 1:44 PM, resident #94's spouse was observed assisting the resident with his lunch in his room. On the overbed table next to the lunch tray were two 30 milliliter (ml) medication cups with multiple pills inside the cups. The resident's spouse stated the medications included eight pills including Tylenol, Parkinson's medication, antihistamine medication, neuropathy medication, stool softener, and laxative. Resident #94's spouse stated, the nurse always left the medications with her to give to the resident with the meal. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-17 · tag F0641 — isolated
    Ensure 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 observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected resident's tobacco use for 1 of 1 residents reviewed for smoking (#511); reflected oxygen (O2) therapy for 1 of 1 residents reviewed for respiratory care, (#511); and accurately reflected active diagnoses for 1 of 1 residents reviewed for psychiatric diagnoses, (#93), of a total sample of 44 residents. Findings: 1. Review of resident #511's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, chronic respiratory failure, and dependence on supplemental O2. Review of resident #511's medical record revealed an admission Observation Report form dated 3/24/25 which indicated he used O2 via nasal cannula (NC). Review of resident #511's physician orders revealed an order dated 4/10/24 for O2 at 3 liters per minute (LPM) via NC. On 4/16/25 at 1:37 PM, resident #511 was observed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0644 — isolated
    Coordinate 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 ensure individuals with a mental disorder, intellectual disability (ID), or other related disorders had accurate Level I Preadmission Screening and Resident Reviews (PASARR) completed upon admission and/or updated as needed to receive appropriate care and services in the most integrated setting appropriate for 2 of 5 residents reviewed for PASARRs, of a total sample of 44 residents, (#4 and #98). Findings: 1. Resident #4 was admitted to the facility on [DATE] with the diagnoses of hypertension, bipolar disease type II, depression, anxiety disorder, and insomnia. Resident #4's medication orders included medications for the diagnoses of bipolar disorder, and anxiety. Review of the Level I PASARR dated 6/29/22 performed pre-admission to the facility did not include the admitting diagnoses such as anxiety, depression, and bipolar disease type II. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #4's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to obtain physician's order for the care and treatment of catheter dressings for 1 of 5 residents sampled for skin conditions, of a total sample of 44 residents, (#412). Findings: Review of resident #412's medical record revealed an admission date of 4/10/25. His diagnoses included iron deficiency anemia secondary to blood loss, end stage renal disease, and need for assistance with personal care. On 4/11/25 his Brief Interview for Mental Status was assessed to be a 13/15, indicating intact cognitive function. Review of resident #412's weekly skin audit dated 4/10/25 noted in the new skin problems section that resident #412 had a surgical wound from a right chest Permacath and a chemoport on the left upper clavicle. A Permacath is a special catheter used for short term dialysis treatment that is tunneled under the skin and leads to a blood vessel going to the heart, (retrieved on 4/28/25 from www.drugs.com). A chemotherapy port is a small implantable device that attaches to a vein usually in the upper chest that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely assessment and follow-up for removal of an indwelling urinary catheter including a urology referral, for 1 of 2 residents reviewed for urinary catheters, of a total sample of 44 residents, (#95). Findings: Resident #95 was admitted to the facility on [DATE] with a diagnosis of acute urinary tract infection. In the hospital discharge paperwork it noted resident #95 had a urinary catheter placed on 3/16/25 related to urinary retention. The discharge paperwork noted the catheter needed to be changed every 30 days and the resident needed a follow-up appointment with a urology specialist. There was no documentation in resident #95's medical record that a urology follow-up had been scheduled by the facility. On 4/16/25 at 5:50 PM, the Director of Nursing (DON) stated Advanced Practice Registered Nurse (APRN) H, had told her he did not want resident #95 to have the indwelling urinary catheter removed until he had a urology…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 interview, and record review, the facility failed to follow up on a triggered excessive weight loss for 1 of 13 residents reviewed for food and nutrition, of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder) following cerebral infarction, dysphagia (difficulty swallowing), dementia, and need for assistance with personal care. Review of the Minimum Data Set Quarterly assessment with Assessment Reference Date of 3/30/25 revealed resident #26 had a Brief Interview for Mental Status score of 3/15 which indicated he had severe cognitive impairment. The MDS assessment showed the resident exhibited weight loss although he was not on a physician-prescribed weight loss prevention regimen. Review of resident #26's weights revealed on 1/10/25, the resident weighed 111.2 lbs. On 3/07/25 resident #26 weighed 109.8 lbs. and on 3/14/25 he weighed 100.4 lbs., an 8% loss in one…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-04-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a system for preventing and controlling infections and communicable diseases for residents by not offering hand hygiene to residents prior to meals and not maintaining a catheter bag dragging on the floor. This had the potential to affect 43 residents eating meals in the dining room, and one of one resident reviewed for urinary tract infections, (#95) of a total sample of 44 residents. Findings: 1. On 4/14/25 at 12:22 PM, during dining observation, 43 residents in the main dining room and the small room off the main dining room, were observed waiting for lunch to be served. At 12:38 PM, the first of three carts with meal trays were delivered from the kitchen and were served to residents. None of the residents were offered hand hygiene before the meal. On 4/15/25 at 12:35 PM, 39 residents were observed waiting for their lunch meal in the main dining room. Five visitors and three residents confirmed they had not been offered 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services according to assessed needs, to promote the highest practicable physical and psychosocial well-being; and failed to follow required processes to prevent neglect by appropriately identifying and communicating care needs and ensuring continuity of care for 1 of 3 residents reviewed for neglect, out of a total sample of 9 residents, (#2). Findings: Review of the facility's policy and procedure for Abuse Prevention Program, dated March 2024, revealed residents had the right to be free from abuse and neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish. or emotional distress. The document indicated the facility would develop and implement policies to prevent abuse and neglect. Review of the medical record revealed resident #2, a [AGE] year-old male, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for a dependent resident related to incontinence care, fingernail care, and shaving facial hair for 1 of 3 residents reviewed for ADL status, out of a total sample of 9 residents, (#2). Findings: Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included prostate gland enlargement, chronic pain syndrome, and generalized muscle weakness. Review of the Minimum Data Set (MDS) Significant Change in Status assessment, with assessment reference date of 12/05/24, revealed resident #2 had a Brief Interview for Mental Status score of 9/15, which indicated he had moderate cognitive impairment. The MDS assessment revealed the resident exhibited no physical or verbal behavioral symptoms, but rejected evaluation or care on one to three days in the look back period. The document showed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-28 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate pharmaceutical services to prevent administration of a prescription ointment by unlicensed nursing staff, for 1 of 1 resident reviewed for medication administration, out of a total sample of 9 residents, (#2). Findings: Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included dermatitis (skin inflammation), pruritis (itching), psoriasis, xerosis (dry, scaly skin), and bacterial skin infection of his left leg. Resident #2 had a care plan, started on 9/19/24, for impaired skin integrity related dermatitis. The goal was the resident's skin would exhibit signs of healing or resolution. The approaches instructed nurses to provide medications as ordered, observe for improvement or decline in condition for the possible need for change in treatment, and obtain/provide treatment as ordered by physician. Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure staff reported neglect of a resident related to not performing cardiopulmonary resuscitation (CPR) to the Risk Manager or Administrator which resulted in late reporting to the State Agency and Adult Protective Services for 1 of 2 residents reviewed for neglect, of a total sample of 8 residents, (#2). Findings: Resident #2 was re- admitted to the facility from the hospital on [DATE] with diagnoses that included dementia, cerebrovascular disease and adult failure to thrive. The medical record revealed he was readmitted on hospice services. Progress notes dated [DATE] at 10:40 PM and 11:16 PM, revealed that at approximately 10:05 PM, Licensed Practical Nurse (LPN) C was notified by the Certified Nursing Assistant (CNA) that resident #2 was not breathing. LPN C assessed the resident and found he had no pulse or blood pressure. The note did not indicate that she checked the resident's code status and initiated CPR as per the physican order, but…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure accommodation for residents who needed their call bell within their reach to alert staff to care needs for 2 of 4 sample residents, (#1 and #2). Findings: 1. Resident #1 was admitted on [DATE], pertinent diagnoses included: cerebral infarction (stroke) and hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction affecting right dominant side. Review of resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed she was impaired on one side of her upper and lower extremities. The assessment revealed she was dependent on staff for bed mobility and to move from a position from lying to sitting. Walking 10 feet was not attempted because the resident did not perform this activity prior to the current illness/injury. The self-care section indicated resident #1 was totally dependent on staff for oral, toileting, and personal hygiene, showers/baths, and upper and lower body dressing.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a dependent resident received the necessary services to maintain activities of daily living (ADL) regarding nail and oral care for 1 of 4 sampled residents, (#1). Resident #1 was admitted on [DATE], with diagnoses to include cerebral infarction (stroke) and hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction affecting right dominant side. Review of resident #1's Minimum Data Set (MDS) Quarterly assessment dated [DATE] noted in the functional abilities self-care section the resident was dependent, meaning the resident was unable to provide any effort, to complete her oral and personal hygiene. The MDS showed her Brief Interview for Mental Status Summary Score was 7/15 which indicated severe cognitive impairment. Section E of the assessment indicated resident #1 did not exhibit physical or verbal behavioral symptoms towards others nor did she display other behavioral symptoms not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 1 resident reviewed for dignity, of a total sample of 16 residents, (#4). Findings: Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and legal blindness. Review of resident #4's Minimum Data Set (MDS) annual assessment with Assessment Reference Date 2/22/24 revealed a Brief Interview for Mental Status score of 0 out of 15, which indicated she was cognitively impaired. The MDS assessment noted resident #4 was totally dependent on staff for activities of daily living (ADLs), including eating. Review of resident #4's care plan, revised on 2/23/24, revealed she required staff assistance with ADLs. Approaches included to, Assure dignity by providing privacy during care, and Provide assistance with meals as needed. Review of resident #4's nutritional status care plan, revised on 2/29/24, revealed she received 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-04 · tag F0554 — isolated
    Allow 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 1 of 5 residents was assessed for self-administration of medications of a total sample of 5 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, dermatitis, rosacea, post mastectomy lymphedema syndrome, and anxiety disorder. On 12/04/23 at 12:24 PM, resident #1 sat in her wheelchair at the side of her bed. On the resident's bedside table was a plastic bag, with label that read Ketoconazole Cre 2%. The plastic bag contained Metronidazole gel 1%, and tube of Clindamycin Phosphate gel 1%. On the bedside table was a vial of Thera Tears and a vial of Ivizia eye drops. Resident #1 stated she used the gels herself but had not used them in two to three days, because they were not doing anything. She stated the eye drops were given to her by her eye doctor and she used the drops daily. Resident #1 could not say if she was assessed for self-administration of medications. She…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene practices while administering intravenous (IV) antibiotics for 1 of 5 residents reviewed for medication administration of a total sample of 44 residents, (#260), and the facility failed to follow appropriate hand hygiene practices during meal delivery per infection control standards. Findings: 1. Review of resident #260's medical record revealed he was admitted to the facility on [DATE] for orthopedic aftercare, the presence of a right artificial knee joint, and type 2 diabetes. Review of resident #260's 5-day Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/29/23 revealed he had a Brief Interview for Mental Status score of 14 out of 15 which indicated he was cognitively intact. The MDS assessment showed resident #260 required supervision for bed mobility and transfers. Review of resident #260's physician orders revealed an order dated 8/22/23 for Cefepime 2 grams IV every 8 hours for…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-01-13 · tag F0554 — isolated
    Allow 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 assessed to self-administer antihistamine nasal spray for 1 of 1 resident of a total sample of 45 residents, (#16). Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, schizophrenia, and allergic rhinitis. The resident's annual Minimum Data Set (MDS) assessment with reference date 10/1/21 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 9/15. On 1/10/22 at 11:54 AM, an 11.1 milliliters Fluticasone Propionate allergy relief nasal spray was observed on the overbed table next to the resident's bed. Resident #16 said she took the nasal spray twice a day because her nose was always runny. On 1/11/22 at 10:19 AM, the Fluticasone Propionate allergy spray remained on the over-bed table next to the resident's bed. When questioned about the spray, the resident got into her wheelchair and took the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 ensure the medical record accurately reflected the resuscitation status of 1 of 1 resident reviewed for Advanced Directives out of 45 total sampled residents, (#9). Findings: Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital with diagnoses that included lung disease, traumatic brain injury, and partial paralysis. Review of resident #9's Minimum Data Set quarterly assessment with Assessment Reference Date of 12/28/21 revealed he had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. A care plan for Advanced Directives, Do Not Resuscitate (DNR) code status initiated 9/24/21 indicated family would provide copies of the DNR form. Interventions included a quarterly review of his Advanced Directives and as needed to ensure, Decisions made were still desired. An additional care plan for Advanced Directives initiated on 10/29/21 revealed resident #9…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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

Fines & penalties

$38,724 in federal fines across 1 penalty.

  • $38,724 — penalty dated 2024-10-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
TOK LTC HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/02/2017
LOWEROB ASSOCIATES II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 01/01/2019
SUBHANI, NOMANIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 10/01/2024
TAPIA, JILLIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 07/18/2024
ROTH, DANIELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/18/2024
QUINTANA, FRANCISCOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/20/2019
RICHARDS MITCHELL & CROSS PAOrganizationADP OF THE SNFsince 05/01/2014

CMS files one row per role, so the 12 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$13.6M
Net patient revenuemost recent cost report
-6.6%
Operating marginrevenue minus expenses
$447K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 19%Other / private 24%

This home reported $447K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$343per resident / day
operating cost
$10,424per month
≈ monthly operating cost
$322per day
avg. revenue, all payers

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

What families pay in FL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105839. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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