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Lady Lake Specialty Care Center and Rehab

630 Griffin Avenue, Lady Lake, FL 32159 · For profit - Limited Liability company · 145 certified beds · (352) 750-6619 Medicare & Medicaid certified

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2 immediate-jeopardy citations
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (60%) runs well above the national median (45%)

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) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
918 Rolling Acres Rd · (352) 259-1991 · Call to confirm hours
Pharmacy
890 N US Highway 27/441 · (352) 753-3257 · Call to confirm hours
Grocery
865 N US-27 · (352) 753-0470 · Call to confirm hours
Park
903 Aloha Way · (352) 753-0637 · Typically dawn to dusk
Place of worship
975 Rolling Acres Rd · (352) 753-8484

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 5 of 5
Short-stay residentsrehab / post-hospital 2 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 increased4.6%8.7%15.4%better
Long-stay residents who lose too much weight3.5%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms13.1%4.6%6.5%worse
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 injury3.0%2.5%3.3%typical
Long-stay residents whose ability to walk worsened9.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers2.0%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control3.4%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 table4.4%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine76.6%94.7%79.4%typical
Short-stay residents rehospitalized after admission20.4%26.1%22.6%typical
Short-stay residents with an outpatient ER visit11.3%9.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.192.131.67better
Long-stay outpatient ER visits per 1,000 resident days1.421.151.80better

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.

40.4% 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 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

40.4%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
52.0%U.S. median 56.6%
Met the expected recovery
0.50U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 52.0% 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 148 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 24% 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 SNF40.4%CMS range 31.8–50.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 9.5–15.910.7%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 discharge52.0%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 discharge43.2%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 discharge55.4%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 identified99.2%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 setting99.3%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 stay0.8%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 worsened0.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.431.02Oct 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

0.49
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.19
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
0.50
RN hoursweekends
60.2%
Total nursing turnover
57.9%
RN turnover

How full it usually is: this home is certified for 145 beds and averages 132.1 residents a day — about 91% occupied, or roughly 13 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 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 3.27 hrs/resident/day on weekends vs 3.62 on weekdays — 10% thinner on weekends. RN hours go from 0.48 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 1 administrator has left in the past year.

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

7
deficiencies at the latest standard inspection (2025-12-18)
8
at the previous standard inspection (2024-07-17)

Deficiencies are fewer than at the previous inspection — improving. 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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2025-12-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when the facility failed to ensure residents were administered physician ordered anti-anxiety medications for 1 of 3 residents reviewed for medication administration, Resident #7. The facility failed to ensure residents with prescribed controlled medications were administered the medications per the physician order when failing to remove the medications from the automated medication dispensing machine, failing to notify the pharmacy prior to running out of medications, and failing to notify the physician when the prescribed medications were not administered for Resident #7, with a history of prescribed Ativan use. Resident #7 was prescribed oral Ativan to be administered three times a day. There was a delay in administering Ativan from 12/12/2025 at 10:00 PM through 12/14/2025 at 6:00 AM, for a total of five missed doses. Resident #7 suffered seizure activity. Ativan was administered by intramuscular route on 12/14/2025 at 8:45 AM to treat the seizure activity.…

    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
  • Immediate jeopardy · J2025-12-18 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility administration failed to assume the full responsibility for the day-to-day operations of the facility and use of resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to implement policy and procedures for physician ordered medication administration. The facility failed to ensure Resident #7 was administered physician ordered Ativan 1 mg every 8 hours on 12/12/2025 at 10:00 PM, 12/13/2025 at 6:00 AM, 2:00 PM, and 10:00 PM, and on 12/14/2025 at 6:00 AM resulting in five missed doses, failed to ensure access to retrieve the physician ordered Ativan from the on-site automatic medication dispensing machine, and failed to notify the physician the ordered Ativan was not administered.The Administration failure to develop and implement a system for verification of access to the medications stored in the on-site automated medication dispensing machine for all licensed nursing staff resulted in Resident #7 suffering a seizure on 12/14/2025…

    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 before2025-12-18 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an accurate Pre-admission Screening and Resident Review (PASRR) for a resident diagnosed with a serious mental illness for 1 of 3 residents reviewed for PASRR, Resident #19.Findings include:Review of Resident #19's admission record documented Resident #19 was admitted on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD) with onset date of 10/28/2024, anxiety disorder with onset date of 8/28/2023, and major depressive disorder with onset date of 8/29/2023.Review of Resident #19's PASRR dated 5/4/2024 showed no documentation of Resident #19's diagnosis of post-traumatic stress disorder under mental illness or suspected mental illness in Section I. PASRR Screen Decision-Making.Review of Resident #19's psychiatric progress note dated 12/5/2025 read, Visit type: Psychiatry: Stable 12-week follow up (on no meds). Past psychiatric history of depression, anxiety, PTSD and insomnia. Diagnostic assessment and plan: post-traumatic…

    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 · D2025-12-18 · 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 ensure residents received wound care as ordered by physician for 1 of 3 residents reviewed for skin conditions, Resident #141.Findings include: During an observation on 12/15/2025 at 9:54 AM, Resident #141 was lying in bed. Resident #141 had a wound dressing on his left shoulder, which was dated 12/11. During an observation on 12/16/2025 at 9:12 AM, Resident #141 was lying in bed, with his left shoulder wound dressing dated 12/11.Review of Resident #141's physician order dated 12/11/2025 read, Left Upper Arm: Cleanse with NS [normal saline], pat dry, apply calcium alginate to wound bed and cover ABD [abdominal] pad and rolled gauze every evening shift.Review of Resident #141's physician order dated 12/11/2025 read, Left Upper Arm: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover ABD pad and rolled gauze as needed.During an interview on 12/17/2025 at 12:25 PM, the Assistant Director of Nursing #2 (ADON #2) stated, I will round with the wound care provider and then all recommendations I…

    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 · D2025-12-18 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 record review and interview, the facility failed to ensure ongoing communication with the dialysis center regarding resident assessment before and after dialysis treatment for 1 resident reviewed for dialysis, Resident #12.Findings include:Review of Resident #12's admission record documented the resident was admitted on [DATE] with diagnosis that included acute respiratory failure with hypoxia, atrial fibrillation (irregular heart rhythms), end stage renal disease (kidneys function less than 15% of normal ability) and dependence on renal dialysis.Review of Residents #12's physician orders showed an order dated 10/25/2025 for dialysis on Tuesdays, Thursdays, and Saturdays.Review of Resident #12's dialysis communication book showed no communication of assessment of Resident #12, no vital signs, and no weights. There was no communication from before or after dialysis treatment and no communication from dialysis.During an interview on 12/18/2025 at 10:26 AM, the Administrator of Dialysis Center stated, We…

    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 before2025-12-18 · 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

    Based on observation, record review, and interview, the facility failed to accurately document wound care treatments for 1 of 3 residents reviewed for skin conditions, Resident #141, failed to document blood pressure and pulse when administering blood pressure medications for 1 of 6 residents reviewed for medication management, Resident #99, and failed to ensure residents had accurate medication orders for 1 of 6 residents reviewed for unnecessary medications, Resident #25.Findings include:1) During an observation on 12/15/2025 at 9:54 AM, Resident #141 was lying in bed. Resident #141 had a wound dressing on his left shoulder, which was dated 12/11. During an observation on 12/16/2025 at 9:12 AM, Resident #141 was lying in bed, with his left shoulder wound dressing dated 12/11.Review of Resident #141's physician order dated 12/11/2025 read, Left Upper Arm: Cleanse with NS [normal saline], pat dry, apply calcium alginate to wound bed and cover ABD [abdominal] pad and rolled gauze every evening shift.During an observation on 12/17/2025 at 12:30 PM, the Assistant Director of Nursing #2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, that facility failed to ensure staff performed hand hygiene and appropriately used personal protective equipment (PPE) while providing wound care for 1 of 3 residents reviewed for skin conditions, Resident #141, and failed to ensure respiratory equipment were stored appropriately for 3 of 5 residents reviewed for respiratory services, Residents #6, #75, and #100, to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 12/17/2025 at 12:37 PM, the Assistant Director of Nursing #2 (ADON #2) asked Staff I, Licensed Practical Nurse (LPN), to perform wound care on Resident #141. Without preforming hand hygiene, Staff I approached the treatment cart and started to collect items needed for wound care. Staff I did not have normal saline in the treatment cart. Staff I returned all supplies back to the treatment card and walked to the central supplies. Staff I returned to the treatment cart. Without performing hand hygiene, Staff I retrieved all wound care supplies. Staff I and 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 ensure foods were prepared under sanitary conditions and failed to ensure food temperatures were documented to be at safe levels prior to meal service to residents. Findings include: An initial tour of the facility kitchen was completed on 7/14/2024 beginning at 9:16 AM. There was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was a black discoloration on the large ceiling vent above the same food preparation area. There were uncovered peeled bananas on the counter underneath the discolored ceiling and ceiling vent. During a follow-up tour of the kitchen on 7/17/2024 beginning at 8:36 AM, there was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was black discoloration on the large ceiling vent above the same food preparation area. There were two large baking sheets of uncovered raw chicken pieces on the counter underneath the discolored ceiling and ceiling vent. During…

    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 · Ecited before2024-07-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to prevent the possible spread of infection by not completing sanitization of blood pressure cuffs, hand hygiene during medication administration, and hand hygiene after the delivery of personal care. Findings include: 1. During an observation on 7/16/2024 at 09:00 AM Staff B, License Practical Nurse (LPN) retrieved the blood pressure cuff from the top of the medication cart and obtained a blood pressure reading for Residents #55. Staff B, LPN returned to the medication cart and placed the blood pressure cuff inside the cart without cleaning/sanitizing the cuff. During an interview on 7/16/2024 at 09:17 AM Staff B, LPN stated, Blood pressure cuffs are to be wiped after each use with Clorox wipes. I should have cleaned the blood pressure cuff after using it. 2. During an observation on 7/16/2024 at 09:25 AM Staff D, Registered Nurse (RN) exited the nutrition room and initiated medication administration for Resident #103. Staff D pulled the wrong medication, then destroyed the wrong medication in a drug buster,…

    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 · D2024-07-17 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure maintenance and housekeeping provided the services necessary to maintain a sanitary and orderly environment for the 200-hall shower room. Findings include: During an observation on 7/14/24 at 10:00 AM during the initial tour of the 200-hall shower room it was observed that the ceiling, walls, and tiles surrounding the shower area were cracked and/or have holes. The walls of the shower room have streaks of a darkened green and brown substance running down the walls. It was also observed to have dirty linen and personal items that were left in the shower room. During this observation the shower floor was dry as were the walls. (Photographic evidence obtained) During observations on 7/15/24 staff were observed wheeling residents into the shower room on the 200-hall for showers. During an observation on 7/15/24 at approximately 10:00 AM the shower room walls in the shower room on the 200-hall were observed to have streaks of a darkened green and brown substance running down the wall. During observations on 7/16/24 staff…

    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 before2024-07-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care services, Residents #591 and #80. (Photographic evidence obtained) Findings include: 1. During an observation on 7/14/24 at 10:00 AM Resident #591 was observed resting in bed wearing a nasal cannula and the oxygen (O2) concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an observation on 7/14/24 at 1:04 PM Resident #591 was observed sitting at the edge of the bed wearing a nasal cannula and the O2 concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an interview on 7/14/24 at 1:04 PM Resident #591stated, I don't touch or adjust the settings on the oxygen concentrator. The staff is the one who touches the settings. During an observation on 7/15/24 at 8:09 AM Resident #591 was observed resting in bed eyes closed wearing a nasal cannula and the oxygen concentrator was observed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-17 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and two medication errors were identified for 1 of 6 residents. The medication errors resulted in a medication error rate of 7.14%. Findings include: During an observation on 7/16/2024 at 9:50 AM of Staff C, Registered Nurse (RN) during the medication pass for Resident #62 it showed Staff C administered one Midodrine HCL (hydrochloride) oral tablet 5 mg (milligrams), and one Vitamin D3 tablet 215 mg/equivalent to 5000 IU (international units). Resident #62's blood pressure results were documented as 140/88. Review of Resident #62's physician orders dated 5/6/2024 read, Vitamin D3 oral tablet give 3000 units by mouth in the morning for supplement. Midodrine HCL oral tablet 5 mg give 1 tablet by mouth three times a day for hypotension [low blood pressure] hold if systolic is greater than 110. During an interview on 7/16/2024 at 11:50 AM Staff D, RN stated, Midodrine should not have been given…

    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
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-07-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and policy and procedure review the facility failed to ensure medications were secure allowing access by unauthorized personnel, residents, and visitors when medications were left unattended on a resident's bed. Findings include: During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room with Staff E, LPN, she confirmed the medications in the medication cup were on Resident #491's bed and were…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-17 · 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

    Based on observation, interview, and record review the facility failed to ensure the accuracy of medical records when errors were identified by licensed nursing staff for medication administration for 1 of 5 residents, Resident #491 and failed to ensure accurate and complete records for 1 of 2 residents, Resident #49, reviewed for hospitalizations. Findings include: 1. During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room 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 · Fcited before2024-04-01 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with professional standards of practice in 6 of 6 medication carts reviewed for medication storage. Findings include: During an observation of Medication Cart #1 on 4/1/2024 at 8:40 AM with Staff A, Licensed Practical Nurse (LPN), there were one opened Humalog insulin with no date opened or expiration date, one opened Lispro insulin with no date opened or expiration date, two unopened Aspart insulin with pharmacy instructions to refrigerate until opened, one opened bottle of olopatadine eye drops with no date opened or expiration date, one opened bottle of Prednisolone eye drops without the original pharmacy packaging and no date opened or expiration date, and two opened bottles of artificial tears with no dates opened or expiration dates. During an observation of Medication Cart #2 on 4/1/2024 at 8:51 AM with Staff A, LPN, there were one opened Humalog insulin with no date opened or expiration date, one opened Lantus insulin with no date opened or…

    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 · E2023-03-09 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 ensure a written bed-hold notice that included all required information was provided to the residents and/or their representatives for 3 of 3 residents reviewed for hospitalization, Residents #47, #191, and #54. Findings include: 1. Review of the admission record for Residents #47 revealed the resident was admitted to the facility on [DATE]. During an interview on 3/6/2023 at 12:36 PM, Resident #47 stated, I went to the hospital in the beginning of January and the end of December most recently. They did not give me any bed hold notices when I left. What are those anyway? Review of the nursing progress note for Resident #47 dated 1/4/2023 at 4:01 AM reads, On 1/4/23 around 0020 [12:20 AM] the resident put on his room call light to notify nursing staff he was having SOB [Shortness of Breath] and asked if he could now go to hospital to be seen, upon entering the room the resident displayed signs and symptoms of shortness of breath and labored breathing,…

    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 · Ecited before2023-03-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #4, and #65. Findings include: 1. During an observation on 3/6/2023 at 9:20 AM, Resident #4 was sitting in bed receiving oxygen through a nasal cannula. The oxygen concentrator was set on 2.5 liters of oxygen. Review of the admission record for Resident #4 revealed the resident was admitted to the facility on [DATE] with the diagnoses including pneumonia, unspecified organism, pulmonary fibrosis (a disease where the lungs become damaged and scarred), chronic respiratory failure with hypoxia (low oxygen levels), and chronic obstructive pulmonary disease. Review of the physician orders for Resident #4 revealed no written orders for administration of oxygen. During an interview on 3/6/2023 at 11:30 AM, Staff D, Licensed Practical Nurse (LPN), confirmed that Resident #4 was using…

    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 · Ecited before2023-03-09 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 5 medication carts and failed to ensure the medications were kept secured. Findings include: 1. During an observation of Medication Cart #1 on [DATE] at 8:55 AM with Staff A, Licensed Practical Nurse (LPN), there were two opened Humulin insulins with no opened or expiration dates, two opened Novolog Insulins with no opened or expiration dates, two Insulin Degludec pens with no opened or expiration dates, one opened Lantus insulin with no opened or expiration dates, two opened Novolog insulins with no opened or expiration dates, two opened bottles of artificial tears with no opened or expiration dates, and one bottle of artificial tears with an expiration date of [DATE] written on the bottle and on the box. There were two medication cups with unlabeled medications, one cup with nine medications…

    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 · Ecited before2023-03-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible development and transmission of communicable diseases and infections. Findings include: 1. During an observation of medication administration for Resident #64 on 3/9/2023 at 5:05 AM, Staff J, Licensed Practical Nurse (LPN), prepared medications without performing hand hygiene, entered the resident's room, assisted the resident in repositioning in bed, administered the medications, exited the room and returned to the medication cart to prepare medications for another resident. During an observation of medication administration for Resident #88 on 3/9/2023 at 5:10 AM, Staff J, LPN, prepared medications without performing hand hygiene. Staff J entered the resident's room, touched the overbed table and siderails, and administered the resident's medications. Staff J exited the room and returned to the medication cart to prepare medications for another resident. During an observation of medication administration 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 · D2023-03-09 · 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 record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents reviewed for oxygen administration, Resident #65. Finding include: Review of the admission record for Resident #65 revealed the resident was admitted to the facility on [DATE] with diagnoses including primary generalized (osteo) arthritis, age-related osteoporosis without current pathological fractures, chronic pain, cough, insomnia, major depressive disorder, hyperkalemia, and anxiety disorder. Review of the physician order dated 12/9/2022 for Resident #65 reads, Oxygen 2 L [Liter] with humidifier via nasal cannula at night one time a day for oxygen use. Review of Resident #65's Medication Administration Record reads, Oxygen 2 L with humidifier via nasal cannula at night on time a day for oxygen use. Start Date: 12/09/2022 2000 [8:00 PM], The staff initialed the MAR for administration of oxygen from 12/10/2022 through 12/31/2022. Review of Resident #65's Weights and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-09 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed to determine whether the resident required special services exceeding those provided by the nursing facility for 2 of 6 reviewed residents, Residents #30 and #123. Findings include: 1. Review of the admission record for Resident #30's revealed the resident was admitted on [DATE] with diagnoses including generalized anxiety, depression, and major depressive disorder. Further review revealed no Level I PASARR. During an interview on 3/7/2023 at 12:33 PM, the Director of Nursing (DON) stated, I was not able to locate a Level I screening for [Resident #30's name]. 2. Review of the admission record for Resident #123 revealed the resident was admitted on [DATE] with diagnoses including hypothyroidism, hyperlipidemia, dementia, major depressive, and anxiety disorder. Further review of medical records revealed no PASARR for Resident #123. During an interview on 3/8/2023 at 11:49…

    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 · D2023-03-09 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a comprehensive person-centered care plan was implemented for 1 of 3 reviewed residents, Residents #77. Findings include: During an observation on 3/6/2023 at 3:42 PM, Resident #77 was lying flat on his back while resting in bed. There were no pressure relieving cushions observed to float resident's heels. During an observation on 3/7/2023 at 10:05 AM, Resident #77 was laying on his back in bed, wearing yellow nonskid socks. No pressure-relieving cushions were in place to float resident's heels. Review of Resident #77's care plan initiated on 12/28/2022 reads, [Resident's name] has the potential for skin impairment/ pressure ulcers r/t [related to]: impaired mobility, h/o [history of] pressure ulcer. Care plan interventions include float heels while in bed. During an interview on 3/8/2023 at 12:51 PM, Staff E, Certified Nursing Assistant (CNA), acknowledged that Resident #77 did not have heels floated. During an observation on 3/8/2023 at 1:03 PM, Staff F, Licensed Practical Nurse (LPN), acknowledged…

    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 · D2023-03-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 medications were administered according to professional standards of practice for 1 of 6 residents with gastrostomy tubes, Resident #31, and failed to ensure follow-up appointments were scheduled for 1 of 3 reviewed residents, Resident #189. Findings include: 1. During an observation of medication administration on 3/9/2023 at 5:34 AM, Staff I, Licensed Practical Nurse (LPN), crushed two medications and placed them in a medication cup and poured five milliliters of water into the medication cup from the water pitcher. Staff I mixed the medication with a spoon and removed two large pieces of ice that were heavily coated with medication and threw the ice into the garbage. Staff I then administered the medications leaving a large amount of medication residual in the medication cup. Staff I did not administer a water flush before administering the medications. During an interview on 3/9/2023 at 6:05 AM, Staff I, LPN, stated, I should not have thrown out the ice. It did have a lot of medication on it. I…

    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 · D2023-03-09 · 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

    Based on record review and interview, the facility failed to ensure that residents maintained an acceptable parameter of nutritional status and were offered intravenous hydration for 2 of 4 residents reviewed for nutrition and hydration, Residents #191 and #13, in a total sample of 62 residents. Findings include: 1. Review of the admission record for Resident #191 documented an admission date of 4/10/2022 with the diagnoses including cerebral infarction (stroke) due to unspecified occlusion or stenosis of left cerebellar artery, nonrheumatic aortic (valve) stenosis without insufficiency, cerebral infarction, unspecified atrial fibrillation (irregular heartbeat), status gastrostomy (a tube placed in the stomach to provide food), essential (primary) hypertension, altered mental status, hyperlipidemia (high cholesterol), other seizures, mild protein calorie malnutrition, and pneumonitis due to inhalation of food and vomit (aspiration into the lungs). Review of the physician orders for Resident #191 dated 4/10/2022 reads, Nothing By Mouth diet. Nothing By Mouth texture. Nothing by mouth…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-09 · 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

    Based on record review and interview, the facility failed to maintain accurately documented medical records for Residents #338 and 38. Findings include: 1. During an interview on 3/6/2023 at 10:41 AM, Resident #338 stated, I do not use an apron to smoke. Normally, I will go outside whenever I like. For the most part, there is no staff outside, just other residents that smoke. During an observation on 3/7/2023 at 9:40 AM, Resident #338 was sitting in his wheelchair in the smoking designated area. Resident # 338 was smoking independently without wearing a smoking apron. Review of Resident #338's Smoking Evaluation with an effective date of 2/10/2023 reads, 03. Summary of Review: A. Based on resident evaluation, indicate need for assist with smoking: 2. Resident may smoke unsupervised in designated smoking areas. B. Indicate resident need for safe smoking aides: a. Resident must wear smoking apron at all times [not checked]. B. Resident requires use of cigarette holder [not checked]. Review of Resident #338's Smoking Evaluation with an effective date of 3/8/2023 reads, 03. Summary of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-07-17 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 accurate nurse staffing information was posted on a daily basis for 3 of 6 days. Findings include: Observation of the displayed nurse staffing information on Sunday, July 14, 2024 at 9:05 AM showed nurse staffing information for Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024 was posted in the front lobby area of the facility. A comparison review of the actual staff working hours on Friday, July 12, 2024, Saturday, July 13, 2024, and Sunday, July 14, 2024 with the Staffing Coordinator revealed the posted nurse staffing information did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses and certified nurses aides on Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024. During an interview on 7/16/2024 at 10:49 AM, the Staffing Coordinator stated the displayed nurse staffing information were projections and did not accurately reflect the total number and actual hours worked by registered nurses,…

    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.

    Nursing and Physician Services 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 53.4-2.4 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 4 of 54.7-0.7 vs chain
The other 35 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Alhambra Healthcare & Rehabilitation CenterSaint Petersburg, FL 2 of 5Cypress Care CenterWildwood, FL 2 of 5Lehigh Acres Healthcare & Rehab CenterLehigh Acres, FL 2 of 5North Beach Healthcare And Rehabilitation CenterNorth Miami Beach, FL 2 of 5Park Meadows Healthcare & Rehabilitation CenterGainesville, FL 2 of 5Rockledge Healthcare & Rehabilitation CenterRockledge, FL 2 of 5Sunset Lake Healthcare And Rehabilitation CenterVenice, FL 2 of 5Village Place Healthcare And Rehabilitation CenterPort Charlotte, FL 2 of 5Villages Healthcare And Rehabilitation Center, TheLady Lake, FL 3 of 5Apollo Healthcare & Rehabilitation CenterSaint Petersburg, FL 3 of 5Club Healthcare And Rehabilitation Center At The VThe Villages, FL 3 of 5Greenbriar Healthcare Rehabilitation And Nursing CBradenton, FL 3 of 5Grove Healthcare And Rehabilitation Center And RehHernando, FL 3 of 5Lexington Healthcare And Rehabilitation CenterSaint Petersburg, FL 3 of 5Shore Acres Care Center And RehabSaint Petersburg, FL 3 of 5South Campus Care Center And RehabLeesburg, FL 3 of 5The Club At Lake GibsonLakeland, FL 3 of 5Viera Healthcare And Rehabilitation CenterViera, FL 4 of 5Advanced Care CenterClearwater, FL 4 of 5Lakes Of Clermont Health And Rehabilitation CenterClermont, FL 4 of 5North Healthcare And Rehabilitation CenterSaint Petersburg, FL 4 of 5North Lake Care Center And RehabLake Park, FL 4 of 5Ridgecrest Healthcare And Rehabilitation CenterDeland, FL 4 of 5The Lodge Healthcare And Rehabilitation CenterOcala, FL 4 of 5Wilton Manors Healthcare & Rehabilitation CenterWilton Manors, FL 5 of 5Carlton Shores Healthcare And Rehabilitation CenteDaytona Beach, FL 5 of 5Gardens Healthcare & Rehabilitation CenterDaytona Beach, FL 5 of 5Isle Healthcare & Rehabilitation CenterOrange Park, FL 5 of 5Kendall Lakes Healthcare And Rehab CenterMiami, FL 5 of 5Plaza Health And RehabGainesville, FL 5 of 5Ponce Therapy Care Center And Rehab, TheSaint Augustine, FL 5 of 5Terrace Healthcare & Rehabilitation CenterGainesville, FL 5 of 5Unity Healthcare And Rehabilitation CenterMiami, FL 5 of 5Villa Healthcare & Rehabilitation CenterDeland, FL 5 of 5Woodland Grove Healthcare & Rehabilitation CenterJacksonville, FL

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

Who owns this facility

Owner / managerTypeRoleShareSince
LADY LAKE SNF HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2023
FL HUD MASTER OPCO HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 08/01/2023
OLIVER, TONYAIndividualW-2 MANAGING EMPLOYEEsince 08/01/2023
ELLENBOGEN, MOSSIndividualCORPORATE OFFICERsince 08/01/2023

2 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.

$10.6M
Net patient revenuemost recent cost report
+8.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 63%Medicare 19%Other / private 19%

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

$329per resident / day
operating cost
$9,994per month
≈ monthly operating cost
$357per 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 106003. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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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