Villages Healthcare And Rehabilitation Center, The
900 Highway 466, Lady Lake, FL 32159 · For profit - Limited Liability company · 120 certified beds · (352) 430-0017 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (23) — 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 (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.9% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 58.5% | 4.6% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.3% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.6% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 86.4% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.5% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 70.1% | 94.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.8% | 9.1% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ 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.
56.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 493 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 338 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 1.15 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.0%CMS range 52.4–60.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.8–13.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 53.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 89.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 84.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.5–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 112.9 residents a day — about 94% occupied, or roughly 7 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 4.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.447 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 4.02 hrs/resident/day on weekends vs 4.54 on weekdays — 11% thinner on weekends. RN hours go from 0.57 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-05-07 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who require nephrostomy services receive such care consistent with professional standards of practice for 1 (Resident #2) of 3 residents reviewed for indwelling catheter care.Findings include: During an observation on 5/06/2026 at 2:30 PM, Resident #2 was sitting up in bed. There was a gauze pad with a transparent occlusive dressing covering her nephrostomy catheter insertion site on her right lower back. The dressing had a half-dollar sized area of bloody drainage and was dated 4/30/2026. (photographic evidence) During an interview on 5/06/2026 at 2:30 PM, Resident #2 stated that the last time she went to the hospital it had been because there was blood in her nephrostomy drainage bag and then the tube was pulled out. At the hospital they reinserted a nephrostomy tube. The dressing [over her nephrostomy catheter] had not been changed since she returned from the hospital. Review of Resident #2's admission Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 care was provided in a manner that maintains each residents' dignity for 1 of 7 residents, Resident #2, reviewed for personal clothing.Findings included: During an observation on 12/11/2025 at 11:25 AM, Resident #2 was lying on his back in bed on an air mattress. The call device was within reach. There was a foley catheter bag clipped to the right side of the bed. There was a wheelchair at the foot of the bed with a pair of pants and a shirt placed over the back of the wheelchair. The resident was wearing a hospital-style gown and had a white blanket over his legs. During an interview on 12/11/2025 at 11:25 AM, Resident #2 stated that he prefers to wear his personal clothing but was not given an option to get dressed this morning, stating, I think they don't want to get me dressed because of this catheter tube. During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed. Review of Resident #2 care plan dated 09/15/2025 read, Focus: Baseline…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received post operative care per the physician's orders for 1 of 3 residents, Resident #1, reviewed for wound care. Findings include: Resident #1 was admitted to the facility on [DATE], with medical diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and Unspecified severe protein-calorie malnutrition. Review of Resident #1's physician's orders dated 5/12/2025 read, Day 5 post op [after surgery] clean right hip with hibiclens. Day 10 post op remove aquacel dressing [a dressing to absorb wound fluids]. Clean right hip surgical site with hibiclens [antiseptic skin cleanser] and 4 by 4s [a square medical bandage] remove staples and apply steri strips [sterile adhesive strips] for 2 wks [weeks].Review of Resident #1's TAR (Treatment Administration Record) for May 2025 did not contain documentation the physician's orders were followed for day 5 post op…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the recurrence of pressure ulcers for 1 of 3 residents, Resident #2, reviewed for pressure ulcers.Findings include: During an observation on 12/11/2025 at 11:25 AM, Resident #2 was lying on his back in bed on an air mattress. The call device was within reach There was a foley catheter bag clipped to the right side of the bed. There was a wheelchair at the foot of the bed. During an interview on 12/11/2025 at 11:25 AM, Resident #2 stated, They haven't turned me since last night. I am getting a sore on my butt, and it hurts. During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed, in the same position that the surveyor observed him in at 11:25 AM. During an observation on 12/11/2025 at 2:18 PM, the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) were observed wearing gowns and gloves, and repositioning Resident #2 in bed. Resident #2's lower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize, evaluate, and address the needs of residents, including but not limited to, residents at risk or already experiencing impaired nutrition, for 3 of 5 residents, Residents #1, #2, and #7, reviewed for nutrition and weight loss.Findings Include: 1) Review of Resident #1's medical record documented an admission date of 5/09/2025, with medical diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and unspecified severe protein-calorie malnutrition Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] documented under Section C - BIMS [Brief Interview for Mental Status] Score 09 = moderate cognitive impairment. Section K – Feeding tube; Proportion of total calories the resident received through parenteral or tube feeding – 51% or more. Review of Resident #1's Care Plan documented, Focus – The resident's nutrition is provided by non-oral methods.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection via indwelling urinary catheters for 1 of 3 residents, Resident #2, reviewed for urinary catheters.Findings Include: During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed. The Resident's urinary catheter collection bag was lying on the floor. Review of Resident #2's care plan dated 09/15/2025 read, Focus: Baseline Care Plan: Resident has a urinary catheter. Date initiated: 09/15/2025. Interventions: Resident has a urinary catheter in place and needs the following care: keep the bag below bladder level, cover the bag for dignity, give catheter care as ordered, report immediately if the catheter comes out, the resident seems to be in pain, the urine becomes dark or cloudy, or there is no urine to empty on your shift. During an interview on 12/11/2025 at 2:13 PM, the Director of Nursing stated, The foley bag should be hanging on the bed frame, off of the floor. Review of the policy and procedure titled,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, specifically without adequate monitoring or adequate indications for use, in 1(Resident #1) out of 3 residents reviewed for unnecessary pain medications. Findings include:Review of Resident #152's physician order dated 9/19/2025 read, Oxycodone HCL oral tablet 5 mg [milligrams] give 1 tablet every 4 hours as needed for pain, for severe pain 7-10 for 3 days.Review of Resident #1's Medication Administration Record (MAR) for September 2025 documented that Oxycodone HCL tablet 5 mg was administered on 9/21/2025 at 2006 (8:06 PM) with a pain level of 3, on 9/22/2025 at 0946 (9:46 AM) for a pain level of 2, on 9/23/2025 at 0946 (9:46 AM) for a pain level of 6, on 9/24/2025 at 0930 (9:30 AM) for a pain level of 6, on 9/24/2025 at 1439 (2:39 PM) for a pain level of 6, on 9/25/2025 at 0900 (9:00 AM) for a pain level of 6, on 9/25/2025 at 2021 (8:21 PM) for a pain level of 4, on 9/26/2025 at 0936 (9:36 AM) for a pain level of 6, and at 2028 (8:28 PM) for a pain level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interview and record review, the facility failed to notify the provider for 1 of 3 residents, Resident #2, reviewed for change in condition and transfer. Findings include:Review of the nursing progress note for Resident #2 dated 6/30/2025 at 11:16 PM read, Pt's [patient's] wife requested pt. to return to hospital and called 911 for pt. to be transported. Unaware until paramedics arrived. When asked why, pt's wife wouldn't give a reason.Review of the medical record for Resident #2 did not provide for documentation of the resident's physician being notified when Resident #2 was transported to or returned from the hospital on [DATE].During an interview on 07/15/2025 at 4:06 PM, the Assistant Director of Nursing (ADON) stated, If a resident is transferred to the hospital, the nurse should inform the doctor and the DON [Director of Nursing], and document that the provider was notified. When a Resident returns from the hospital, the expectation is for the nurse to obtain vital signs, perform a skin check,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to prevent the possible spread of infection by failing to ensure staff performed hand hygiene during medication administration for 2 of 2 residents, Residents #11 and #12, reviewed for medication administration. Findings include:During an observation on 07/16/2025 at 09:00 AM Staff E, Licensed Practical Nurse (LPN) entered Resident #11's room, did not complete hand hygiene, and used an automatic blood pressure cuff on Resident #11's right wrist and obtained the blood pressure reading. Staff E, LPN exited the resident's room, did not perform hand hygiene, walked back to the medication cart, and placed five tablets and one capsule (oral medications) into a medication cup. Staff E, LPN entered Resident #11's room, did not perform hand hygiene and handed Resident #11 the medication cup. Resident #11 proceeded to take the medications orally with water. Staff E, LPN exited Resident #11's room, did not perform hand hygiene, walked back to the medication cart in the hallway, and placed a new medication cup on top of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record reviews, the facility failed to ensure proper hydration for 1 of 3 residents, Resident # 363. Findings include During an observation on 05/05/25 at 11:14 AM Resident #363 was sitting in a wheelchair at his bedside table that had a breakfast tray on it. The resident ate approximately 75% of a bowl of cheerios with milk. Review of Resident #363's physician order dated 4/2/25 read, Sodium Chloride Intravenous Solution 0.45 % (Sodium Chloride) Use 50 ml/hr [milliliters an hour] intravenously [IV] one time a day every Tuesday, Thursday, Sunday for AKI (Acute Kidney Injury), dehydration. 50 ml/hr for a total of 500 milliliters only three days a week. During an interview on 05/06/25 at 12:13 PM, Staff C, LPN (Licensed Practical Nurse) stated A nurse with the last name [Staff D's last name] was on last night, the patient [Resident #363] was not hooked up to any IV fluids when I saw him and gave him meds this morning at around 09:30 AM. Sometimes the night nurses start the IV fluids earlier than ordered so that it will finish by the time the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-05-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to administer enteral nutrition for 1 of 3 residents, Resident #92, and fluids as ordered for hydration and water flushes as order by the physician. Findings include: During an observation of Resident #92 on 5/5/25 at 10:12 AM the feeding pump was set at 45 milliliter/hour (ml/hr) administering Glucerna 1.5 and 30 ml/hr H2O (water) flush. During an observation of Resident #92 on 5/5/25 at 2:35 PM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. (Photographic evidence obtained) During an observation of Resident #92 on 5/6/25 at 8:36 AM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. During an observation of Resident #92 on 5/6/25 at 12:06 PM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. Review of Resident #92's physician order dated 3/25/25 read, Glucerna 1.5 at 60 ml/hr via pump 24 hrs [24 hours/continuous] and H2O at 55 ml/hr via pump 24 hrs. Review of Resident #92's Nutrition Risk Evaluation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observations, interviews, and record reviews, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 2 of 4 residents, Resident #36 and #363, reviewed for oxygen therapy. Findings Include: 1) During an observation on 05/05/25 at 09:55 AM, Resident #36 was observed lying in bed wearing nasal cannula (NC) with oxygen being administered at 3 liters/minute (l/min). There was no date on the oxygen tubing. Review of the electronic medication administration record (MAR) read, Change, date oxygen tubing and bag weekly every Thursday midnight shift every night shift every 7 day(s) Wash concentrator air filters with soap and water weekly on Thursday midnight shift, be sure oxygen in use sign is on the door. Start Date 05/03/2025. 2) During an observation on 05/05/25 at 11:26 AM Resident #363 was observed lying in bed, holding the oxygen nasal cannula tubing in his hands. The oxygen concentrator was administering oxygen at 4 liters/minute, and the oxygen tubing was not dated. During an observation on 05/06/25 at 02:14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-08 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observations, interviews, and record review, the facility failed to maintain the kitchen equipment in a clean and sanitary manner for 3 of 4 nourishment rooms. Findings Include: During an observation on 5/5/25 beginning at 9:28 AM with the Assistant Dietary Manager showed at 9:54 AM in the 500 Hall nourishment room, there were brown and red splattered substances on the interior base of the freezer. There was an orange sticky substance splattered on the inside walls of the microwave. At 10:03 in the 200 Hall nourishment room, there was a brown splattered substance on the back wall of the refrigerator, there was food build up on the microwave oven plate and opaque splatters on the exterior front glass of the microwave oven, at 10:15 AM in the 100 Hall nourishment room, there was a brown splattered substance on the lower refrigerator drawers, and a brown built up sticky substance on the interior base of the freezer. During an interview on 5/5/25 at 10:20 AM the Assistant Dietary Manager stated, The nutrition rooms should be cleaned daily. I usually do rounds in the morning to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to maintain complete and accurately documented medical records for 2 of 5 residents, Residents #365 and #363, reviewed for medication administration and unnecessary medications. Findings include: Review of Resident #365's physician order read, Metoprolol 25 mg [milligrams] PO [oral] BID [twice daily], 0.5 tablet [1/2 tablet]. Hold for SBP [systolic blood pressure] less than 110, HR [heart rate] below 60 BPM [beats per minute]. Review of Resident #365's Medication Administration Record (MAR) for May 2025 did not provide for documentation of the resident's heart rate or blood pressure as ordered prior to administering metoprolol to Resident #365 on 5/1/2025 at 8:00 AM, 5/2/2025 at 8:00 AM, 5/2/2025 at 9:00 PM, 5/3/2025 at 8:00 AM, 5/4/2025 at 8:00 AM, 5/4/2025 at 9:00 PM, 5/6/2025 at 8:00 AM, and 5/7/2025 at 8:00 AM. During an interview on 05/06/25 at 01:28 PM Staff C, Licensed Practical Nurse (LPN) stated The CNA [Certified Nursing Assistant] gives me the vital signs and I check them before giving 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.
- Potential for harm · Dcited before2025-05-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection by failing to adhere to posted infection control signage and standards of practice, failing to maintain hand hygiene during medication administration, failing to maintain hand hygiene during wound care, and failing to handle and store tube feeding products per the manufacturer's recommendations. (Photographic evidence obtained) Findings include: 1) During an observation on 5/6/25 at 10:02 AM the door to Resident #61's room had a sign posted for Enhanced Barrier Precautions that read, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Devise care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled or discarded upon expiration, failed to ensure test strips were not expired, and failed to ensure the kitchen environment and equipment were kept clean (Photographic evidence obtained). Findings include: During observation on 2/12/2024 at 9:15 AM while conducting a walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were pooling of water in the dish room, dirty towels were placed under the juice containers, and test strips expired on 12/1/2023 were being used for the pot and pan sink. During an interview on 2/12/2024 at 9:35 AM, the CDM confirmed the water leak in the dish room, a leak under the juice machine, and the expired test strips being used to check the sanitation. During an observation on 2/13/24 at 7:30AM while conducting follow-up tour of the kitchen with the CDM, there were a buildup of a black and grey substance on the wall behind the dish machine and a small bucket full of water, and numerous dirty towels/rags under the juice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-15 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 conduct a comprehensive assessment in a timely manner for 1 of 5 residents reviewed for unnecessary medications, Resident #146. Findings include: Review of Resident #146's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to indwelling urethral catheter, presence of urogenital implants, parkinsonism, Alzheimer's disease, unspecified mood disorder and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #146's Minimum Data Set (MDS) records revealed the resident's admission MDS assessment was not completed. During an interview on 2/14/2024 at 12:16 PM, Minimum Data Set Coordinator 1 confirmed that Resident #146's admission minimum data set assessment was due on 1/16/2024 and that the assessment had not been completed timely. Review of the facility policy and procedures titled MDS Transmission last reviewed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure PICC (Peripherally Inserted Central Catheter) line dressing was changed for 1 of 1 resident with PICC line, Resident #69. Findings include: During an observation on 2/12/2024 at 10:20 AM, Resident #69 had a PICC line in his right arm. The PICC line was covered with a dressing dated 2/1/24 and the clear covering was cracked and peeling at the upper left edge. During an interview on 2/12/2024 at 10:20 AM, Resident #69 stated, No one has come in to change my dressing for over a week. Review of Resident #69's physician order dated 1/24/2024 read, Change dressing 24 hours post PICC line insertion, then every week and PRN [as needed]. If gauze is used dressing must be changed every 24 hours as need . Start Date: 01/24/2024. During an interview on 2/14/2024 at 9:20 AM, Staff B, Licensed Practical Nurse (LPN), stated, His dressing is compromised and should have been changed when the nurse flushed his line. During an interview on 2/14/2024 at 9:30 AM, the Director of Nursing stated, The dressing is compromised.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-09-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and maintain kitchen equipment in a clean and sanitary condition in the main kitchen and 4 of 4 neighborhood kitchens, potentially affecting all 114 residents, and the facility failed to serve food in accordance with professional standards for food service safety in 1 of 2 neighborhoods observed. Findings include: 1. During the initial tour with the Food Services Manager on 9/6/2022 beginning at 9:09 AM, the following were observed: a) Chopped ham and carrots in the walk-in refrigerator that were not labeled or dated, b) Raw frozen hamburger patties open to the air in the freezer, with the plastic covering not closed over the meat, c) A plate containing a pureed meal that was unlabeled and undated in the two door cooks cooler, d) A hotel pan of French fries and a sandwich between two disposable plates that was unlabeled and undated in the dialysis refrigerator, e) a buildup of a black substance inside the door of the oven 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.
- Potential for harm · E2022-09-09 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 that the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 3 of 6 medication carts reviewed, and the medications were not left unattended in the resident rooms. Findings include: During an observation of Medication Cart #1 on 9/6/2022 at 9:06 AM with Staff E, Licensed Practical Nurse (LPN), there were one opened Humalog insulin pen with no opened or expiration dates, and one unopened Humalog insulin pen with the pharmacy instructions to refrigerate until opened. During an interview on 9/6/2022 at 9:10 AM, Staff E, LPN, stated, All insulin should be refrigerated if they aren't opened and have the date they were opened on them. During an observation of Medication Cart #2 on 9/6/2022 at 9:18 AM with Staff F, LPN, there were one bottle of Atropine ophthalmic solution with no opened or expiration dates, one opened bottle of Prednisolone ophthalmic solution with no opened or expiration dates, one opened bottle of Ciprofloxacin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-09-09 · tag F0880 — failed to prevent and control infections — patternProvide 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 maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene and cleaned the needleless connectors of midline catheters during medication administration in 7 of 9 observations of medication administration. Findings include: 1. During an observation of medication administration on 9/7/2022 at 7:50 AM, Staff G, Licensed Practical Nurse (LPN), did not perform hand hygiene, unlocked the medication cart, poured medications for Resident #93, entered the resident's room, and administered the resident's medications. Staff G left the resident's room and returned to the medication cart and began to prepare another resident's medications. Staff G did not perform hand hygiene. During an observation of medication administration on 9/7/2022 at 7:57 AM, Staff G, LPN, poured medications for Resident #448, entered the resident's room and administered the medications. Staff G returned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 residents with an indwelling urinary catheter were assessed for removal of the urinary catheter or had an appropriate diagnosis for catheterization for 1 of 3 residents reviewed, Resident #96. Findings include: An observation on 9/6/2022 at 11:26 AM showed Resident #96 had an indwelling urinary catheter draining to bedside drainage. An observation on 9/8/2022 at 11:52 AM showed Resident #96 was lying in bed with an indwelling urinary catheter. During an interview on 9/8/2022 at 11:53 AM, Resident #96 stated, I still have this catheter. I don't know why I have it. I have only seen the facility doctor [Physician's name] and nobody else. During an interview on 9/8/2022 at 12:01 PM, Staff F, Licensed Practical Nurse (LPN), stated, It does not look like he [Resident #96] has not been seen by urologist. His diagnosis is urinary retention. During an interview on 9/8/2022 at 12:17 PM, Staff H, Registered Nurse (RN), 500 Unit Manager,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-09-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 in accordance with professional standards of practice for 1 of 2 residents reviewed for oxygen administration, Resident #17. Findings include: During an observation on 9/6/2022 at 10:16 AM, Resident #17 was lying in bed, alert, pleasant, and head of the bed elevated. The resident was receiving oxygen via a nasal cannula (n/c) at 3.5 L/Min (liters per minute) with humidification. During an interview on 9/6/2022 at 10:16 AM, Resident #17 stated that he did not adjust his oxygen, that it was done by the nurse. During an observation on 9/7/2022 at 9:57 AM, Resident #17 was lying in bed, alert, pleasant, and head of the bed elevated. The resident was receiving oxygen via a n/c at 3 L/Min with humidification. During an observation on 9/8/2022 at 8:40 AM, Resident #17 was lying in bed, head of the bed elevated, and he was receiving intravenous fluids. The resident was receiving oxygen via a n/c at 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE VILLAGES NURSING AND REHAB HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/31/2023 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 90% | since 12/31/2023 |
| FLANDERS, JANEE | Individual | W-2 MANAGING EMPLOYEE | — | since 12/31/2023 |
| MANELA, ROBERT | Individual | CORPORATE OFFICER | — | since 12/31/2023 |
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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-08, 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.