Baya Pointe Nursing And Rehabilitation Center
587 SE Ermine Ave, Lake City, FL 32025 · For profit - Corporation · 90 certified beds · (386) 752-7800 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (62%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 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.
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 | 3.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.6% | 5.5% | 5.4% | better |
| 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 | 0.0% | 4.6% | 6.5% | check this* — see note marked star 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 | 3.3% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.8% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.0% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 10.5% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.9% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.2% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 36.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.0% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.41 | 1.15 | 1.80 | better |
* 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.
‡ 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.
48.7% 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 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.2% 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 45 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 48.7%CMS range 37.7–59.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 8.3–15.1 | 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 | 62.2% | 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 | 53.3% | 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 | 68.9% | 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 | 100.0% | 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 | 98.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 2.0% | 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 | 7.9%CMS range 4.6–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 90 beds and averages 87.4 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.07 hrs/resident/day on weekends vs 3.46 on weekdays — 11% thinner on weekends. RN hours go from 0.38 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · D2026-05-26 · 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 record review and interview, the facility failed to maintain accurate and complete records for 1 (Resident #1) of 3 residents reviewed.Findings include:Review of Resident #1's Discharge summary dated [DATE] documented the discharge location name and address as Resident #1's home address/his Responsible Party/Daughter's home address. There was no documentation of Resident #1's name or that of his Responsible Party/daughter in the section designated for Resident/Representative Acknowledgement.Review of Resident #1's social worker progress note dated 4/23/2026 read, Resident stated that he would like to discharge home to address [an address not listed on Resident #1's admission record] on 4/23/26. Resident stated that brother [name of brother] will be picking him up from the facility.During an interview on 5/26/2026 at 12:54 PM, the Director of Social Work stated, He [Resident #1] wanted to leave and he didn't trust his daughter. I opened the discharge assessment [Discharge Summary] and put the address [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.
- Potential for harm · Dcited before2026-05-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate and complete clinical record for one (Resident #1) of three residents reviewed for discharge. The discharge documentation contained an inaccurate account of the resident's discharge location and lacked documentation of the resident's discharge disposition and the date and time of discharge.Findings include: During an interview on 5/26/2026 at 12:54 the Director of Social Work stated, He [Resident #1] wanted to leave and he didn't trust his daughter. I open the discharge assessment [Discharge Summary] and put the address [of where the resident is going after discharge]. During an interview on 5/26/2026 at 2:02 PM Staff A, LPN (Licensed Practical Nurse) - Unit Manager stated, He (Resident #1) left with his brother on 4/24 [2026]. I do not remember the brother's name, I think it's on the discharge summary. I remember asking his address. I remember cross-referencing the address on the facesheet with [Resident #1's name]. I couldn't…
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 before2026-01-22 · 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 record review and interview, the facility failed to ensure medical records were accurate for 1 of 3 residents reviewed for wound care, Resident #1.Findings include:Review of Resident #1's physician order dated 12/17/2025 read, Wound Care: Right Buttock; Cleanse with generic wound cleanser, pat dry, place Calcium Alginate [absorbent dressing] over wound bed, then cover with a bordered gauze dressing. Change daily and PRN [as needed] every night shift for wound care. Order Status: Active. Start Date: 12/17/2025.Review of Resident #1's Treatment Administration Record (TAR) for January 2026 for completion of right buttock wound care showed no entries documented on 1/9/2026 and 1/10/2026 on night shift.Review of Resident #1's physician order dated 12/29/2025 read, Wound Care: Clean left buttock with wound cleanser, pat dry, apply skin prep to peri wound, cover with honey gel, then calcium alginate, then cover with silicone superabsorbent [absorbent dressing]: daily and PRN every night shift for wound care tx [treatment]. Order status: Active. Start Date: 12/29/2025.Review 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.
- Potential for harm · Dcited before2025-08-14 · 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, interview, and record review, the facility failed to administer medications as ordered by the physician for 1 of 5 residents, Resident #2, reviewed for unnecessary medications.Findings include:Review of Resident #2's admission record documented diagnosis that include end stage renal disease, chronic systolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and essential primary hypertension.Review of Resident #2's physician order dated 4/29/25 read, Entresto Oral Tablet 24-26 MG [milligrams] (Sacubitril-Valsartan) Give 0.5 tablet by mouth two times a day related to essential primary hypertension.Review of Resident #2's August Medication Administration Record documented Entresto had a chart of code 4 (4=outside parameters) on 8/2/2025 at 0900 (9:00 AM), on 8/3/2025 at 0900 and 2100 (9:00 PM), and on 8/6/2025 at 0900. Review of Resident #2's nursing and medication administration notes for the period of 8/1/2025 through 8/9/2025 did not contain documentation of the physician being notified the Entresto was not being…
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 · D2025-08-14 · 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 observation, interview, and record review, the facility failed to provide respiratory services consistent with professional standards of practice for oxygen administration for 2 of 5 residents, Residents #86 and #87, reviewed for oxygen therapy.Findings include:During an observation on 8/12/2025 at 9:37 AM Resident #87 was observed being administered oxygen via tracheostomy mask at 4 liters per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle (used to hold distilled water to add moisture to the oxygen therapy airflow to prevent dryness and irritation that can occur from breathing dry oxygen for extended periods) dated 8/12/25 and the bottle was empty. During an observation on 8/12/2025 at 11:35 AM Resident #87 was observed in bed with the head of bed elevated, and was observed with oxygen being administered via tracheostomy mask at 4 liters of oxygen per minute by an oxygen concentrator. On the oxygen concentrator was a humidification bottle dated 8/12/25 and the bottle was empty. Review of Resident #87's admission record documents…
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 before2025-08-14 · 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 observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection when failing to ensure staff followed infection control standards for enhanced barrier precautions for 1 of 3 residents, Resident #88 reviewed for incontinence care and failing to ensure hand hygiene was performed during medication administration for 2 of 6 observations of medication administration.Findings Include During an observation on 8/13/2025 at 9:22 AM there was a sign on Resident #88’s door which read, “Enhanced Barrier Precautions (a set of infection control practices designed to reduce the spread of multidrug-resistant organisms).” Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) were observed providing incontinent care for Resident #88. Staff A and Staff B were not wearing gowns. During an interview on 8/13/2025 at 9:30 AM the Director of Nursing (DON) verified Resident #88 had a physician’s order for enhanced barrier precautions and staff should have worn a gown and gloves when providing direct patient care. 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.
- Potential for harm · Dcited before2025-06-30 · 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 observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing high contact care for 1 (Resident #5) of 2 residents reviewed for wound care.Findings include: Review of Resident #5's admission record showed the resident was admitted on [DATE] with the diagnoses including unspecified open wound, right knee, subsequent encounter. During an observation on 6/30/2025 at 11:05 AM, there was a sign posted on the door frame of Resident #5's room that indicated she was on Enhanced Barrier Precautions. During an observation on 6/30/2025 at 11:15 AM, Staff A, Licensed Practical Nurse (LPN), gathered wound care supplies and gloves. Staff A proceeded to wash her hands with soap and water and donned a pair of gloves. Staff A provided wound care to Resident #5, wearing gloves as her only form of personal protective equipment (PPE). During an interview on 6/30/2025 at 11:25 AM, Staff A, LPN, stated, Enhanced barrier precautions are 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.
- Potential for harm · E2024-05-10 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 received prescribed therapeutic diet for 3 of 5 reviewed residents, Residents #9, #58 and #68. Findings include: 1. Review of Resident #58's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease, other speech disturbances, and deaf nonspeaking. During an observation on 5/6/2024 at 12:25 PM, Resident #58 received the afternoon meal tray on his bedside table. There was no health shake on the resident's meal tray. During an observation on 5/7/2024 at 8:03 AM, Resident #58 received the morning meal tray on his bedside table containing scrambled eggs, a slice of toast, and a mound of hot cereal. There was no hot or cold fluids, drinks, or house Health shake on the resident's tray. Review of the facility's dining slip dated 5/7/2024 on the morning meal tray for Resident #58 read, Consistent Carbohydrates (CCD) Tuesday Breakfast: Scrambled eggs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-10 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 3 of 5 residents reviewed for nutrition, Residents #9, #58, and #68, and for 3 of 5 residents reviewed for skin conditions, Residents #1, #55, and #227. Findings include: 1. During an observation on 5/6/2024 at 12:25 PM, Resident #58 received the afternoon meal tray on his bedside table. There was no health shake on the resident's meal tray. During an observation on 5/7/2024 at 8:03 AM, Resident #58 received the morning meal tray on his bedside table containing scrambled eggs, a slice of toast, and a mound of hot cereal. There was no hot or cold fluids, drinks, or house Health shake on the resident's tray. Review of Resident #58's physician order dated 4/27/2023 revealed a Health Shake supplement to be given one time a day on the breakfast tray. During an interview on 5/8/2024 at 1:04 PM, Staff B, Certified Nursing Assistant (CNA), stated, He [Resident #58] loves the Health Shakes, but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-10 · 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 ensure staff performed hand hygiene during medication administration, wound care, and meal service, failed to ensure staff cleaned medical equipment, and failed to ensure staff followed infection control standards for urinary catheter care to help prevent the possible spread and transmission of communicable diseases. Findings include: 1. During an observation on 5/6/2024 from 11:55 AM to 12:15 PM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, delivered drinks and silverware to residents seated in the dining room at various tables without performing hand hygiene. Staff F donned gloves without performing hand hygiene, scooped some ice into a resident's drink cup, replaced the ice scoop in the ice bucket, and doffed the gloves and did not perform hand hygiene. Staff F and Staff G refilled drink glasses, put cream and sugar in residents' hot drink cups, assisted residents with cutting their food, refilled drinks, brought used plates and dishes to the tray rack, delivered desserts, and picked up…
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 12 citations
- Potential for harm · E2024-05-10 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe physical environment for 4 of 6 residents reviewed for respiratory services, Residents #14, #16, #42 and #47. Findings include: 1. During an observation on 5/6/2024 at 12:42 PM, there was a portable five-liter oxygen concentrator unit resting up against the right side of Resident #16's bed. The concentrator was plugged into the wall outlet and the unit was turned off. There was nasal cannula oxygen tubing attached to the concentrator unit and the tubing was coiled up on the floor under the bed (Photographic evidence obtained). During an observation on 5/7/2024 at 12:42 PM, a portable oxygen concentrator unit was resting up against the right side of Resident #16's bed. The unit was plugged in, turned off, and the attached nasal cannula oxygen tubing was coiled up on the floor under the resident's bed. During an interview on 5/6/2024 at 12:43 PM, Resident #16 stated, I don't use oxygen. That must be my roommate's tank. I can't…
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 · D2024-05-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the staff provided privacy while performing wound care for 1 of 5 residents reviewed for skin conditions, Resident #55. Finding include: During an observation on 5/8/2024 at 1:50 PM, Staff A, Registered Nurse (RN), donned gown and entered Resident #55's room with the wound treatment cart and paper treatment record. Staff A entered the resident's restroom and washed her hands. Staff A did not close the resident room door or the blinds of the window facing employee parking lot. Staff members were across the parking lot near cars. While Staff A was providing wound care, another staff member stood at the doorway and thanked Resident #55 for cupcakes his family had provided. During an interview on 5/8/2024 at 2:07 PM, Staff A, RN, stated, I should have closed the door when entering the room to provide privacy while performing care. During an interview on 5/8/2024 at 3:00 PM, the Director of Nursing stated, Staff should be ensuring privacy is provided when providing care for residents. Review of the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, interview, and record review, the facility failed to ensure a clean and homelike environment in 1 of 4 residential halls (300 Hall) and in the main dining room (Photographic evidence obtained). Findings include: 1. During an observation on 5/6/2024 at 10:00 AM, there were black lines along the lower wall of the 300 Hall. On the wall to the right of Resident #3's room, the wallpaper on the lower wall was rippled, peeling away from the wall. During an interview on 5/8/2024 at 12:58 PM, the Maintenance Director stated, The black marks along the wall are from the residents' wheelchairs. The rippled wallpaper outside of [Resident #3's room number]; I don't believe it's due to water damage, it's just old and needs to be replaced. Review of the facility policy and procedures titled Cleaning and Disinfection of Environmental Surfaces last reviewed on 1/15/2024, showed that it read, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection of healthcare…
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 · D2024-05-10 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the residents with newly evident serious mental disorder were referred for assessment for 1 of 6 residents reviewed for Pre-admission Screening and Resident Review (PASARR), Resident #23. Findings include: Review of Resident #23's admission record showed the resident was originally admitted to the facility on [DATE]. The resident's diagnoses included major depressive disorder, anxiety disorder, and paranoid schizophrenia (onset date: 3/2/2023). Review of Resident #23's Level I PASARR completed on 2/11/2020 did not indicate diagnosis of schizophrenia. Section IV showed no level II PASARR evaluation was required due to no diagnosis or suspicion of serios mental illness or intellectual disability. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the diagnosis of schizophrenia under section I. Active diagnoses. Review of Resident #23's records showed no level I PASARR completed after diagnosis of schizophrenia…
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 · D2024-05-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a person-centered care plan was developed for management of epilepsy for 1 of 4 residents reviewed for accidents, Resident #54. Findings include: Review of Resident #54's admission record showed the resident was most recently admitted on [DATE] with diagnoses including Parkinsonism, epilepsy, lack of coordination, abnormal posture, muscle weakness, dementia, anxiety disorder, and paranoid schizophrenia. Review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had a diagnosis of seizure disorder or epilepsy under Section I. Active Diagnoses. Review of Resident #54's physician order dated 11/2/2023 read, Divalproex Sodium ER [extended release] Oral Tablet Extended Release 24 Hour 500 mg [milligram] (Divalproex Sodium). Give 1 tablet by mouth at bedtime related to epilepsy, unspecified, intractable, with status epilepticus. Review of Resident #54's physician order dated 11/2/2023 read, Divalproex Sodium Oral Tablet…
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 before2024-05-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards of practice for 1 of 2 residents with peripherally inserted central catheter (PICC) lines, Resident #47 (Photographic evidence obtained). Findings include: Review of Resident #47's admission record showed the resident was most recently admitted on [DATE] with diagnoses including paraplegia, chronic respiratory failure with hypoxia, cellulitis of right lower limb, acute kidney failure, and metabolic encephalopathy. During an observation on 5/6/2024 at 1:53 PM, Resident #47 had a PICC line dressing to the right upper arm dated 4/26/2024. During an observation on 5/7/2024 at 1:24 PM, Resident #47 had a PICC line dressing to the right upper arm dated 4/26/2024. Review of Resident #47's physician order dated 4/28/2024 read, Ertapenem Sodium Injection Solution Reconstituted 1 GM [gram] (Ertapenem Sodium). Use 1 gram intravenously one time a day related to severe sepsis…
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 · D2024-05-10 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure 1 of 1 resident receiving dialysis services, Resident #42, received treatment and care in accordance with professional standards of practice. Findings include: Review of Resident #42's physician order dated 3/22/2024 read, Dialysis communication form in the dialysis communication book to be completed by nurse prior to and upon return from dialysis clinic. Two times a day every Tue, Thu, Sat [Tuesday, Thursday, Saturday]. Review of Resident #42's Dialysis Communication Form dated 5/7/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 5/2/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site, bruit/thrill, and bleeding, were documented upon return. Review of Resident #42's Dialysis Communication Form dated 4/27/2024 showed no vitals including blood pressure, pulse, respiration, temperature, pain, access site,…
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 before2024-05-10 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis. Findings include: During an initial tour on 5/6/2024 at 9:00 AM, the nurse staffing information was posted on the left side of the receptionist area upon entrance to the facility, which was dated 5/3/2024. During an interview on 5/8/2024 at 10:02 AM, the Administrator stated, The sheets were filled out, but the receptionist is new and did not know they were in the back of the one dated 5/3/2024. Usually, the staffing coordinator will come in early and review the census and update the sheet. This is done between 8:30 AM and 9:00 AM. We do not have a written policy. We follow the federal guidelines. During an interview on 5/9/2024 at 3:45 PM, the Staff Coordinator stated, I was out on vacation and came back Monday morning. I get in and change the federal staffing around 8:30 AM-9:00 AM. Get with admission before the census. The sheets were filled out. We had a new receptionist. They all will be behind one another all the way until Monday. Monday when I get here, I make…
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 · D2024-05-10 · 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 observation, interview, and record review, the facility failed to ensure food items were stored in accordance with professional standards for food safety (Photographic evidence obtained). Findings include: During an observation while conducting a tour of the nourishment room on the rehabilitation wing conducted with the Certified Dietary Manager (CDM) on 5/7/2024 at 6:50 AM, there were one opened box of cinnamon mini squares, one opened family size box of Honey Bunches of Oats, one opened box of Welch's Juicefuls, and one opened box of Wheat Bran Flakes stored in a cabinet with no open date or resident name. There was also one opened half gallon container of vanilla ice in the freezer with no open date or resident name. During an interview on 5/7/2024 at 6:52 AM, the CDM confirmed the cereal boxes and ice cream were not labeled with an open date or resident identifier. Review of the facility policy and procedures titled Food: Safe Handling for Foods from Visitors revised on 2/2023 and reviewed on 1/16/2024 showed it read, Policy Statement: Residents will be assisted in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 the drugs and biologicals were stored properly. Findings include: During an observation on 1/9/2023 at approximately 12:05 PM, there was a bottle of Tylenol and an inhaler in Resident #45's top drawer of bedside table. During an interview on 1/9/2023 at approximately 12:05 PM, Resident #45 stated that the nurse told her not to keep her medication out in the open but to keep it in her drawer. During an observation on 1/11/2023 at 8:40 AM, there was an unattended medication cup with approximately 10 pills on Resident #45's bedside table. There were a bottle of Tylenol and several loose blister pill-packs in the top drawer of the resident's bedside table. There were no staff members in sight. (Photographic evidence obtained). During an interview on 1/11/2023 at 8:45 AM, Staff C, Registered Nurse (RN), confirmed the medication left unattended at the bedside and in the resident's top drawer. Staff C stated that medications should not be left unattended and that the nurse who administered the medications was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-12 · 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 ensure staff followed appropriate infection control precautions during serving the meal trays to prevent the possible development and transmission of communicable diseases and infections. Findings include: During an observation on 1/9/2023 at approximately 12:17 PM, Staff A, Certified Nursing Assistant (CNA), placed the lunch tray on the overbed table in Resident #31's room. Staff A touched the overbed table, the bed linens, and the resident's right arm, and then exited the room. Staff A did not perform hand hygiene after touching Resident #31's overbed table, bed linens and the resident. Staff A removed another lunch tray from the food cart for another resident. During an observation on 1/9/2023 at approximately 12:20 PM, Staff B, CNA, touched the hand grips on Resident #61's wheelchair and positioned the wheelchair. Then, Staff B touched Resident #61's overbed table to position the table in front of the resident. Staff B proceeded to set up Resident #61's food tray, and then exited the room. Staff B then…
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.
- No harm found · Ccited before2026-05-05 · tag F0732 — widespreadPost nurse staffing information every day.
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 current and accurate nurse staffing data was posted for residents, staff, and visitors.Findings include: During an observation on Friday, 5/4/2026, at 9:31 AM the posted nurse staffing information was dated Friday 5/1/2026. During an interview on 5/4/2026 at 9:31 AM, the Director of Nursing acknowledged the nurse staffing information posted on Monday, 5/4/2026 at 9:31 AM was not current and was last updated on Friday, 5/1/2026. She stated the scheduler had the responsibility to ensure the posted nurse staffing information was accurate and current throughout the weekend. Review of the facility policy and procedure titled Care Staffing Policy, revised 10/2025, read, Purpose: To ensure the facility maintains sufficient, competent direct care staff to meet resident needs in compliance with all applicable federal and [Name of State] state regulations. The policy specified Staff Posting Requirements: 3. Staff Posting (BIPA) [Benefits Improvement and Protection Act of 2000] the daily staffing posting required under 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.
“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 ASTON HEALTH — 38 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 | 2.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 37 homes this chain runs (chain average 2.7★, 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 |
|---|---|---|---|---|
| BAYA POINTE OPCO HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2024 |
| FRIEDMAN, LEOPOLD | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 05/01/2024 |
| ASTON HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2024 |
| FRANKLIN, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/24/2025 |
| MARTINEZ IRIZARRY, AXEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/24/2025 |
| RUSSELL, ALEXANDER | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2024 |
| SHEPPARD, LAUREN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2024 |
| GUTMAN, SAMUEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 05/01/2024 |
| ACS PRO GLOBAL SOLUTIONS | Organization | ADP OF THE SNF | — | since 05/01/2024 |
| BAYA OSPREY MT LLC | Organization | ADP OF THE SNF | — | since 02/24/2025 |
| BAYA REALTY LLC | Organization | ADP OF THE SNF | — | since 05/01/2024 |
| CITADEL CONSULTING GROUP | Organization | ADP OF THE SNF | — | since 05/01/2024 |
| FBO REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/01/2024 |
| OSPREY AND BAYA INVESTORS LLC | Organization | ADP OF THE SNF | — | since 05/01/2024 |
| OSPREY AND BAYA REALTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 05/01/2024 |
CMS files one row per role, so the 20 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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.
This home reported $449K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 105846. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.