Lake City Healthcare And Rehabilitation Center
298 SW Prosperity Place, Lake City, FL 32024 · For profit - Limited Liability company · 113 certified beds · (386) 269-3900 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 (28) — 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)
- nursing-staff turnover (63%) 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 | 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 | 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 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.9% | 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 | 9.0% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.6% | 9.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 18.0% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.8% | 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 | 2.9% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.1% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.3% | 9.1% | 12.0% | worse |
| 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 | 1.45 | 1.15 | 1.80 | better |
‡ 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.
57.5% 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 246 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% 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 194 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% 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 | 57.5%CMS range 50.8–64.4 | 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 | 11.1%CMS range 8.4–14.2 | 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 | 56.7% | 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 | 61.3% | 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 | 46.4% | 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 | 99.0% | 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 | 60.0% | 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 | 0.0% | 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 | 2.4% | 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 | 7.0%CMS range 4.5–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 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 113 beds and averages 109.1 residents a day — about 97% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.34 hrs/resident/day on weekends vs 3.37 on weekdays — 1% thinner on weekends. RN hours go from 0.38 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · E2025-04-10 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received appropriate wound care for 2 of 4 residents reviewed for skin and wound care, Residents #23 and #49, and 1 of 8 residents reviewed for medication management, Resident #65. Findings include: 1) During an observation on 4/7/2025 at 10:19 AM, Resident #49 was sitting in a chair, dressed in street clothes. The resident had one dressing on his abdomen with drainage, which was dated 4/4, one dressing on his wrist, of dry gauze, dated 4/4, one dressing on his upper thigh with no apparent drainage, under an elastic wrap, with no date visible, and one dressing on his lower back, which could not be fully observed. During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his wounds were last cleaned on Friday, 4/4/2025, with their dressings changed at that time. Review of Resident #49's admission Assessment, dated 3/24/2025, documented the following information in the wound/skin section: a surgical incision on the right side of the abdomen; a G-tube (gastrostomy tube) on the left…
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 before2025-04-10 · 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 followed infection control standards for storing respiratory therapy equipment for 3 of 4 residents reviewed for respiratory services (Residents #45, #51, and #87), for 3 of 6 residents reviewed for enhanced barrier precautions (Residents #6, #93, #114), for 1 of 4 residents reviewed for skin conditions (Resident #2), for 4 of 5 residents reviewed for medication administration (Residents #61, #116, #321 and #324) to help prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was a passive nebulizer mask and mouthpiece on top of the resident's desk across from his bed, which was not bagged (Photographic evidence obtained). Review of Resident #45's physician order dated 4/1/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (milligrams per 3 milliliters). Directions: 3 ml inhale orally via nebulizer every 6 hours as needed for SOB [shortness of breath] or wheezing via…
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 · D2025-04-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 3 of 8 residents reviewed, Residents #2, #18, and #49. Findings include: 1) During an interview on 4/7/2025 at 12:20 PM, Resident #2's Son stated, [Resident #2's name] sometimes has a hard time seeing and will have a hard time doing things herself. She [Resident #2] needs help with feeding and getting dressed. Review of Resident #2's Quarterly MDS assessment dated [DATE] read, Section B- Hearing, Speech and Vision . B1000. Vision. Ability to see in adequate light (with glasses or other visual appliances). 0. Adequate . B1200. Corrective Lenses. Corrective lenses (Contacts, glasses, or magnifying glass) used in completing B1000, Vision. 0. No. Review of Resident #2 Optometry Evaluation dated 11/20/2024 showed the resident used corrective lenses. During an interview on 4/10/2025 at 11:15 AM, Staff L, Registered Nurse (RN) stated, [Resident #2's name] has glaucoma and has trouble with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents reviewed for unnecessary medications, Resident #61. Findings include: Review of Resident #61's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including bipolar disorder (onset date of 3/10/2025), major depressive disorder, and anxiety disorder. Review of Resident #61's Level I PASRR dated 3/5/2025 showed anxiety disorder and depressive disorder listed under mental illness. No bipolar disease was listed. Review of Resident #61's hospital Discharge summary dated [DATE] read, Hospital course to date . complex past medical history including . bipolar disease. Review of Resident #61's MDS assessment dated [DATE] showed anxiety disorder, depression and bipolar disorder under Section I- Active Diagnoses. During an interview on 4/10/2025 at 8:15 AM, the Administrator stated, When a resident is admitted…
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 · D2025-04-10 · 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 9 residents reviewed, Residents #3 and #114. Findings include: 1) Review of Resident #3's transfer/discharge report showed the resident was admitted on [DATE] with diagnoses including generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of Resident #3's physician order dated 3/5/2025 read, Behaviors- Monitor for the following: Sad affect, continuous crying, seems withdrawn, mood changes, Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. Review of Resident #3's visit note for psychiatric services dated 3/6/2025 read, DX [Diagnosis] . 1: Generalized anxiety disorder: Patient is stable. Staff to monitor, document, and report worsening symptoms of anxiety symptoms: excessive worry, not able to control worry, restlessness/agitation, being easily…
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 before2025-04-10 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the medication regimen recommendations agreed by the physician were followed for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 2/25/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if appropriate. The physician's response was documented as, Agree; will do. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if…
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 · D2025-04-10 · 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 record review and interview, the facility failed to ensure residents' medication regimen was free from unnecessary drugs, for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 1/9/2025 that read, Currently receiving Guaifenesin LA [long acting] tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Agree; will do. DC [Discontinue]. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Currently receiving Guaifenesin LA tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Disagree; State Reason: PRN [as needed]. The physician signed the recommendation on 4/1/2025. Review of Resident #8's physician order dated 1/7/2025 read, Guaifenesin ER [extended release] 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 before2025-04-10 · 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 used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways. Findings include: 1) During an observation on 4/7/2025 at 10:11 AM, Resident #95 was lying in bed. There was one bottle of nasal saline spray on top of the nightstand. During an interview on 4/7/2025 at 10:11 AM, Resident #95 stated, I have used the spray for years. I will use the nasal spray at night if I feel clogged. During an interview on 4/7/2025 at 12:48 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, [Resident #95's name] should not have medication at bedside. We do not really have any resident that self-administers medication. If they do, we would have to evaluate the resident and care plan them. We would also have to put an order in place. 2) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was one bottle of lubricant eye drops on top of the bedside table and one bottle of antifungal powder on top 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 · D2025-04-10 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received dental services for 1 of 2 residents reviewed for dental services, Resident #18. Findings include: During an observation on 4/7/2025 at 9:30 AM, Resident #18 was edentulous. During an interview on 4/7/2025 at 9:30 AM, Resident #18 stated, I'm on mechanical soft because my dentures broke a while back and they still have not gotten me any. I hate having no teeth and not being able to eat. I've seen dental and they told me it'd be an issue because of my overbite. I don't want any surgery or anything. I just want my teeth back. During an interview on 4/9/2025 at 11:10 AM, Registered Dietician (RD) stated, I don't believe there is an issue with her swallowing. The only reason she's on mechanical soft is because of her having no teeth. During an interview on 4/9/2025 at 11:45 AM, Social Services Assistant (SSA) stated, I know [Staff E, Unit Manager's name] and [previous Social Services Director's name] were working on something about her dentures, but I'm not sure exactly what it 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 before2025-04-10 · 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 was safely stored in the areas of the nutrition room and kitchen walk-in freezer. Findings include: During an initial tour of the kitchen on 4/7/2025 at 9:10 AM with the Dietary Manager, there was one plastic see through bag containing food items with no identifying label or date in the walk-in freezer. During an interview on 4/7/2025 at 9:20 AM, the Dietary Manger stated, I don't know what it is. It should have a label and be dated. Review of the facility policy and procedure titled Food Storage revised on 1/17/2019 read, Policy: Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure . 15. Frozen Foods . d. All foods should be covered, labeled and dated. All foods will be checked to ensure that foods will be consumed by their safe use by…
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 18 citations
- Potential for harm · D2025-04-10 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide therapy evaluation and services for 1 of 3 residents reviewed for rehabilitation, Resident #27. Findings include: During an interview on 4/8/2025 at 10:40 AM, Resident #27 stated, I used to have therapy and then I was participating in the restorative program. I was walking with a walker and they were providing different trainings. It all stopped and they never came and got me again. The facility got rid of the restorative program. I would like to have therapy again. Review of Resident #27's physician order dated 9/20/2024 read, PT [Physical Therapy] to eval [evaluate] and treat as indicated . Order Status: Active. Review of Resident #27's physician order dated 9/20/2024 read, OT [Occupational Therapy] to eval and treat as indicated . Order Status: Active. Review of Resident #27's care plan initiated on 3/12/2025 showed the resident had activity of daily living self-care performance deficit related to hemiplegia and hemiparesis following cerebral infraction affecting left dominant side, with the intervention…
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 · D2025-04-10 · 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 observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for behaviors (Resident #3), for 2 of 8 residents reviewed for medication management (Residents #54 and #72), and for 1 of 3 residents reviewed for skin and wound care (Resident #49). Findings include: 1) Review of Resident #3's physician order dated 3/5/2025 read, Behaviors- Monitor for the following: Sad affect, continuous crying, seems withdrawn, mood changes, Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. Review of Resident #3's Treatment Administration Record (TAR) for April 2025 for monitoring behaviors showed staff documented X from 4/1/2025 through 4/8/2025 at 7:00 AM and 7:00 PM. Review of Resident #3's physician order dated 3/5/2025 read, Antidepressant Medication- Monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash,…
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 · D2025-04-10 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain an effective, data driven Quality Assurance and Performance Improvement (QAPI) program related to weight loss and obtaining weights for 1 of 3 current performance improvement plans. Findings include: Review of Weight Loss Performance Improvement Plan initiated on 2/11/2025 read, Action Steps: Quality Review initiated for residents who have lost significant weight in a time of 5% (30 days); 7.5% (90 days), and 10% (180 days). Appropriate MD [Medical Doctor]/Representative notification RD [Registered Dietitian] Consult, Interventions in place. Residents to be reviewed weekly in risk meeting until weight loss and stable X [times] 4 weeks. Care plan in place and appropriate. Nursing staff educated on weight loss with emphasis on: Making sure the correct documentation for meal consumption. Resident preferences. Interventions in place. Make sure weighing is consistent (same lift pad and leg rest, etc.) RD consult. Care plans in place with interventions. Menus posted daily. Residents to be reviewed weekly in risk meeting…
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 · D2025-04-10 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to establish antibiotic stewardship program to monitor antibiotic use for 2 of 5 residents reviewed, Residents #30 and #39. Findings include: 1) Review of Resident #39's records showed a physician order dated 2/14/2025 for Hiprex 1 gram (1 tablet by mouth two times daily for prophylactic antibiotic). During an interview on 4/9/2025 at 10:30 AM, the Advanced Practice Registered Nurse 2 (APRN 2) stated, She [Resident #39's name] is so susceptible to UTI's [Urinary Tract Infections] that she seems to do better on preventative. When asked if he had ever considered an antibiotic time out, the APRN 2 stated, If it's something that's required, we can, but I haven't thought about it. During an interview on 4/9/2025 at 10:40 AM, the APRN 2 stated, I was in talking to my residents and when I saw [Resident #39's name], she just looked and sounded awful. I listened to her and her lungs were yuck sounding and she had a bad cough, so I ordered her Augmentin. When asked where the documentation for this assessment was, the APRN…
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 before2024-01-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure expired or outdated food was properly discarded in the areas of the kitchen coolers or refrigerators and that all kitchen equipment were cleaned and maintained in proper working order. Findings include: During an observation while a walk-through tour of the kitchen on 1/16/2024 at 9:15 AM with the Certified Dietary Manager (CDM), there were two full containers and one partially opened container of cottage cheese with the manufacture's expiration date of 1/8/2024 on all three containers in the walk-in cooler. Paper products including food containers, Styrofoam cups, and plastic utensils were being used on the tray line for all residents receiving a meal tray. The microwave oven had numerous dried food particles inside on the sides, top and base. The stove drawer had a large amount of buildup of black and brown food particles and debris. A tabletop mixer had food particles and debris. There was a buildup of dirt and grease on the top and running down the sides of the deep fryer. During an interview 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 before2024-01-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) services received nail care for 1 of 3 residents reviewed, Resident #81. Findings include: Review of Resident #81's admission record revealed the resident was admitted on [DATE] with diagnoses including need for assistance with personal care, cognitive communication deficit, adult failure to thrive, major depressive disorder, and dementia without behavioral disturbance. Review of Resident #81's care plan, with a revision date of 12/7/2023, reads, Focus: [Resident #81's name] has potential impairment to skin integrity r/t [related to] limited mobility . Interventions . Keep fingernails short. Review of Resident #81's nail care task sheet read, Check nails every shift for length, cleanliness and sharp edges. During an observation on 1/16/2024 at 10:40 AM, Resident #81 was seated outside of his room in his wheelchair. Resident #81's fingernails on his right and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the insulin pens used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 medication carts observed. Findings include: During an observation of Medication Cart #2 on [NAME] Hall on 1/17/2024 at 9:20 AM with Staff A, License Practical Nurse (LPN), there was one Insulin lisp 100/ml [milliliter] injectable pen for Resident #10 with an opened date of 12/4/2023. During an interview on 1/17/2024 at 9:22 AM, Staff A, LPN, stated, The insulin expired on January 1, 2024. We should probably write the expiration date on the medication. I will throw it away. During an observation of Medication Cart #1 on Magnolia Hall on 1/17/2024 at 9:24 AM with Staff B, LPN, there was one Basaglar Kwikpen 100 unit/ml insulin pen for Resident #106. The insulin pen was unopened and undated. The insulin pen was not cold to touch, and there was no condensation on the bag. The insulin pen bag had a label that reads,…
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 before2024-01-19 · 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 performed hand hygiene during medication administration to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 1/17/2024 at 8:32 AM, Staff A, License Practical nurse (LPN), exited Resident #32's room after administering the resident's medication. Staff A returned to medication cart and began preparing medications for Resident #10 without performing hand hygiene. Staff A obtained Resident # 10's medications and mixed the medications in fluids and then proceeded to Resident #10's room. Staff A obtained manual vital signs (blood pressure 122/64, heart rate 67 and oxygen saturation 96%) without donning gloves or performing hand hygiene. Staff A administered oral (by mouth) medications to Resident #10. Staff A exited Resident #10's room and returned to the medication cart, unlocked the medication cart and obtained Resident #10's Insulin pen. Staff A returned to Resident #10's room, donned gloves without performing hand hygiene and administered…
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 before2022-07-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food was prepared and stored in a safe and sanitary manner. Findings include: An initial observation of the main kitchen was completed with Staff A, Dietary Aide, beginning at 7/24/2022 at 9:45 AM. There was an undated plastic bag of chicken and a tray of individual servings of coleslaw stored in the walk-in refrigerator and an opened bag of cookies stored on a shelf in the kitchen. There was undated cheese, lettuce and delicatessen meats stored in a salad bar. There was food debris on the interior shelf of the salad bar. There was brown and tan substances and food debris build up on the fryer and a grey substance build up on the stove top. During an interview on 7/24/2022 beginning at 9:45 AM, Staff A verified the plastic bag of chicken and individual servings of coleslaw should be dated. She verified the bag of cookies should be closed and the fryer, stove top and salad bar needed cleaning. During an interview on 7/25/2022 at 1:40…
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 · E2022-07-27 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 observation, interview and record review, the facility failed to provide a therapeutic diet intervention as recommended by the Registered Dietician for 1 (Resident #20) of 2 residents reviewed for nutrition. Findings include: Review of Resident #10's care plan, start date: 7/21/2022, revealed Resident #10 was at risk for malnutrition related to difficulty swallowing and requiring an altered diet. Resident #10's care plan documented nutritional interventions that included weight loss noted, supplement added. Review of Resident #10's weight history showed on 6/3/2022, Resident #10 weighed 139 pounds and on 7/2/2022, Resident #10 weighed 131 pounds which was a 5.76% weight loss. Review of Resident #10's Nutrition Risk Screen with Mini Nutritional Assessment, dated 4/21/2022, documented Resident #10 had diagnoses that included anemia and a recommendation that Resident #10 receive a health shake three times a day. Review of Resident #10's Nutrition Risk Screen with Mini Nutritional Assessment, dated…
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 before2022-07-27 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure the licensed pharmacist conducted a medication regimen review at least monthly for 2 residents (Resident #18 and #75) and failed to ensure the physician acknowledged and responded to the pharmacist's recommendations for 1 resident (Resident #67) of 5 residents reviewed for unnecessary medications. Findings include: Review of Resident #18's pharmacy consultation report records failed to reveal documentation the consultant pharmacist had reviewed Resident #18's medication regimen during October 2021. Review of Resident #75's pharmacy consultation report records failed to reveal documentation the consultant pharmacist had reviewed Resident #75's medication regimen during June 2022. Review of Resident #67's pharmacy consultation report record, dated 6/24/2022, documented the pharmacist recommended the physician consider discontinuing polyethylene glycol due to lack of use in the previous 60 days. Review of Resident #67's clinical record failed to reveal documentation the physician had responded to the pharmacist's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review the facility failed to ensure dignity for residents with urinary catheters for 1 (Resident #189) of 2 residents on the 300 hallway out of a total of 8 residents with urinary catheters. Findings include: During an observation on 07/24/22 at 11:40 AM Resident #189 was lying in bed. The resident had a urinary catheter drainage bag on the right side of the bed facing the door. The drainage bag was not covered with a privacy bag. Resident #189 was re-admitted to the facility on [DATE] with diagnosis that include respiratory failure, severe sepsis (body's response to an infection damages its own tissues) and C-Diff (Clostridium Difficile, a digestive illness). During an interview on 7/24/2022 at 11:50 AM Resident #189 stated I don't know why the bag is not covered. During an interview on 7/24/2022 at 12:03 PM Staff B, Licensed Practical Nurse (LPN) stated, I can see that the urinary catheter drainage bag is not covered by a privacy bag. I do not know why it is not covered. Review…
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 · D2022-07-27 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 an assessment was completed and transmitted for the residents discharged from the facility within 14 days of discharge for 2 of 3 residents reviewed, Residents #2 and #3. Findings include: Review of Resident #3's records revealed that the resident was discharged on 3/31/2022 to the resident's home with family. Review of Minimum Data Set (MDS) did not show a discharge assessment on Resident #3. Review of Resident #2's records revealed that the resident was discharged on 3/31/2022 to the resident's home with family. Review of Minimum Data Set (MDS) did not show a discharge assessment on Resident #2. During an interview on 7/26/2022 at 12:02 PM, Staff G, Registered Nurse MDS Coordinator, stated that Resident #2 and Resident #3 had missing discharge assessments that they should have had at the end of PPS (perspective payment system), weather a return was anticipated or not anticipated to the facility. Review of the facility policy titled MDS 3.0 Completion dated April 1, 2022, reads, Policy: Resident are assessed, using…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written summary of the baseline care plan to 1 of 4 residents reviewed for baseline care plans, Resident #339. Findings include: Review of Resident #339's clinical record revealed the resident was most recently admitted to the facility on [DATE] with diagnoses that included: displaced fracture of right tibial tuberosity, subsequent encounter for closed fracture with routine healing; morbid (severe) obesity due to excess calories; synovial cyst of popliteal space (Baker), right knee; unspecified asthma, uncomplicated; hyperlipidemia, unspecified; essential (primary) hypertension; and personal history of COVID-19. Review of the resident's Brief Interview of Mental Status (BIMS) completed on 7/26/22 revealed the resident was cognitively intact with a score of 15. Review of the resident's baseline care plan completed on 7/21/22 revealed the section labeled, A copy of this care plan and an Order Summary have been provided to me was blank. 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 before2022-07-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide personal hygiene for resident's dependent on staff for activities of daily living for 1 (Resident #29) of 5 residents reviewed. Findings include: Observation of Resident #29 on 07/24/22 at 11:59 AM revealed the resident had long and jagged fingernails with visible dark matter underneath the nails. Observation of Resident #29 on 7/26/22 at 8:40 AM revealed the resident had fingernails that were long and jagged. Observation of Resident #29 on 7/26/22 at 10:00 AM with Staff D, CNA (Certified Nurse Assistant) who confirmed the resident's fingernails were long and jagged. During an interview on 7/26/22 at 10:00 AM Staff D stated that Resident #29 is total care and that he received hygiene care this morning. Staff D stated [Resident #29's name] fingernails look bad, it looks like it's been a while since they have been taken care of. I'm going to do that right away. He is my resident, and I should have [provided care]. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-27 · 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 was provided consistent with professional standards of practice for 2 (Residents #63 and #337) of 4 residents reviewed for oxygen administration. Findings include: 1. Review of Resident #63's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, unspecified, and acquired absence of other specified parts of digestive tract; ileus, unspecified; major depressive disorder, recurrent, unspecified; hypokalemia; hypothyroidism, unspecified; unspecified atrial fibrillation; urinary tract infection, site not specified; muscle weakness (generalized); essential (primary) hypertension; hypoxemia; and dependence on supplemental oxygen. Review of Resident #63's physician orders dated 6/17/22 read, Oxygen at 4L [liters] via NC [nasal cannula, a small flexible tube that sits in the nose] QHS [every night at bedtime] and prn [as needed] SOB…
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 · D2022-07-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 an anti-anxiety medication prescribed on an as needed basis was not prescribed for more than 14 days, failed to ensure the physician acknowledged and responded to the pharmacist's recommendations for a gradual dose reduction of an atypical antipsychotic, and failed to ensure the physician acknowledged and responded to the pharmacist's recommendation for the addition of a stop date on an as needed antianxiety medication for 1 (Resident #18) of 5 resident reviewed for unnecessary medications. Findings include: Review of Resident #18's pharmacy consultation report, dated 9/25/2021, showed the pharmacist recommended the physician consider a gradual dose reduction of the antipsychotic medication Rexulti 1 milligram daily for schizoaffective disorder to 0.5 milligrams daily. Review of Resident #18's clinical record failed to reveal documentation the physician had responded to the pharmacist's recommendation to consider a gradual dose reduction of Resident #18's prescribed antipsychotic medication Rexulti 1 milligram daily…
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 before2022-07-27 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to remove expired medication and supplies from 2 of 2 medication storage areas and dispose of expired medication in accordance with facility protocol. Findings include: During a tour of the 300-unit medication room on [DATE] at 10:35 AM with the Director of Nursing and the Infection Control Nurse/Assistant Director of Nursing (ADON) outdated over the counter (OTC) medication was observed: 2 boxes of Famotidine 10 milligram with an expiration date of 05/2022 (photographic evidence obtained). During a tour of the 200-unit medication room on [DATE] at 11:05 AM with the ADON, expired COVID 19 testing swabs was observed: 6 envelopes with an expiration date of 06/2021 (photographic evidence obtained). During an interview on [DATE] at 10:37 AM with the ADON, she stated the central supply clerk was the person who stocks the OTC medications and is expected to check the dates. During an interview on [DATE] at 11:07 AM with the ADON stated swabs are not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 EXCELSIOR CARE GROUP — 33 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 | 2.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 32 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| LAKE CITY OPERATING HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/09/2021 |
| BDCC CONSUTKING GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| FDZ CONSULTING LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| JZ CONSULTING LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| RUBIWEB FLORIDA SERVICES GROUP USA LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| POWERS, BRIAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| RUBENSTEIN, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| WEBER, ARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/09/2021 |
| ZAHLER, JACOB | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2022 |
CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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 $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 106126. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-10, 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.