North Lake Care Center And Rehab
750 Bayberry Drive, Lake Park, FL 33403 · For profit - Limited Liability company · 85 certified beds · (561) 881-8144 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)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,206 in federal fines (most recent 2024-10-23)
- its facility-reported quality-measure score sits well above its independent inspection score
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 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 improved from 3 to 4 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 | 1.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.7% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.3% | 0.9% | worse 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 | 5.1% | 4.6% | 6.5% | better |
| 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 | 0.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 9.5% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 8.7% | 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 | 7.8% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 0.7% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.1% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.9% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.79 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.17 | 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.
Met the expected recovery: 82.3% 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 34 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 7.6–16.9 | 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 | 82.3% | 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 | 67.7% | 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 | 79.4% | 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 | 98.3% | 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 | 100.0% | 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 | 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 | 3.5% | 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 | 7.1%CMS range 4.0–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.29 | 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 85 beds and averages 78.1 residents a day — about 92% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.77 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.26 hrs/resident/day on weekends vs 3.53 on weekdays — 8% thinner on weekends. RN hours go from 0.85 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide appropriate supervision to 1 of 3 sampled residents assessed as at risk for elopement. The deficient practice allowed Resident #1 to exit the facility on 10/12/24 at approximately 8:50 PM, through an unsecured door on the second floor. The findings included: The facility's policy, titled, Wandering and Elopements, with a revision date of March 2019, documented, in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review revealed Resident #1, a resident with severe cognitive impairment, eloped from the facility on 10/12/24 at approximately 8:40 PM. The record revealed Resident #1 was observed by an individual from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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 observation, interview, policy and record review, the facility failed to inform the physician of a significant weight loss for 1 of 3 sampled residents reviewed for nutrition, Resident #6.The findings included:Review of the facility's policy titled Change in a Resident's Condition or Status revised February 2021, revealed Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of the facility's policy titled Weight Assessment and Intervention revised March 2022 revealed The threshold for significant unplanned and undesired weight loss will be based on the following criteria 1 month -5% weight loss is significant; greater than 5% is severe. Record review revealed Resident #6 was initially admitted to the facility on [DATE] with diagnoses that included Heart Failure, Type 2 Diabetes Mellitus and Peripheral Vascular Disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment…
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 · D2025-09-11 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 report and resolve a grievance for 1 of 1 sampled resident reviewed for grievances, Resident #11. The findings included:Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial/moderate assistance with activities of daily living.Record review revealed Resident #11 was care planned on 04/23/25 for self-care deficit with dressing, grooming, and bathing as evidenced by needs set up to supervision with personal care tasks due to generalized weakness, and limited endurance. An intervention included to provide staff assistance with dressing, grooming, bathing as needed. An interview was conducted with Resident #11 on 09/08/25 at 11:30 AM. Resident #11 stated he had had concerns over the the care he receives on 2nd shift (3-11 PM). The resident stated they are slow to respond to his call light, and they are rude in responding. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain labs as ordered and failed to notify the physician of the missed labs for 1 of 1 sampled resident, Resident #54. The findings included:Record review revealed Resident #54 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required partial/moderate assist with activities of daily living.Review of Resident #54's orders revealed an order dated 09/03/25 for, Urinalysis with reflex to culture, CBC (Complete Blood Count) with differential, BMP (Basic Metabolic Profile) in AM [morning]. Further review of Resident #54's record revealed the urine culture, CBC, and BMP were not conducted or obtained. Further review of Resident #54's record did not reveal any indication the physician was notified of the missed labs. An interview was conducted with the Director of Nursing (DON) on 09/10/23 at 12:00 PM. The DON acknowledged the above. The DON further stated it was missed.
- Potential for harm · D2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and have dialysis communication forms post treatment for 1 of 1 sampled resident reviewed for dialysis, Resident #3.The findings included:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses included End Stage Renal Disease (ESRD). A comprehensive assessment dated [DATE] documented the resident had moderate cognitive deficit and required supervision for activities of daily living. The assessment further indicated the resident received dialysis. Review of Resident #3 care plan documented the resident was care planned on 08/11/25 for potential for complications related to hemodialysis for treatment of ESRD, receives dialysis on: Tuesday and Saturday. An intervention included to complete dialysis communicate tool on dialysis days and review upon return from dialysis. Review of Resident #3's Dialysis Communication Interchange forms revealed missing dialysis communication forms for 08/12/25, 08/30/25, 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 before2025-09-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and observation, the facility failed to appropriately reconcile controlled medications for 2 of 4 sampled residents reviewed for medication reconciliation, Resident #1 and Resident #16.The findings included:Review of the facility's policy titled Controlled Substances, publication date and revision date not supplied, under the heading of Policy Interpretation and Implementation, documented, in part: Under that section is the subsection with the heading Dispensing and Reconciling Controlled Substances. Item 1 documented: Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Item 2 documented: The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following:Records or personnel access and usage. Medication administration records.Declining inventory records; andDestruction, waste, and return to pharmacy records. On 09/11/25 at 12:28 PM, an observation was made of the DIV 4 med…
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 before2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included, but are not limited to, time frames for the different steps in the process for 2 of 5 sampled residents sampled for unnecessary medications, Residents #2 and #5. The findings included:Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction with a revised date of April 2025 included in part the following: Tapering/GDR (Gradual Dose Reduction) may be used as an approach to finding an optimal dose or determining if continued use of a medication will benefit the resident. In addition, the staff and practitioner consider GDR under certain circumstances including when: a) the resident's clinical condition has improved or stabilized, b) the underlying causes of the original target symptoms have resolved, c) non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms; or d) a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to initiate behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #6. The findings included: Record review revealed Resident #6 was initially admitted to the facility on [DATE] with diagnoses that included Heart Failure, Type 2 Diabetes Mellitus and Peripheral Vascular Disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 06/25/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitively intact. Review of the Physician order's revealed on 09/05/25 the resident was started on Quetiapine Fumarate 25 milligrams (mg) tablet to give 1 tablet by mouth two times a day for psychosis. On 09/10/25, Quetiapine Fumarate was increased to 50 mg at bedtime related to schizoaffective disorder. Review of the physician's orders revealed no behavior monitoring order for this medication since the start of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · 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 observations, interviews and record review, the facility failed to secure medications at all times for 1 of 21 sampled residents with medications observed at the bedside, Residents #42. The findings included:Review of the facility's policy titled, Storage of Medications with no date included in part the following: The facility stores all drugs and biologicals in a safe, secure and orderly manner.Review of the facility's policy titled, Self-Administer of Medications with no date included in part the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Adrenocortical Insufficiency, Anxiety Disorder and Unspecified Glaucoma. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental…
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 · D2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to have an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 sampled resident reviewed for infection, Resident #54. The findings included: Record review revealed Resident #54 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required partial/moderate assist with activities of daily living. Resident #54 had diagnoses including Dysuria (difficulty urinating) and Benign Prostatic Hyperplasia (BPH, enlarged prostate). Record review revealed Resident #54 was care planned for alteration in elimination as evidence by frequent incontinence of bladder and bowel, impaired mobility, and difficulty with urine stream due to diagnosis of BPH, at risk for UTI (Urinary Tract Infection). Interventions included; administer medications as ordered, observe for effectiveness and for side effects, observe…
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 · E2024-05-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to provide housekeeping and maintenance services in order to maintain a clean, comfortable, sanitary and home like environment in 9 of 30 rooms and the Community Shower Room. The findings included: On 05/16/24 at approximately 2:00 PM, an environmental tour was conducted with the Director of Maintenance. The following was observed: a. In room [ROOM NUMBER], the hand washing sink in the bathroom was clogged in a manner that the basin was slow to drain. b. In room [ROOM NUMBER], the toilet was clogged and the faucet at the hand washing sink was not secured to the sink. c. In room [ROOM NUMBER], there was no drain plug in the tub to allow the tub to hold water, and there was duct tape covering a screen on the sides of the window mounted air conditioning unit. d. In room [ROOM NUMBER], the basin and faucets of the tub and the were dirty and there were urinals in need of being changed. e. In room [ROOM NUMBER], the surface of the over bed table for the door…
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 19 citations
- Potential for harm · E2024-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow facility-wide policies and procedures for 17 of 18 residents on Enhanced Barrier Precautions (EBP), including Residents #9, #1, #29, #236, #18, #13, #45, #54, #48 and #53, as evidenced by no gowns at or outside of the residents' doors; and failed to maintain an appropriately clean environment in the facility's laundry rooms to prevent cross contamination of the laundry with various forms of debris. The census at the time of survey was 83 residents. The findings included: 1. Review of the policy, titled, Enhanced Barrier Precautions, not dated, provided by the Director of Nurses (DON) on 05/16/24 at 1:45 PM revealed the following, in part: .EBPs are utilized to prevent the spread of multi-resistant organisms (MDROs) for residents . Under 11. PPE [Personal Protective Equipment]is available outside of the resident rooms . Review of the Center for Disease Control (CDC) guidelines, as the website provided by the DON, documented, in part, that 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 · D2024-05-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure showers as per resident preference and facility schedule for 1 of 4 sampled residents, Resident #19, reviewed for choices. The findings included: Review of the record revealed Resident #19 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS revealed the resident needed set-up assistance of staff for bathing and showering. Review of the comprehensive admission MDS dated [DATE] documented it was very important for Resident #19 to choose between a bath and a shower. During an interview on 05/13/24 at 2:57 PM, when asked if she received baths and / or showers as she would like, Resident #19 stated staff never offer her a shower and she rarely gets them. When asked how often she would like a shower, 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 · D2024-05-16 · 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
Based on interview, record review and observation, the facility failed to maintain residents' fingernails for 2 of 6 sampled residents identified with long fingernails, Resident #45 and Resident #48. The findings included: The facility's policy, titled, Fingernails/Toenails Care, from MED-PASS, Inc, (Revised February 2018), under General Guidelines, item 3 documented in part, Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. a. On 05/13/24 at 3:28 PM, an interview was conducted with Resident #45. At that time, it was noted that Resident #45 had fingernails that extended past his fingertips by about ½ inch, on both hands. When asked about the length of the fingernails, Resident #45 stated he would like to have his nails trimmed. On 05/15/24 at 10:02 AM, a second observation was made, and it was noted that Resident #45 still had untrimmed fingernails. On 05/16/24 at 2:30 PM, Resident #45 showed the surveyor that his fingernails had now been trimmed. The resident stated that the staff had trimmed his nails, and he 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 before2024-05-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the safe transfer for 1 of 27 sampled residents, Resident #18, resulting in skin damage to the resident; and failed provide devices to ensure the safety of the resident while smoking for 1 of 2 sampled residents reviewed for smoking, Resident #80. The findings included: 1. Resident #18 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE] documented Resident #18 was not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented Resident #18 was dependent upon staff for all Activities of Daily Living (ADLs) and was 'always incontinent' of urine and bowel. Resident #18's diagnoses at the time of the assessment included: Anemia, Atrial fibrillation, Hypertension, Orthostatic hypotension, Peripheral Vascular Disease (PVD), Gastro-esophageal reflux disease (GERD), Obstructive uropathy, Hyperkalemia, Aphasia, Cerebral…
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 · D2024-05-16 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record reviews, the facility failed to assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for 1 of 2 sampled residents reviewed for the use of bed rails, Resident #134. The findings included: The facility's policy, titled, Bed Safety and Bed Rails, revised August 2022, documented, in part: Use of Bed Rails 5. If attempted alternatives do no adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs. b. the resident's risk associated with the use of bed rails. c. input from the resident and/or responsible party. d. consultation with the attending physician. 7. The resident assessment also determines potential risks to the resident associated with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to follow physician's orders related to the timing for administration of medication for 3 of 6 sampled residents, Residents #19, #63 and #68, as evidence by: Resident #19 was receiving two medications with a potential drug to drug interaction, in which nursing staff failed to administer at the ordered time; and Residents #63 and #68 complained medications were not provided timely. The findings included: Review of the policy, titled, Administering Medications, revised April 2019 documented, in part, . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety…
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 before2024-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the pharmacist failed to identify a timing issue with a possible drug to drug interaction for 1 of 5 sampled residents, Resident #19. The findings included: Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety medication and an antidepressant. Review of the current orders revealed Resident #19 was receiving the antidepressant medication mirtazapine 15 milligrams (mg) which was ordered at bedtime, and scheduled for 9:00 PM. Resident #19 was also receiving the antianxiety medication alprazolam 0.25 mg which was ordered for the evening at 6:00 PM. The order for the alprazolam specifically documented, Please do not administer with mirtazapine. Review of the corresponding Medication Administration Record (MAR) documented Resident #19 was receiving both…
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 · D2024-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Record review revealed Resident #19 was admitted to the facility on [DATE]. Review of the current orders revealed the resident was currently taking an antidepressant and an antianxiety medication. Further review of the orders revealed as of 01/08/24 nursing staff was to monitor for resident behaviors twice daily on day and night shifts, and document any intervention provided and outcomes, and monitor for side effects of these medications. Review of the current May 2024 Behavior Monitoring Flow sheet revealed a lack of monitoring on the 05/01/24 day shift, 05/06/24 day shift, 05/07/24 day shift, 05/08/24 day shift, 05/13/24 night shift, and the 05/14/24 night shift. This resulted in a failure to monitor behaviors on 6 of 29 shifts. Review of the April 2024 Behavior Monitoring Flow Sheet revealed a lack of monitoring on the folowing shifts: 04/02/24 day shift, 04/03/24 night shift, 04/07/24 day shift, 04/08/24 both shifts, 04/09/24 both shifts, 04/10/24 day shift, 04/13/24 day shift, 04/14/24 night shift,…
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 · D2024-05-16 · 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 ensure accuracy of records for 1 of 3 sampled residents, reviewed as closed records, Resident #83, as evidenced by failure to ensure accurate documenation in the residnet's record that reflected the resident's discharge. The findings included: Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence of Cigarettes. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 01/29/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. Review of the MDS for Resident #83 dated 02/29/24 titled and documented that Discharge Return Anticipated. Review of the MDS for Resident #83, dated 02/29/24, titled and documented that 'Discharge Return Not Anticipated (Modification).' Review of the Nurses Note for Resident #83 dated 03/02/24 documented: 'Report received that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, record review and observation, the facility failed to offer, educate, and obtain consent for pneumonia vaccine for 5 of 5 sampled residents reviewed for vaccine provision, Resident #53, Resident #35, Resident #22, Resident #18, and Resident #34; as evidenced by Residents #53 and #18 did not have Pneumococcal consents or refusals, and all 5 residents did not have evidence of being offered the vaccines or of being provided education. The findings included: Review of the facility's policy regarding the Pneumococcal Vaccine had documentation, in part, for Policy Interpretation and Implementation that documented as follows: Section Item 3: Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine . Provisions of such education is documented in the resident's medical record. Item 7: Administration of the pneumococcal vaccines are made in accordance with current…
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 · D2024-05-16 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record reviews, the facility failed to ensure bed rails were maintained in working condition and inspected for fitness and function for 1 of 2 sampled residents reviewed for bed rails. The findings included: The facility's policy, titled, Safety and Bed Rails, revised August 2022, documented, in part: Policy Interpretation and Implementation 6. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. 7. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI (Quality Assurance Performance Improvement) committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. 8. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 9. Bed rails are properly installed and used…
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 · D2024-05-16 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure accessibility and functioning of call bells for 2 of 27 sampled residents, Residents #9 and #53. The findings included: Review of the facility's policy, titled, Call System, Resident, dated September 2022, documented, in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 2. Call system communication may be audible or visual. The system may be wireless. 3. The resident call system remains functional at all times. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternate means of communication that is usable for the resident is provided and documented in the care plan. 1. Record review for Resident #9 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-03-02 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 follow the approved menu and failed to periodically update the menu for 6 of 52 sampled residents on a Regular Diet (sampled Residents #30, #29, #276, #72, #71, #32); 5 of 14 sampled residents on a Mechanical Soft Diet (sampled Residents #15, #4, #64, #42, #63); 1 of 4 sampled residents on a Pureed Diet (sampled Resident #9); and 1 of 4 sampled residents on a Renal Diet (sampled Resident #9). The findings included: 1. During review of the Approved Menu for the lunch meal of 02/27/23, the following was noted: *3-ounce portion of Honey Glazed Ham to be served to Regular Diet *3-ounce portion of Beef Steak to be served as alternate entree for Regular Diets *Seasoned Roasted Potatoes - to be served to Regular diets. Further review noted no documentation that the mashed potatoes were documented to be served to Mechanical Soft Diets, Purred Diets. Observation of the lunch tray line in the Main Kitchen on 02/27/23 at 11:30 AM, accompanied with the Certified Dietary Manager (CDM) noted the following: At the request 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 · E2023-03-02 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
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 interview, the facility failed to maintain mechanical and electrical equipment in the main kitchen in a safe operating condition. The findings included: During a second kitchen / food service observation tour conducted on 02/28/23 at 11:30 AM and accompanied with the Certified Dietary Manager (CDM), the following were noted: 1. The wall mounted air-conditioning unit located near the dish machine was steadily dripping condensation. Further observation noted the dripping condensation had pooled and was dripping further down onto the dish machine run. It was discussed with the CDM the potentially contaminated condensation could come into contact with clean dishes and staff. The surveyor requested the unit be shut down and repaired prior to further use. It was also reviewed that the unit required to be moved to different location within the kitchen that is not threat to to food or dish contamination. 2. Observation of the exhaust hood system noted a [NAME] pipe ran from the commercial…
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 · D2023-03-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to meet professional standards for services provided for administering insulin provided in pen style for 1 of 4 sampled s observed for medication observation pass, Resident #11. The Findings included: Review of the FDA and the Institute for Safe Medication Practices provided labelling guidance and recommendations aimed at preventing errors, as documented on their web address included: https://www.fda.gov/downloads/Drugs/. The document included: Do not withdraw insulin from an insulin pen cartridge. Using insulin pens as mini insulin vials, by drawing up insulin into an insulin syringe, can lead to inaccurate dose measurement the next time the insulin pen is used with a pen needle for dose delivery. The reason for this is related to air entering the pen unintentionally, dose interfering with the proper mechanics of the pen. Review of the facility's policy titled, Insulin Administration with a revised date of September 2014 included: To provide guidelines for the safe administration of insulin to residents 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 · D2023-03-02 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, records review, and interviews, the facility failed to provide feeding assistance to 1 of 1 sampled resident (Resident #63) during dining, as ordered and required by the resident. The findings included: Review of the clinical record documented Resident #63's diagnoses included Cardiovascular Aneurysm with Hemiparesis, Diabetes Mellitus, Psychosis, Dementia, and Anxiety Disorder. Review of the Annual Minimum Data Set (MDS) section C, dated 12/18/22, documented Resident #63 obtained a score of 11 of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #63 had cognitive deficits. Section G of the form, titled, Functioning Status, documented the resident required supervision for eating and one-person physical assist. Review of the Care Plan (CP), dated 09/15/22 and updated 12/16/22, revealed Resident #63 was at risk for an alteration in: nutrition and/or hydration related to her receiving therapeutic & mechanically altered diet, having poor dentition, requiring staff assistance at meals, and having visual impairment. On 02/27/23 at 1:24 PM,…
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 before2023-03-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure smoking evaluations were completed and the care plan was updated related to smoking for 1 of 3 sampled residents reviewed for smoking / accidents (Resident #11), and failed to retain and store all smoking materials for 1 of 3 sampled residents reviewed for smoking / accidents (Resident #20). The findings included: Review of the facility's policy, titled, Smoking Policy-Residents with a revised date of 10/05/22, included: The facility will establish and maintain a safe designated smoking area and safe smoking practices for the residents. Smoking is only allowed in the designated outdoor areas of the facility during designated times. Smoking is not allowed during inclement weather. Oxygen is not permitted within 50 feet from the designated smoking areas. The center will have safety equipment available in designated smoking areas including: a fire blanket, smoking aprons, a fire extinguisher, and non-combustible self-closing…
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 before2023-03-02 · 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 observations, interviews, and record review, the facility failed to ensure medications were attended and secured related to 1 of 1 sampled resident (Resident #15), failed to secure medications at the bedside for 1 of 1 sampled resident (Resident #42), failed to lock an unattended medication cart, and failed to secure medications being returned to the pharmacy. The findings included: Review of the facility's policy, titled, Storage of Medications with a revised date of November 2020, included: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Unlocked medications carts are not left unattended. 1. During record 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 · D2023-03-02 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 special eating equipment and utensils for 1 of 5 sampled residents reviewed for nutrition (Resident #32). The findings included: During the review of the clinical record of Resident #32 on 02/27/23, the following was noted: Date of re-admission [DATE] Diagnoses included: Heart Failure, ASHD (Atherosclerotic Heart Disease), Vitamin Deficiency, Altered Mental Status, Contracture of Right Hand, and Dysphagia. The current physician orders included: 01/16/21: No Added Salt Diet 03/11/22: Built-Up Utensils with Meals 02/27/23: Divided Plate with Meals. Weight History: 02/8/23 = 158 pounds 01/5/23 = 161 pounds 12//9/22 =162 pounds Ht (height) = 72 inches BMI (body mass index) = 21.4 (Nutritional Risk). MDS: Dated 02/10/23 (Quarterly Assessment) documented: Sec C= BIMS (Brief Interview for Mental Status) =6 (severe cognitive impairment ) Sec D: Low Interest, feeling depressed, Sec G: Eat = Supervision with eating Sec K: No Swallow Issues,…
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
$10,206 in federal fines across 1 penalty.
- $10,206 — penalty dated 2024-10-23
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NORTH LAKE NURSING HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| FL SNF TRUST I | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| FL SNF TRUST II | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| BLACKMAN, RUSSELL | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
4 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.
About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
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 105640. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.