Lake Worth Rehabilitation Center
1201 12th Avenue South, Lake Worth, FL 33460 · For profit - Corporation · 120 certified beds · (561) 586-7404 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has abuse, neglect, or exploitation citations (F0609, F0610) — most recent Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,685 in federal fines (most recent 2025-06-13)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 5.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.1% | 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 | 1.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.7% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.9% | 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 | 2.5% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 5.8% | 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 | 24.9% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.6% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 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.
35.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.6% 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 46 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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 | 35.7%CMS range 21.2–51.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.5–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.6% | 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 | 71.7% | 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 | 60.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 70.1% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.5–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 99.0 residents a day — about 82% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.21 hrs/resident/day on weekends vs 3.70 on weekdays — 13% thinner on weekends. RN hours go from 0.79 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2025-06-13 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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, record and policy review; the facility failed to ensure reporting of 2 of 2 incidents involving events with major injuries both affecting 1 of 2 sampled residents (Resident #11) reviewed for accidents. The findings included: The facility's Abuse and Neglect Prohibition policy effective 10/24/22 and revised 8/2023 revealed, The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but no later than 2 hours after forming the suspicion of the events that cause the allegation involve abuse or result in serious bodily injury. The center will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. The surveyor requested a policy on falls and was told by Staff D, Registered Nurse, Regional Nurse Consultant on 06/13/25 at 2:49 PM that there is no fall…
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.
- Actual harm · Gcited before2025-06-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, record review and policy review; the facility failed to thoroughly identify and investigate the alleged witnessed fall and unwitnessed fall for 1 of 2 sampled residents reviewed for accidents (Resident #11). The findings included: The facility's policy titled Change in Condition effective 1/2023 and updated 9/2023 revealed All completed incident reports must be forwarded to the Director of Nursing and Administrator for review within 24 hours of the event. The facility's Abuse and Neglect Prohibition policy effective 10/24/22 and revised 8/2023 revealed The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. A review of the Electronic Health Record (EHR) revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Chronic Atrial Fibrillation, Unspecified; Unspecified dementia; and Anxiety. Her Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to collect a urine test to rule out a urinary tract infection (UTI) for 1 of 3 sampled residents (Resident #1). The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, required substantial/maximum assist with activities of daily living and had been on antibiotics. A review of Resident #1's physician orders revealed an order dated 01/09/26 for urinalysis. Further review of the resident's records did not reveal the urinalysis was ever collected. Furthermore, there was no indication the physician was notified, nor a documented reason the urinalysis was not collected.An interview was conducted with Resident #1's power of attorney (POA) on 02/09/26 at 12:00 PM. The POA stated Resident #1 was prone to have UTIs. The POA further stated the resident started to exhibit familiar signs to her of developing a UTI, and she asked 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 before2025-06-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident had a current order for a nebulizer treatment medication, failed to secure that medication observed at the bedside for 1 of 16 sampled residents receiving nebulizer treatments (Resident #85), and failed to ensure the resident received a psychotropic medication at the prescribed time for 1 of 4 sampled residents observed for medication administration (Resident #85). The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Anxiety Disorder. Her Brief Interview for Mental Status (BIMS) score on a quarterly Minimum Data Set with a target date of 05/01/25 was 15. This indicated she was cognitively intact. On 06/10/25 at 10:19 AM, an interview was conducted with Resident #85. The resident stated she is supposed to get a medication for anxiety early in the morning and she never gets it early. She stated she feels…
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 · D2025-06-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to prevent complications for a resident who received enteral feeding. This affected 1 of 1 sampled resident, (Resident #300), who was reveiwed for enteral feeding (tube feeding). This had the potential to affect 4 residents who were dependent on enteral feeding for nutrition at that time. The findings include: A review of the facility's Procedural Guidelines for Enteral Nutrition effective 01/2023 stated that the nurse must administer the enteral feeding regimen according to the formula, the system type, and the method of delivery ordered by the physician. It also stated that feeding tube orders must include the following information: the product to be used, the rate and/or timing of administration, the total volume to be given per 24-hour period, the total calories provided per 24-hour period, the route of delivery (i.e. via gastrostomy tube, jejunostomy tube), the method of administration (i.e. pump, bolus), and the volume of water given…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-13 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Administrator failed to carry out her duties as outlined in her job description which included risk management and overall management of the facility which affected 1 of 2 sampled resisdents reviewed for accidents (Resident #11). The findings included: A review of the signed job description for the Administrator revealed the Administrator serves as risk manager for the facility and is responsible for the overall management of the facility. The Administrator ensures all required records are maintained and submitted, as appropriate, in an accurate and timely manner. A review of the Electronic Health Record (EHR) revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Chronic Atrial Fibrillation, Unspecified; Unspecified dementia; and Anxiety. Her Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/24. This indicated at that time she was severely…
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 · D2024-08-12 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an environment free of pests in 4 of 15 rooms on the 2 South Unit (room [ROOM NUMBER], #241, #250 and #251). The findings included: Review of the second floor Maintenance Report Logbook, located at the nurse's station, revealed the following: - Concern regarding roaches in room [ROOM NUMBER]-A on 06/12/24, documented as 'fixed' on the same day. - Infestation of roaches in room [ROOM NUMBER] and 241 on 07/28/24 reported by staff. During a room-by-room tour on 08/12/24 at 10:05 AM, the following observations were made: In room [ROOM NUMBER], 2 (two) live juvenile roaches and multiple dead roaches were observed behind the [NAME]. There was also one dead juvenile roach observed on the resident's bed, while the resident was sleeping. In room [ROOM NUMBER], 2 (two) live and mature roaches were observed on the wall and floor behind vacant bed-A. In room [ROOM NUMBER], 2 (two) live juvenile roaches were observed on the floor in 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 · E2024-03-01 · 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 observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on 1 of 2 units/floors in the facility (2nd floor secured unit). This affected Residents #67, #24, #85, #51, #79, #57, #58, #68, #40, #31, #59, #32, #91, #28). The findings included: The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained): room [ROOM NUMBER]B - overbed light string was off; Resident's daughter stated the string pulls off very easily. The daughter must pull on the short little string to turn the light on or off. The toilet in bathroom has debris. room [ROOM NUMBER]A - Stained privacy curtains, bedside chairs, and linens. room [ROOM NUMBER]B - Rust on bottom rail of bed; light string missing from over-bed light and lying over bedside nightstand. room [ROOM NUMBER]B - Over-the-bed table with corner in disrepair. When asked how long it had been…
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 before2024-03-01 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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, interview, and policy review, the facility failed to provide an ongoing activity program based upon assessments, care plans, and personal preferences, for 2 of 2 residents who voiced concerns related to the lack of activities (Resident #51 and #9), and for 5 of 5 residents observed only in their rooms, with a lack of sensory stimulation, and or assessed as needing either one-to-one activities or friendly visits (Residents #79, #91, #37, #43, and #40). The findings included: Review of the Activities Policy implemented 10/16/23 and revised 02/07/24 documented, 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: . (The policy then describes multiple different types of activities provided by the facility.) This policy lacked any information for one-to-one or sensory type activities for the cognitively impaired residents. At the time of the survey, 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 · E2024-03-01 · 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 resident care equipment in a safe and sanitary condition related to specialized mattress and wheelchairs for 7 of 32 sampled residents (#24, #68, #40, #32, #91, #21, #28). The findings included: 1) Review of the record revealed Resident #28 was admitted to the facility on [DATE] with a large pressure injury to his sacrum. This wound healed and re-opened in June 2023. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was totally dependent on staff for all activities of daily living and had two pressure injuries. Review of the orders documented the initiation of a low airloss specialty mattress as of 10/14/22. This order documented to check for placement and settings every shift. During an observation on 02/26/24 at 11:28 AM, Resident #28 was noted in bed, lying on a specialty air mattress. Observation of the specialty air mattress pump control unit revealed clear packing-type tape wrapped around the cord…
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 · D2024-03-01 · 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, record review, and policy review, the facility failed to ensure showers as per resident preference and schedule for 1 of 2 sampled residents reviewed for choices (Resident #51). The findings included: Review of the policy Shower Policy implemented 10/10/22 documented, Procedures: 1) Administer resident shower twice weekly and/or as often as necessary as per facility protocol. 2) If reasonably practicable, try to accommodate resident's preference in the shower schedule. 3) Shower refusal by the resident shall be relayed by the assigned CNA to the charge nurse. 10) document. Review of the record revealed Resident #51 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating he was cognitively intact. Further review of this MDS documented Resident #51 needed substantial assistance for showering. Review of the Annual 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 · Dcited before2024-03-01 · 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 record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 32 sampled residents related to oxygen use for Resident #91 and discharge status for Resident #57. The findings included: 1) Review of the record revealed Resident #91 was admitted to the facility on [DATE], was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of the current orders documented to keep the resident's oxygen saturation at 90% or greater as of 02/07/24. Although the orders lacked a specific order for as needed oxygen, review of the oxygen saturation levels from 02/07/24 through 02/13/24 in the vital sign section of the electronic medical record (EMR) documented oxygen use on 5 of those 7 days. Review of the current MDS assessment dated [DATE] lacked any documented oxygen use for Resident #91. Review of the corresponding care plan initiated 02/25/24 documented Resident #91 was at risk for altered respiratory status and to administer oxygen as…
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 14 citations
- Potential for harm · D2024-03-01 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer 1 of 1 sampled resident for a Level II resident review, as indicated by the pre-admission screening and resident review (PASRR) Level I review completed by hospital staff (Resident #67). The findings included: Review of the record revealed Resident #67 was admitted to the facility on [DATE], transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of the PASRR Level I screen completed by the hospital on [DATE] documented by checkmark that Resident #67 had depressive disorder as documented in Section 1A, and was currently receiving services for MI (mental illness). Further review of this PASRR documented in Section II.1. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. Section II. 3. A. documented the resident had received recent treatment for a mental illness…
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 · D2024-03-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise the care plan for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #33). The findings included: Review of the record revealed Resident #33 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and returned on 07/15/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked any documented use of opioids (narcotic pain medications). Review of the current physician orders lacked any opioids, and indicated Tylenol was the only medication ordered for pain. Review of the current care plan initiated on 09/04/22 and revised on 02/07/23 documented Resident #33 was at risk for pain or discomfort related to (multiple diagnosis and conditions) . and oxycodone 5 milligrams being administered every eight hours as needed. This care plan also documented an intervention to administer Naloxone (a medication to reverse an opioid overdose) as needed. Further review of the record 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 · D2024-03-01 · 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 observation, interview, and record review, the facility failed to coordinate care between the facility and dialysis for 1 of 2 residents reviewed for dialysis (Resident #29). The findings included: 1) Resident #29 was admitted to the facility on [DATE], with diagnoses included End Stage Renal Disease. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was receiving Hemodialysis. Resident #29 as care planned for at risk for complications related to hemodialysis. Dialysis Days: M-W-F in house. An intervention included collaborate care services with dialysis center. A review of the facility's Dialysis Resident Communication Report from 01/29/24 until 02/28/24 revealed no documentation in the Dialysis Center Staff section of the Communication Report revealed no documentation of any medicine given in dialysis, except on 02/28/24 (Wednesday), where it was documented Heparin and Micera (medicine to increase Red Blood Cells) 50 micrograms (mcg) was given. 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 · D2024-03-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices after wound care for 1 of 2 sampled residents observed for wound care (Resident #43); Failed to follow best practice to prevent transmission of blood-borne pathogens using the ultra-mist machine for 1 of 1 sample residents with specialized wound care (Resident #43); and failed to maintain clean oxygen tubing for 1 of 2 residents reviewed for respiratory care (Resident #91). The findings included: A review of the facility's policy Wound Cleansing and Dressing, revised on 9/25/23, documented: Cleanse the wound using normal saline or wound cleanser. Change gloves and perform hand hygiene as needed to prevent contamination. Apply new dressing after cleansing the wound. 1) A wound care observation for Resident #43 was conducted with the Wound Care Nurse (WCN) on 02/28/24 at 11:50 AM. The wound care nurse cleaned the resident's sacral wound as ordered. The WCN continued wound care with the same gloves on. 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 · F2022-10-27 · 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
Based on observation and interview, the facility failed to serve food in a sanitary manner. The findings included: On 10/24/22 at 9:43AM, during an initial tour of the main kitchen, accompanied by the Food Service Director, the following was observed: (1) The oven was dirty with burnt on grease and food. (2) During an inspection of the walk-in refrigerator, there was a full crate of 8oz (ounces) of fat free milk with a date of 10/19/22. The cartons of milk were observed on the residents' breakfast trays to be served to the resident for breakfast. (3) There were two, 24oz containers of cottage cheese observed. The expiration date for one of the containers was 09/26/22 and the other 10/17/22. (4) A staff nurse was observed in the kitchen. The nurse was not wearing any head covering. (5) The toaster was dirty with baked on bread crumbs. (6) The floor and the ceiling vent in the preparation area was dirty with black dust. On 10/24/22 at 11:25 AM, the Food Services Director was informed of the findings. On 10/26/22 at 11:30 AM, a follow up visit to the main kitchen was conducted,…
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 before2022-10-27 · tag F0641 — patternEnsure 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 interview and record review, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment was completed for for 5 of 23 sampled residents, related to Hospice (Resident #31), catheter (Resident #47), nutrition (Resident #79 and Resident #99), and medications (Resident #121). The findings included: 1) Resident #31 was admitted to the facility on [DATE]. A comprehensive MDS assessment dated [DATE], documented the resident was not on hospice services. A review of Resident #31's physician orders revealed an order dated 07/01/22 for admission to hospice. Resident #31 was also care planned for hospice services. An interview was conducted with the MDS Coordinator on 10/27/22 at 3:00 PM. The MDS Coordinator acknowledged Resident #31 was inaccurately assessed on the MDS assessment dated [DATE]. 2) Resident #47 was admitted to the facility on [DATE]. An MDS assessment dated [DATE] documented the resident had a urinary catheter. A review of the residents orders did not reveal any orders for 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 · D2022-10-27 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 staff recieved training in abuse, neglect, and exploitation upon hire and annually, as per facility policy and facility assessment, for 8 of 14 sampled staff personnel records reviewed for training (Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O, and Staff P). The findings included: Review of the facility's policy for abuse, neglect and exploitation dated 01/01/2022 documents new employees should be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. Existing nursing home staff should receive annual education and in-service training. A review of the Facility Assessment also documents that trainings for new hires at orientation and annually include abuse, neglect, exploitation prevention. Review of 14 staff members for abuse training revealed that 8 did not have abuse training, of the 8 staff files reviewed, 2 were agency staff and 6 were facility staff. The following personnel files were reviewed with the Human Resource Director on 10/27/22…
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 before2022-10-27 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 there was a documented thorough investigation for 3 of 4 sampled residents, reviewed for incident investigations (Resident #98, Resident #102 and Resident #172). The findings included: 1) Review of Resident #98's medical record revealed Resident #98 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia, Age-related Osteoporosis, Pathological Fracture, Unspecified Psychosis and Major Depressive Disorder. The Annual MDS (Minimum Data Set) dated 09/01/22 documented the BIMS (Brief Interview for Mental Status) with no score which indicated the resident was not able to complete the interview. Review of the Progress Notes, dated 09/05/22 at 2:31 PM, documented the following: the resident was complaining, moaning of pain on left hip. Full assessment completed, no discolorations or bruises noted on the site. On 09/05/22 11:57 X- Ray done and faxed to Medical Doctor (MD) after reviewing it, new order received to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-27 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 that activities meet the needs for 1 of 3 sampled residents reviewed for Activities (Resident #58). The findings included: Record review for Resident #58 revealed an admission to the facility on [DATE]. The resident's MDS (Minimum Data Set) assessment, dated 07/31/22, documented the resident's Brief Interview for Mental Status (BIMS) score was 0, indicating severe cognitive impairment. The resident's function level was documented as total dependence on the staff. Review of Resident #58's care plan for activities documented that the staff should ensure that the resident's TV (television) should be tuned to a Spanish channel as needed, due to the fact the resident is Spanish speaking only. On 10/24/22 at 10:22 AM, Resident #58 was observed in her room in bed and the TV tuned to an English channel. On 10/25/22 at 9:30 AM, an observation of the resident's room revealed the resident was in bed and the television was again tuned to an…
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 · D2022-10-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement preventative measures of ordered specialty air mattresses, repositioning, offloading, and wound care, to prevent the development or worsening of pressure ulcers for 3 of 4 sampled residents (Resident #84, #109, and #274). The findings included: 1) An observation on 10/24/22 at 9:30 AM revealed Resident #84 lying in bed, dressed, with a Hoyer (a mechanical devise used to transfer a dependent resident from one surface to another) lift pad under the resident. A specialty air mattress was noted, but the power switch was not turned on. The specialty air mattress felt flat and lacked air. A supplemental observation on 10/24/22 at 11:31 AM revealed Resident #84 still in bed, in the same position as noted at 9:30 AM, with the Hoyer lift pad still under the resident. The specialty air mattress was still powered off. An observation on 10/25/22 at 9:10 AM revealed Resident #84 in bed, dressed, with the Hoyer lift pad under her. 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 · D2022-10-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to ensure monitoring of hydration status, provision of recommended extra fluids, and timely provision of IV (intravenous) fluids for 2 of 4 sampled residents (Residents #116 and #172). The findings included: Review of the requested policy Critical Values Reporting Procedure (not dated), documented procedures for abnormal lab results, but lacked any specifics related to a critical lab result. This policy included the process that abnormal lab results were to be called or faxed to the attending physician on the same day results were received. Review of the policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification dated 04/22/22 documented, Policy: It is the policy of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results. Definitions: Promptly means that results shall be relayed with little or no delay…
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 · D2022-10-27 · 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 observation, interview, and record review, the facility failed to accurately document medicating residents with controlled medications for 2 of 4 sampled residents (Resident #73, and #62). The findings included: 1) A narcotic medication reconciliation was conducted on 10/27/22 at 9:15 AM for Resident #73. A review of the Medication Monitoring/Control Record revealed the resident was medicated with Percocet (pain medication) on 10/22/22 at 6:30 AM, 10/23/22 at 10:14 PM, and 10/23/22 at 3:10 PM. A review of Resident #73's Medication Administration Record (MAR) did not reflect the resident was administered any Percocet at those times. The Director of Nursing was made aware of the above. 2) A medication storage observation and random narcotic reconciliation was completed on 10/27/22 at 11:39 AM, with Staff E, a Licensed Practical Nurse (LPN) for the medication cart on the 2E unit. Review of the narcotic book revealed Resident #62 had an order for Lorazepam (Ativan/an anti-anxiety medication) to be given every six hours as needed. Further review of this Medication…
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 · D2022-10-27 · 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
Based on observation, record review, interview, and policy review, the facility failed to ensure proper storage and labeling of drugs and biologicals. Specifically, 1 of 1 treatment carts was left open and unattended during a wound care observation for Resident #109; a medication was improperly disposed of during the medication pass observation for 1 of 7 residents; and an opened PPD (purified protein derivative) vial in the medication refrigerator was not properly labeled. The findings included: Review of the policy Medication Storage dated 04/02/22 documented, General Guidelines: a. All drugs and biologicals will be stored in locked compartments . 1) A wound care observation for Resident #109 was conducted on 10/26/22 at 1:54 PM, with the Wound Care Nurse, who gathered the supplies to include Dakins (a chloride type liquid) and Santyl (a debriding ointment). While gathering the supplies, Resident #99 stood next to the cart, talking to her stuffed animals. The Wound Care Nurse entered the residents room, leaving the treatment cart unlocked against the wall, with the drawers facing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-03-01 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to state in their admission Agreement (pg. 15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 100 out of 100 residents. The findings included: A review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement' was completed on 02/28/24. The separate 'Arbitration Agreement' and 'Arbitration Program Guide' contained all required regulatory language. However, within the admission Agreement (Agreement between the Facility and Resident/Representative) there is a paragraph on page 15 (Item #26) which states: WAIVER OF RIGHT TO JURY TRIAL. BY SIGNING THIS AGREEMENT RESIDENT AND RESPONSIBLE PARTY ARE WAIVING (A) THE RIGHT TO A JURY TRIAL FOR ANY CLAIM(S) BROUGHT HEREIN AND (B) INSOFAR AS THE ARBITRATION AGREEMENT IS EFFECTIVE ARE AGREEING TO ARBITRATE CLAIMS PROVIDED FOR THEREIN INCLUDING ANY AND ALL CLAIMS ARISING OUT OF OR RELATED TO THE FACILITY SERVICES…
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
$26,685 in federal fines across 1 penalty.
- $26,685 — penalty dated 2025-06-13
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 SOVEREIGN HEALTHCARE HOLDINGS — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.7 | -1.7 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.1 | +0.9 vs chain |
| Quality measures | 4 of 5 | 4.5 | -0.5 vs chain |
The other 42 homes this chain runs (chain average 3.7★, per CMS)
Showing 40 of 42; lowest-rated first.
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 | Since |
|---|---|---|---|
| SOVEREIGN HEALTHCARE HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2024 |
| CRONQUIST 2015 FAMILY TR | Organization | INDIRECT OWNERSHIP INTEREST | since 05/01/2024 |
| JOHN J NOTERMANN BUSINESS TR | Organization | INDIRECT OWNERSHIP INTEREST | since 05/01/2024 |
| MANGINE, JOHN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| BERKADIA COMMERCIAL MORTGAGE LLC | Organization | 5% OR GREATER SECURITY INTEREST | since 05/01/2024 |
| HEALTH SERVICES PROPERTIES LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 05/01/2024 |
| LWRE, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 05/01/2024 |
| BELL, CHARLES | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| CHERY, DAWN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| KAAR, SUSAN | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 05/01/2024 |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/05/2026 |
| CRONQUIST, ROYCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| MELTON, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| NOTERMANN, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| SPURLOCK, TANISHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/05/2025 |
| WATT, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/15/2025 |
| NOTERMANN, BRENDA | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 01/05/2026 |
| FORVIS MAZARS LLP | Organization | ADP OF THE SNF | since 01/01/2025 |
| SOVEREIGN HEALTHCARE DISBURSEMENTS LLC | Organization | ADP OF THE SNF | since 05/01/2024 |
| KELLY, MICHELLE | Individual | ADP OF THE SNF | since 05/01/2024 |
CMS files one row per role, so the 33 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105659. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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.