The Club At Lake Gibson

Location & what’s nearby

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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

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.

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.

47.7% 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 270 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 192 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 0.71 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 119.8 residents a day — about 100% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.18 hrs/resident/day on weekends vs 3.69 on weekdays — 14% thinner on weekends. RN hours go from 0.55 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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.

21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2026-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 record review, observations and interviews the facility failed to ensure adequate supervision and appropriate use of equipment to safely transfer one resident (#1) out of five residents reviewed for sit to stand transfers with the assistance of two staff members. Findings included:During an observation interview on 5/6/26 at 10:11 a.m., Resident #1 said Staff A, CNA, did not have assistance from another staff member when the injury occurred. She said Staff A, CNA, had difficulty maneuvering the sit to stand lift over the raised threshold ('hump') in the bathroom doorway and repeatedly repositioned the lift to move it over the threshold. Resident #1 said when she began sliding she informed Staff A, CNA, to call for assistance and the staff member continued to push the lift out of the bathroom She said as she continued sliding downward, she began yelling help. Staff A, CNA went to the doorway to request assistance. While Staff A, CNA was at the doorway, the resident slid from the [vendor3000] lift onto…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-05-08 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interviews, and policy review, the facility failed to ensure nursing staff were competent in using the sit to stand mechanical lift for one resident (#1) of five residents sampled.Findings Included:On 4/12/26 staff failed to review and follow Resident #1's care plans related to functional abilities and the resident slid from a [vendor 3000] sit to stand machine and sustained a fractured femur and dislocated shoulder.On 4/12/26 at approximately 8:00 p.m. Staff A, Certified Nursing Assistant (CNA) used the [vendor 3000] sit to stand mechanical lift to transfer Resident #1. Without asking for assistance from another staff member Staff A, CNA attached the transfer sling (used for support) to the lift, did not secure the standing sling (used to secure legs to knee pads) clip attachment around Resident #1's lower legs and transported the resident from the toilet to the resident's bed, approximately 28 feet. During the transport Resident #1 slid to the floor with both arms elevated above their head and r suspended in the transfer sling. As a result of the facility's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-12-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 observation, interview, and record review, it was determined the facility failed to 1.) ensure staff implemented training received related to usage of a transfer lift, which resulted in a fractured right arm for one (Resident #50) of seven residents reviewed for falls; and 2.) assess, document, and treat an staff/resident incident, which resulted in a right elbow skin injury for one (Resident #322) of thirteen residents reviewed for accidents. Findings included: 1. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease. Review of nurses' notes, written on 11/22/2022 at 1527 (3:27 p.m.), revealed the resident had been sent to the hospital due to a right arm dislocation. The note identified the resident as alert and oriented with a pain level of 10 out of 10. An additional nurse's note, identified as a late entry and dated and timed at 11/22/2022 at 1506 (3:06 p.m.), indicated the resident had been assessed by an RN (registered nurse)…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and prevention program to prevent the spread of infection was implemented by 1.) failing to use appropriate personal protective equipment (PPE) while performing care for three residents (#113, #49, and #84) on Enhanced Barrier Precautions on three (Upper 300 Hall, Lower 400 Hall, and Upper 400 Hall) of four facility Halls and 2.) failing to follow professional standards of practice for storage of respiratory equipment for one resident (#269) of four residents observed on respiratory therapy. Findings included: 1.) During an observation on 1/27/2025 at 11:23 AM, Resident #113 had an Enhanced Barrier Precaution (EBP) sign on the wall beside the room door and a storage container containing PPE, including masks, gloves, and gowns, beside Resident #113's door. Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA were observed in the resident's room standing on either side of the resident 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-30 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure 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 observations, interviews, and record review, the facility failed to ensure medications and biologicals were securely stored for one resident (Resident #43) of one resident sampled for medication storage. Findings included: On 1/28/2025 at 8:05 AM, in Resident #43's room, one tube of topical menthol analgesic was observed on the bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment was observed on the bedside nightstand. An interview was conducted with Resident #43 following the observation. Resident #43 stated he used the topical menthol analgesic for back pain and he used the Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment on his feet. Review of Resident #43's care plan, revision on 1/29/2025, read Observe resident taking his/her medications as needed to ensure proper storage and self administration of medication. Provide a lock box for resident to store medications PRN [as needed]. Obtain order from physician stating that resident is able to self administer medications. Provide education of proper storage of medications and monitor 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 reviews, the facility failed to administer medications in accordance with resident preference for one (#1) of three residents sampled for medication administration. Findings included: A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, pleural effusion, and asthma. Resident #1 was discharged from the facility on 9/30/2024. A review of Resident #1's medical record revealed the following orders: - An order, dated 9/11/2024 for Trelegy Ellipta 100-62.5-25 micrograms (mcg) aerosol powder, breath activated, give one inhalation by mouth in the morning for COPD/shortness of breath. The order was discontinued on 9/29/2024. - An order, dated 7/6/2024 for Trelegy Ellipta 100-62.5-25 mcg aerosol powder, breath activated, give one inhalation by mouth once daily. The order was discontinued on 7/6/2024. A review of Resident #1's progress notes…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-24 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to assess, maintain in a sanitary manner, and provide dressing changes for one (#5) of three residents with central intravenous (IV) catheters. Findings included: On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed and appeared to be alert and oriented to person and situation. An intravenous pole with pump was observed in the corner of the room, visible from the doorway. The resident confirmed having an intravenous site, holding up his right arm where a single lumen peripherally inserted central catheter (PICC) was observed. The woven outside portion of the dressing appeared to be worn and old, the transparent middle portion revealed an approximate quarter-size area of a dried red/black substance surrounding the catheter insertion site. One side of the woven portion of the dressing was no longer attached to the resident. The dressing did not reveal a date of when it was applied, the needless connector was not attached to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-24 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two (#5 and #7) of three residents sampled for Intravenous (IV) sites had Enhanced Barrier Precautions posted and Personal Protective Equipment (PPE) available nearby. Findings included: On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed. The observation revealed the resident had a single lumen peripherally inserted central catheter (PICC) inserted into the right upper extremity. The resident stated the PICC was due to having an antibiotic for a urinary tract infection (UTI) and had the IV site for at least a week. The observation revealed the door or entryway to Resident #5's room was not posted with Enhanced Barrier Precautions and the nearest available PPE was in front of room [ROOM NUMBER], 2 rooms away from the resident. On 10/23/24 at 9:44 a.m. an observation was made of Resident #7's doorway. The door or entryway to the room was posted for Enhanced Barrier Precautions and did not have available PPE. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-07-18 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medication was stored appropriately in three out of three medication carts audited and on two out of two units related to unlocked treatment cart, medication on the floor, and medication unlocked on medication carts. Findings included: An observation was conducted on 7/17/24 at 9:50 a.m. of a treatment cart at the end of the 300-hall sitting outside of a resident room. The nurse was inside the room, behind the privacy curtain. The medication cart had 2 intravenous medications and 1 topical medication sitting in the attached plastic side compartment that has no lock. No other staff were in the hall. The nurse, Staff E, Licensed Practical Nurse (LPN) exited the resident room and was interviewed at that time. The nurse said she brought the medications to her cart, and she was going to go hang them up. An observation was conducted on 7/17/24 at 12:27 p.m. of a treatment cart unlocked near the 300-unit nurses' station. No staff were at…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-12-02 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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, observations, and record reviews, the facility failed to provide nursing and related services that enabled residents to attain and maintain their highest practicable physical, mental and psychosocial well-being for seven (Residents #52, #59, #92, #321, #323, #26, and #50) of forty-four sampled residents related to call light response when assistance was required. Findings included: During an interview, the Director of Nursing (DON) stated, at 2:07 p.m. on 12/1/22, that a call light should not be shut off until the need was taken care of. On 12/1/22 at 2:22 p.m., during an interview with the Regional Director of Clinical Services (RDCS), DON, and Nursing Home Administrator (NHA), the RDCS and NHA stated the call light monitoring system did not allow for reports, (call light times) and could only be seen in real time. The RDCS stated she believed the facility would have to purchase that (reports) capability. An observation was conducted on 11/29/22 at 9:22 a.m., of a call light response…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-12-02 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection prevention and control standards were maintained related to 1.) two (Residents #49 and #68) diagnosed with scabies; 2.) cleaning and maintenance of shared resident care equipment for two (Resident #75 and one unidentified); 3.) hand hygiene during wound care procedures for one Resident #52); 4.) sanitary maintenance of respiratory care equipment for two (Residents #323 and #325); and 5.) sanitary maintenance of urine catheter drainage bags for three (Residents #326, #21, and #224) residents of forty-four sampled residents. Findings included: 1. On 11/30/22 at 8:20 a.m., an observation was made of a contact isolation sign posted on the room door of Residents #49 and #68. An interview was conducted at that time with Staff R, Licensed Practical Nurse (LPN.) Staff R stated Resident #68 had gone to a dermatologist on 11/29/22 and was determined to have scabies. A review of admission records indicated 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-12-02 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 reviews, and interviews the facility failed to ensure an accurate advance directive for code status based on the resident's expressed wishes for one resident (#323) out of forty-four sampled residents. Findings included: A review of the admission Record showed Resident #323 was admitted on [DATE]. The admission Record for the resident included diagnoses not limited to Chronic Obstructive Pulmonary Disease with (acute) exacerbation, acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, acute pulmonary edema, and subsequent non-ST elevation (NSTEMI) myocardial infarction. An electronic record review, on [DATE] at 3:38 p.m., identified Resident #323 wished to be a Full Code, identifying that in an emergency situation the resident had chosen for staff to initiate cardio-pulmonary resuscitation (CPR). A Social Service progress note, dated [DATE] at 12:38 p.m., indicated the Resident had signed a DNR (do not resuscitate) with hopes the MD (medical…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-12-02 · tag F0637 — isolated
  Assess the resident when there is a significant change in condition
  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 a review of the resident's Minimum Data Set Assessments, medical record, and facility policy on Hospice/Palliative/End of Life Care, and interview with facility staff, it was determined the facility failed to complete a significant change assessment when one resident (#16 ) of a total sample of 44 residents, chose the Hospice benefit. Findings included: Review of the admission Record revealed Resident #16 was initially admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with neuropathy and an above the knee amputation, rheumatoid arthritis, and chronic pain. A review of the resident's medical record revealed an order for Hospice care dated 08/29/2022. A Quarterly Minimum Data Set (MDS) Assessment was completed on 09/14/2022 which indicated the resident was on Hospice. A review of a list of all MDS assessments completed for Resident #16 did not reveal a significant change assessment to reflect the resident and Power of Attorney's decision to elect the Hospice benefit…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 26 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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 $753K 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 2024. 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, FY2024). 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