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Vivo Healthcare Lakeland

1919 Lakeland Hills Blvd, Lakeland, FL 33805 · For profit - Limited Liability company · 185 certified beds · (863) 688-5612 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Apr 20253 immediate-jeopardy citations$152,495 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $152,495 in federal fines (most recent 2025-02-28)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • about 29% of its spending goes to commonly-owned related companies

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1733 Lakeland Hills Blvd · (863) 688-1528 · Call to confirm hours
Pharmacy
1705 Lakeland Hills Blvd · (863) 272-7565 · Call to confirm hours
Grocery
1803 N Florida Ave · (863) 510-5026 · Call to confirm hours
Park
226 Oconee St · Typically dawn to dusk
Place of worship
1945 N Florida Ave · (863) 683-6781

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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.4%8.7%15.4%better
Long-stay residents who lose too much weight13.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms6.9%4.6%6.5%typical
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.1%2.5%3.3%worse
Long-stay residents whose ability to walk worsened4.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.5%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers7.0%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control10.2%10.5%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table5.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine94.8%94.7%79.4%better
Short-stay residents rehospitalized after admission19.9%26.1%22.6%better
Short-stay residents with an outpatient ER visit8.6%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days4.092.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.171.151.80better

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.

41.4% 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 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.4%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
53.4%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 53.4% 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 133 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.4%CMS range 30.9–53.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.1–16.610.7%Oct 2022–Sep 2024no 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 discharge53.4%56.6%Oct 2024–Sep 2025CMS 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 discharge50.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.6%50.0%Oct 2024–Sep 2025CMS 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 identified99.1%98.7%Oct 2024–Sep 2025CMS 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 setting95.1%100.0%Oct 2024–Sep 2025CMS 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 discharge98.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 3.7–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS 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

0.44
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.30
RN hoursweekends
41.5%
Total nursing turnover
61.3%
RN turnover

How full it usually is: this home is certified for 185 beds and averages 171.5 residents a day — about 93% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below 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 3.04 hrs/resident/day on weekends vs 3.60 on weekdays — 16% thinner on weekends. RN hours go from 0.49 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2025-06-26)
7
at the previous standard inspection (2023-03-02)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

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

  • Immediate jeopardy · J2025-04-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 protect the resident's right to be free from neglect for two residents (#1 and #2) out of five residents identified by the facility at risk for elopement, to prevent elopement. Serious harm occurred on 4/19/25, when Resident #1 was allowed to walk away from the facility unnoticed, walk along high traffic streets for eight miles, and end up on an Interstate Highway where he was found by the [State Highway Patrol]. Resident #1 was taken to a higher level of care for evaluation and treatment of dehydration. On 3/25/25 Resident #2 exited the facility through an emergency exit door and was found 10 -15 feet from the door walking away from the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/ or death to Resident #1 and resulted in the determination of Immediate Jeopardy occurring on 4/19/25. The findings of Immediate Jeopardy were determined to be removed on 4/30/25…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2025-02-28 · 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 Cross Reference F921 Based on observations, interviews, and record review, the facility failed to provide supervision and failed to prevent accident hazards to prevent a fall with injury for one resident (#6) of 19 ambulatory residents in the memory care unit. The facility failed to replace a clean-out drain located in a high traffic area of the facility's memory care unit and failed to promptly and effectively address flooring issues, resulting in an unsafe walkway, where Resident #6 tripped and fell. On 1/20/2025, Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk independently and complete Activities of Daily Living (ADLs) at her prior functional level. The resident suffered a significant change due to a fractured right femoral head requiring a surgical intervention of a right hip arthroplasty. The facility's failure to provide supervision and prevent accident hazards caused serious harm and injuries to Resident #6 and placed 18…

    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
  • Immediate jeopardy · J2025-02-28 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Cross Reference F689 Based on observations, interviews and record reviews, the facility failed to provide a safe environment, free from flooring hazards for staff, the public, and 19 ambulatory residents in the facility's secure memory care unit. One (Resident #6) of the 19 ambulatory residents fell on 1/20/2025, sustained a fracture to the right femoral head (top of thigh bone), required a transfer to a higher level of care, and surgical intervention due to a floor repair that was not completed by the facility. The injuries to Resident #6 caused a significant decline in her ability to ambulate and complete activities of daily living (ADLs) at her prior functional level. The facility's failure to maintain a safe walking environment caused serious injury and harm to Resident #6 and placed 18 additional ambulatory memory care residents, staff, and visitors at risk for serious injury, harm, and/or death. This failure resulted in the determination of Immediate Jeopardy on 1/20/25. The findings of Immediate Jeopardy…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure dental services were provided for one resident (#1) out of one resident sampled for timely dental care. Findings included: On 3/26/2026 at 10:33 A.M. an interview was conducted with Resident #1 who stated receiving dental care at the facility was always a big issue. Resident #1 stated their mouth feels weird and that the resident had told the facility numerous times. Resident #1 stated he had seen the dentist one time and never after that. Resident #1 said, Yes, I have ongoing dental problems with dental pain when I eat. Resident #1 stated he mainly eats soft stuff to accommodate the discomfort. Resident #1 stated there was an issue with scheduling his dental appointments and that the facility stated it was due to insurance or paperwork. The resident stated they had to start initiating his appointments because with the facility takes forever. The resident said once the appointments are scheduled at the last minute his appointments are…

    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 · E2025-06-26 · 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 observation, interviews, and record review the facility failed to follow sanitary infection control practices related to 1) proper storage and disposal of toileting items in two resident rooms (112 and 110), 2) proper nail length for three staff members (Staff P, Staff M, Staff Q), 3) and proper hand hygiene during meal service for one observed meal (6/23/25) during four days of survey. Findings Included: 1. During an observation on 06/23/2025 at 11:10 a.m., of room [ROOM NUMBER] B a plastic urinal was located opened on floor under the bed, with a wet area. During an observation on 06/23/2025 at 11:04 a.m., of room [ROOM NUMBER] bathroom an adult brief with yellow and brown markings was located in front of the toilet on the floor. (photographic evidence obtained) 2. During an observation on 06/23/2025 at 9:44 a.m., Staff P, Registered Nurse (RN), was observed with artificial nails longer than 1/4 inch. During an observation on 06/23/2025 at 9:43 a.m., Staff M, RN was observed with artificial nails…

    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 · D2025-06-26 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation from the hallway on 06/24/2025 at 9:46 a.m., Resident #146 was observed sitting up on the side of his bed with his legs hanging off, sleeping. Resident #146 was observed to have on a white T-shirt and a brief. Review of Resident #146's admission record revealed and admission date of 03/19/2025. Resident #146 was admitted to the facility with diagnosis to include Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Other Lack of Coordination, Major Depressive Disorder, Recurrent, Moderate, Mood Disorder Due To Known Physiological Condition with Mixed Features, Unspecified Dementia, Unspecified Severity, With Mood Disturbance. Review of Resident #146's Quarterly Minimum Data Set (MDS), dated [DATE] revealed, Section C-Cognitive Patterns had a Brief Interview Mental Status (BIMS) of 06 out of 15 indicating severe cognitive impairment. During an interview on 06/25/2025 at 5:47 p.m., Staff O, Certified Nursing Assistant (CNA), stated residents should be treated with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a homelike environment for four resident rooms (Rooms # 407, 422, 429) out of eight rooms sampled and failed to store equipment appropriately in one out of two shower rooms. Findings include: During a facility tour conducted on 6/23/2025 at 11:00 a.m., room [ROOM NUMBER] was observed with pictures hanging off the wall over a resident bed. room [ROOM NUMBER] observed with a high-rise seat positioned over the toilet in the resident's bathroom with dirty tape attached to the seat. room [ROOM NUMBER] was observed with torn, unfinished dry wall behind a resident's bed. During an observation made on 6/23/2025 at 11:00 a.m., one of two shower rooms was used as a storage room to store a bed, walker, and reclining chairs. An interview was conducted on 6/26/2025 at 8:45 a.m., with Staff T, Registered Nurse, RN/ Unit Manager. Staff T stated she has worked at the facility for 4 years. She stated she did not know why equipment was stored in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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, and record review, the facility failed to ensure alleged resident to resident violations were reported to the governing agency in accordance with the State law for one (Resident #28) out of two residents sampled. Findings include: On 06/23/2025 at 2:08 P.M. an observation of Resident #28 revealed she had a dark purple and bluish area around her left eye. A review of Resident #28's admission Record showed she was admitted to the facility on [DATE] with diagnoses including but not limited to Anoxic Brain Damage, Autistic Disorder, Chronic Pain Syndrome, and Aphasia. A review of Resident #28's Minimum Data Set (MDS), Section C, dated 3/30/2025 revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A review of a Change in Condition Assessment for Resident #28 dated 6/17/2025 revealed, swelling and bruising noted around left eye with intervention of X-Ray of left side of face, ice as needed. A review of the Facial X-Ray for Resident #28…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated for two residents (#69, #141) out of twelve residents sampled for PASRR. Findings include: 1. A review of Resident #69's admission Record revealed he was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Secondary diagnoses included mood disorder, major depressive disorder and insomnia. Review of the Level I PASARR, dated 03/24/2025 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II…

    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
  • Potential for harm · Dcited before2025-06-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet goals and address the resident's medical, physical, mental and psychosocial needs for three residents (#363, #28, and #49) out of thirty five residents sampled. Findings include: 1. On 6/24/2025 at 9:57 A.M., Resident #363 was observed with both legs over the right side of his bed. The bed was in a high position where the resident's feet were dangling in the air. The floor on the right side of his bed contained a bedside table, an overflowing trash can, a tied-up bag full of linens, and three wheelchair footrest adapters. There were no staff around the room at this time. An unknown staff member came to the resident's room, and she stated, I left the room to find someone to help her transfer him into the wheelchair. On 6/26/2025 at 11:21 A.M., Resident #363 was observed with both legs over the right side of his bed again. The bed was in a lowered position where his…

    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
  • Potential for harm · D2025-06-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide Activities of Daily Living (ADL) for two residents (#154) related to removal of facial hair and (#367) related to showers out of four residents sampled for ADL. Findings Included: 1. During an interview on 06/23/25 at 11:10 a.m., Resident #154 was observed with long white strands of hair on her lip and chin. Resident #154 stated I wish they would help me pluck this hair off of my face. Review of Resident #154's admission record revealed an admission date of 05/21/2025. Resident #154 was admitted to the facility with diagnosis to include Need for Assistance with Personal Care, Neuromuscular Dysfunction of Bladder, Unspecified, Colostomy Status, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites and Multiple Sclerosis. Review of Resident #154's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) of 14 out of 15 showing intact cognition. Review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, interviews and record review the facility failed to provide nursing care and services related to 1) failure to schedule appointments for one (Resident #134); and 2) failure to administer medications in a timely manner for two (Resident #106 and Resident #90) out of 35 residents sampled. Findings Included: 1. During an interview on 06/25/2025 at 9:13 a.m., Resident #134 stated he had a catheter, but they recently removed it. He stated he had not seen a Urologist. During an interview on 06/25/2025 at 9:56 a.m., Resident #134's Family Member (FM) and emergency contact stated Resident #134 was referred to see a Urologist at the beginning of June, but has never been told if it was scheduled. The FM stated, the resident saw a Neurologist because he recently started having what she believed to be seizures when he sits up in bed. The Neurologist ordered a imaging exam (MRI) and the test has not had done. I have asked the doctor and the nurses about scheduling the MRI with sedation because he is…

    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 before2025-06-26 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure side effect monitoring was in place for one resident (#141) out of five residents sampled for unnecessary medications. Findings include: A review of Resident #141's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include dementia, psychotic disorder with delusions, mood disorder, major depressive disorder and generalized anxiety disorder. A review of Resident #141's Order Summary Report revealed the following orders: - Divalproex Sodium Oral Tablet Delayed Release 250 milligram (MG) (Divalproex Sodium) Give 3 tablet by mouth three times a day for bipolar disorders, seizures - OLANZapine Oral Tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for Bipolar Disorders - Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for HTN [hypertension] - Potassium Chloride ER [extended release] Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · Dcited before2025-06-26 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-eight medication opportunities were observed, and two errors were identified for one resident (#133) out of six residents observed. These errors constituted a 7.14% medication error rate. Findings included: On 06/25/25 at 9:31 a.m. an observation was made of Staff F, Registered Nurse (RN). Staff F dispensed the following medications for Resident #133. -Losartan 100 milligram (mg) tablet -Lidocaine patch -Zonisamide 100 mg tablet -Nifedipine 60 mg capsule -MiraLAX powder Staff F began by dispensing one Losartan 100mg tablet into a small medicine cup. The staff member then poured an unidentified amount of MiraLAX into the same small medicine cup. She stated it is about a capful of MiraLAX and that's how much they give. Staff F then poured the powder and Losartan tablet from the small medicine cup into a larger drinking cup. The staff member then pulled an additional Losartan 100mg tablet and placed it into a separate empty medicine cup. The other two…

    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 · D2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure 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 record review, observation and interviews, the facility failed to ensure food was properly stored and free of expired food(s) for residents in the kitchen. Findings included: During an observation on 06/23/2025 at 9:38 a.m., of the Walk in Freezer revealed 4 boxes with a red label and writing Tyson; A brown box with a red label, and black writing Keep frozen 0°F-10°F; 2 brown boxes with red writing Frozen Cookie Dough; A brown box with black writing; A bag of ice; A white container with green and red markings; A clear container with purple writing; Unidentifiable debris. (photographic evidence obtained) During an observation on 06/23/2025 at 9:42 a.m., of the Walk in Fridge, revealed A brown box with a clear bottle with a green liquid, a yellow rag, and white bags; A brown cardboard box with wrinkled green bell peppers with gray and black bio growth; A tan 4 wheeled cart with an open green tabbed can; A box of tomatoes with yellow string particles; A silver container labeled boiled eggs with the plastic wrap ripped; A white bucket with an open green lid labeled pickles with…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-30 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an effective performance improvement plan to prevent the elopement of one resident (#1) out of five residents identified by the facility at risk for elopement. Findings included: 1. A review of Resident #2's admission record revealed an admission date of 11/5/23 with the following diagnoses: Heredity and idiopathic neuropathy, asthma with status asthmaticus, protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), mood disorder, major depressive disorder, and dementia. A Review of Resident #2's Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of is 0 indicating severe cognitive impairment. A review of Section E-Behavior showed wandering behavior has occurred 1-3 days. A review of Resident #2's Care Plan, dated 4/21/25 showed the following: Focus area of elopement/wanderer r/t History of…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-28 · tag F0583 — failed to protect personal privacy — widespread
    Keep residents' personal and medical records private and confidential.
    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 of videos posted on social media platforms without consent, review of resident records, policy and procedures review, and staff, family and resident interviews, the facility did not ensure personal privacy and confidentiality for ten of sixteen sampled residents (#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16). Findings Included: Review and observation of videos posted on social media platforms on 8/8/24, 10/2/24, 10/8/24, 12/2/24, and additional dates that could not be determined showed Resident #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 dancing or in the background of the videos, which also contained various staff members. These videos were recorded in various locations within the facility to include the secure memory care unit and hallways with room numbers where residents resided. Review of the social media videos showed they were originally posted by Staff I, Admissions Coordinator and had been reposted and edited by an unknown number of users on social media. Multiple videos…

    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 · Dcited before2025-02-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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 interview and policy review the facility failed to ensure an allegations of neglect were reported related to a fall with major injury due to the facility's failure to ensure a safe environment, free from flooring hazards for one resident (#6) of 19 ambulatory residents in the facility's memory care unit. Findings included: Review of a progress note dated 1/20/25 at 12:43 p.m. revealed the resident had an unwitnessed fall in the hallway this A.M. Resident (#6) was observed lying on right side and crying out in pain to lower back and right leg. On 1/20/25 Resident #6 was ambulating in the hallway outside her room and suffered a fall significantly impairing the ability to walk and complete Activity of Daily Living (ADLs) independently. Resident #6 suffered a significant change due to a fractured right femoral head fracture requiring a surgical intervention. The fall which could have resulted in death, caused Resident #6 permanent physical impairment. Review of the Reportable Event Log, dated 1/2024,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure documentation was accurate and complete for one (#4) of one resident related to the documentation of a change in condition resulting in cardio-pulmonary resuscitation (CPR) being administered. Findings included: Review of Resident #4's admission Record revealed the resident was most recently admitted to the facility on [DATE]. The record included diagnoses of idiopathic hypotension, acute respiratory failure with hypoxia, unspecified pulmonary hypertension, paroxysmal atrial fibrillation, unspecified heart failure, and dependence on supplemental oxygen. Review of Resident #4's clinical record showed a Hospital Transfer Form, dated 1/29/25 at 1:40 p.m. showed the resident was a Full Code. Review of a Situation, Background, Appearance, and Review/Notify (SBAR) assessment dated [DATE] at 9:37 a.m. showed notification to the provider of resident change in condition related to food and/or fluid intake (decreased or unable to eat and/or drink adequate…

    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
  • Potential for harm · E2024-06-05 · tag F0573 — pattern
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    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 provide one (Resident #3) of one family-requested medical record in a timely manner. Findings included: Review of Resident #3's medical record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified Alzheimer's disease, unspecified peripheral vascular disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified edema. An interview was conducted on 6/4/23 at 12:30 p.m. with the Medical Records Director (MRD). The MRD reported only one family member had requested medical records and the request had been made on July 28, 2023. The staff member reported sending the attorneys Resident #3's face sheet and death certificate and did not get a response from them for two or three months. The MRD reported speaking to the Business Office Manager about general matters and had been informed the attorneys had not been getting paid (the facility was sold at the end of June 2023). She stated 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to ensure physician-ordered laboratory tests were completed for one (Resident #6) of three residents sampled for diagnostic laboratory testing. Findings included: An observation and interview were conducted with Resident #6 on 6/4/24 at 2:07 p.m. The resident stated the provider had informed him that blood work was going to be done but it had not been done. The resident reported being told about the laboratory testing a couple weeks ago and again last week. Review of a provider note, dated 5/24/24, revealed the plan for Resident #6 included to obtain a weekly Creatinine level, status post renal transplant, and to avoid nephrotoxic agents including Diuretics. Review of a provider note, dated 5/30/24, showed the resident was seen to follow up on Physical Therapy/Occupational Therapy and ultrasound results. The provider's plan was for Vitamin B12/Folate Levels with next blood draw. Review of a provider note, dated 5/31/24, revealed Resident #6 was seen by the provider while sitting in a wheelchair and complained…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-02 · tag F0644 — widespread
    Coordinate 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, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for four (Residents #22, #67, #64, and#126); and 2.) ensure the accuracy of a PASRR Level I for six residents (#68, #130, #74, #98, #114, and #115) admitted with mental health diagnoses of fifty-four sampled residents. Findings included: 1. A review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of dementia, schizoaffective disorder, and major depressive disorder. A diagnosis of epilepsy was added to Resident #22's medical record on 9/26/2020. A review of Resident #22's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/4/2023 revealed under Section I - Active Diagnoses, Resident #22 had diagnoses of non-Alzheimer's dementia, seizure disorder or epilepsy, depression, and schizophrenia. A review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-02 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure timely meal service in one (400 unit) of four units for eleven (Residents #91, #102, #127, #116, #48, #37, #113, #33, #94, #29, and #14) of fifty four sampled residents. Findings included: On 2/27/2023 at 12:00 p.m., a tour of the 400 unit, consisting of two halls, (rooms 401 - 413, and 414 - 430) was conducted. The wall across from the nurses station, and next to the nursing assignment board was a framed sheet of paper that indicated all three meal service times. The sheet of paper indicated the following: Meal Service times 400 hall (Breakfast 7:30 a.m. until 8:15 a.m.; Lunch 11:30 a.m. until 12:15 p.m., Dining room open at 11:30 a.m., Dinner 4:30 p.m. until 5:15 p.m. Dining room open at 4:30 p.m. Photographic evidence was obtained On 2/27/2023 at 12:42 p.m. the first lunch tray cart arrived on the floor for rooms 414 - 430. All but two residents who resided on this unit ate in their rooms. Two staff members took the trays from the cart and passed and set up meals to residents while in their rooms.…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for three (Resident #114, #126, and #135.) of thirty-two sampled residents Findings included: 1. An observation on 02/28/23 at 5:45 PM, showed Resident #126, who resided on the 100 hall, wandering down the 400 hallway. During an interview on 02/28/23 at 5:45 PM, the Regional Nurse Consultant (RNC) identified Resident #126 as a wanderer and stated, he always stays on his path. A review of the facility's documentation revealed an Elopement Book which identified Resident #126 as an elopement risk. Photogenic evidence was obtained. An observation on 03/01/23 at 11:55 AM, showed Resident #126 wandering down the 400 hallway. A record review of Resident #126's medical record showed a care plan with a focus of potential for elopement with exit seeking thoughts that was initiated on 12/09/22. The interventions put in place were to include Resident #126 in the Elopement…

    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
  • Potential for harm · D2023-03-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, interview, and record review, the facility failed to ensure Care Planning problem areas to include 1. Advance Directives/Code Status, and 2. Utilization of Hospice services were reflective of the residents' current medical state and choices, for one (Resident #100) of fifty-four sampled residents. Findings included: On [DATE] at 2:02 p.m., [DATE] at 7:45 a.m., and [DATE] at 8:50 a.m., Resident #100's was visited. She was observed in her room all three times lying in bed, under the covers, and with her eyes closed. The call light was within her reach and she was not presenting with any behaviors, pain or discomfort. Room appeared generally clean and maintained. Resident #100 was not interviewable. A review of Resident #100's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE] for long term care services. A review of the diagnosis sheet revealed diagnoses to include but not limited to Seizures, Dementia, Intellectual disabilities, and Anxiety. A review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to monitor for possible behaviors and side effects related to the use of psychotropic medications for three (Residents #22, #23, and #67) of eight residents reviewed for psychotropic medication use. Findings included: 1. A review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, major depressive disorder, and dementia. A review of Resident #22's physician's orders revealed an order dated 1/13/2023 for quetiapine fumarate 25 milligrams (mg) by mouth at bedtime for a diagnosis of schizoaffective disorder. Resident #22's physician's orders also revealed an order dated 6/6/2022 for target behavior monitoring for Seroquel (quetiapine fumarate) for behaviors of visual/auditory hallucinations, combativeness, and agitation every shift for need of medication monitoring. Indicate number of times behavior observed; number code for intervention used;…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-02 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication administration error rate of less than five percent. A total of twenty-six medication administration opportunities were observed with six errors for two (Residents #120 and #19) of four residents sampled for medication administration, which resulted in a medication administration error rate of 23.08%. Findings included: A review of Resident #120's physician's order revealed the following orders: - An order, dated 4/7/2022 for Cetirizine Hydrochloride (HCl) 10 milligrams (mg) by mouth one time a day with an administration time of 8:00 AM. - An order, dated 4/7/2022 for Lisinopril 5 mg by mouth one time a day with an administration time of 8:00 AM. - An order, dated 8/22/2022 for oxybutynin chloride 10 mg by mouth two times a day with administration times of 8:00 AM and 4:00 PM. - An order, dated 10/18/2022 for Depakote 125 mg by mouth two times a day with administration times of 9:00 AM and 9:00 PM. An observation of medication administration was conducted on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-02 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 interview, the facility failed to ensure residents were provided with dietary meals and food items of their choices for two (Residents, #102, and #29) of fifty-four sampled residents . Findings included: On 2/27/2023 at 9:40 a.m., Resident #102 was visited while in her room. She was observed in a private room and was lying in bed with the HOB (head of bed) at approximately 45 degrees. Resident#102 agreed to an interview and revealed she had been having problems with her meals to include: 1. Food does not taste good, 2. Vegetables are overcooked to mush, 3. Meal service is always late and does not like to eat so late for each meal service., and 4. Meal service is always late and not at times she and other prefers. The resident still had her breakfast tray on her over the bed table. She revealed she had spoken to various staff as well as other residents have done the same. She revealed the staff would not listen to them and would not serve them any earlier. An observation…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one of thirty-one sampled residents (#5), who required the use of foot boots/splints while in bed, were implemented per the care plan during four of four days observed (6/8/2021, 6/9/2021, 6/10/2021, and 6/11/2021). Findings included: On 6/8/2021 at 9:40 a.m. resident #5 was observed in her room and seated in a w/c (wheel chair) and watching television and/or reading. No immediate concerns were observed. At 10:15 a.m. resident #5 was in her room and seated in bed upright and with the over the bed table placed next to her. Resident #5 was observed with a thin sheet covering her upper legs and lap. Further observations revealed her feet were not covered by the sheet and her bare feet were exposed. There were no splints/soft boots observed on either feet. Further, feet were not propped up on any type of pillow. The same observation was made with resident not wearing any feet splints/soft boots, while in bed at 2:14 p.m. There were no…

    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
  • Potential for harm · D2021-06-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observations, record reviews, and interviews the facility failed to ensure one (#53) out of one resident sampled for pressure ulcers received wound care in a sanitary manner. Findings included: The admission Record for Resident #53 indicated that the resident was initially admitted on [DATE] and more recently on 5/19/21. The record included diagnoses not limited to unstageable pressure ulcer of sacral region, stage 4 pressure ulcer of left buttock, and dependence on renal dialysis. The 5-day Minimum Data Set, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognition. The MDS indicated that Resident #53 had one stage 3 pressure ulcer and two stage 4 pressure ulcers. An observation was conducted, on 6/10/21 at 10:20 a.m., of Staff Member G, Licensed Practical Nurse (LPN) performing wound care for Resident #53's three pressure ulcers. The LPN placed a paper towel barrier on the over-the-bed table, returned to the treatment cart, placed a couple of 4x4…

    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 before2021-06-11 · 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 observations, interviews, and record reviews the facility did not ensure accident hazards were addressed to prevent bruising to a resident's legs for 1 (Resident #30) out 6 residents sampled in hall 400. Findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses to include history of falling, Parkinson's disease, Type 2 diabetes, Unspecified Dementia without behavioral disturbance and peripheral vascular disease. During a facility tour on 06/08/21 2:29 p.m., Resident #30 was observed in room lying in bed. Resident #30 did not respond to questions as to whether he was in pain. On 06/09/21 09:59 a.m., Resident #30 was observed in bed, bed noted high, leaning to the left. his left arm heavily bruised. A review of the admission MDS (minimum data set) dated 03/20/21 revealed: Section C: BIMS (brief interview for mental status) 05 indicating severe cognitive impairment. Section D: Resident did not have any documented concerns with mood, feelings of sadness or trouble sleeping.…

    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 · D2021-06-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 1 (Resident #45) of 33 sampled residents had a urinary catheter and catheter tubing properly positioned for 3 of 4 observations made from 6/9/2021 to 6/11/2021. Findings included: On 6/9/2021 at 12:19 pm resident #45 was observed in his wheelchair (without footrests) between rooms [ROOM NUMBERS] approximately 3-4 inches of the catheter tubing was observed hanging down and dragging on the floor under resident #45's wheelchair. On 6/10/2021 at 7:09 am resident #45 was observed asleep in bed with his catheter bag lying on the floor on the right side of the bed, at that time staff H, Social Services Director entered the room and moved the Catheter bag from the floor on to the mattress of resident #45's bed. On 6/10/2021 at 2:48 pm resident #45 was observed in the hallway outside his room facing towards his room door. Resident #45 was seated in his wheelchair and resident #45's catheter bag was on the floor approximately 6 inches from…

    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 · D2021-06-11 · 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, record reviews, and interviews the facility failed to store medications properly in three (400-1, 300 hall, 100-3) out of seven medication carts and one (400 Hall) out of five medication storage rooms regarding unlocked medication carts, lack of refrigeration when needed, food items stored in the medication refrigerator, items not labeled with an open date and expired medications. Findings included: On 6/10/21 at 12:23 p.m., an observation was conducted with Staff Member E, Licensed Practical Nurse (LPN), of the 400-1 medication cart. The cart contained an unopened bottle of Latanoprost in a clear bag labeled from the pharmacy. The pharmacy label identified that staff were to store the unopened bottle of Latanoprost in the refrigerator. Staff E stated that the Latanoprost was delivered today and had been kept out because the other bottle for the same resident was empty. She reviewed the opened bottle of Latanoprost and determined that it still had 2-3 doses left in it. Photographic evidence obtained. On 6/10/21 at 12:40 p.m., Staff Member E reviewed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-11 · tag F0925 — failed to control pests — isolated
    Make 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, facility file review and staff interviews, the facility failed to ensure their pest control company was effective in keeping two of thirty resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) in hallway 400 free from live ants. Findings include: During a facility tour on 06/09/21 02:15 p.m., live ants were observed crawling on resident #30's bed, approximately 10 small black ants. An immediate follow up was conducted with Staff K, LPN. Staff K made the observation and stated, that is not good we have to get resident #30 out of that bed right away. An immediate room inspection was conducted in room [ROOM NUMBER]. Ants were noted crawling on bed (mattress and sheet), window seal, bedside table, and privacy curtain. Food remnants (green peas) were noted on the floor by the corner of the air conditioning unit. A jar of fish was observed on the table, noted to have bio growth inside the bottle. Rooms 420 to 430 were inspected to rule out infestation. room [ROOM NUMBER], located next 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.

    Environmental 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$152,495 in federal fines across 12 penalties. 1 Medicare payment denial on record.

  • $8,672 — penalty dated 2025-02-28
  • $8,673 — penalty dated 2025-02-28
  • $84,692 — penalty dated 2025-02-28
  • $4,587 — penalty dated 2023-11-13
  • $4,587 — penalty dated 2023-11-06
  • $4,587 — penalty dated 2023-10-30
  • $4,587 — penalty dated 2023-10-23
  • $4,587 — penalty dated 2023-10-10
  • $4,587 — penalty dated 2023-10-02
  • $13,762 — penalty dated 2023-09-11
  • $4,587 — penalty dated 2023-08-28
  • $4,587 — penalty dated 2023-08-21
  • Medicare payment denial — starting 2025-04-05 for 46 days

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 VIVO HEALTHCARE — 12 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 →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 1 of 51.9-0.9 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 11 homes this chain runs (chain average 2.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PALM TERRACE J DEK OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/31/2016
ALLEGIANT HEALTHCARE OF FLORIDA LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
ASMSY LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
IRVING LANGER 2014 FAMILY TRUST U/T/AOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
SOLOMON VIZCAYA HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
ZAIDYS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
FEIN, ARIELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
GOLDNER, SAMUELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
KARMEL, JACOBIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/16/2017
BENTZ, BRIANIndividualW-2 MANAGING EMPLOYEEsince 11/16/2017

6 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.

$15.1M
Net patient revenuemost recent cost report
-17.9%
Operating marginrevenue minus expenses
$5.1M
Related-party expense29% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 7%Other / private 19%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $5.1M paid to related parties — landlords or management companies under common ownership — equal to about 29% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$353per resident / day
operating cost
$10,728per month
≈ monthly operating cost
$299per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

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 105354. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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.

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