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Palms Care Center And Rehab

3370 NW 47th Terrace, Lauderdale Lakes, FL 33319 · For profit - Corporation · 120 certified beds · (954) 733-0655 Medicare & Medicaid certified

Call the home — (954) 733-0655 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)$11,517 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $11,517 in federal fines (most recent 2024-10-24)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4900 W Oakland Park Blvd · (954) 735-7550 · Call to confirm hours
Pharmacy
3099 N State Road 7 · (954) 485-9161 · Call to confirm hours
Grocery
Aldi0.5 mi
3301 N State Road 7 · (855) 955-2534 · Call to confirm hours
Park
4300 NW 36th St · (954) 535-2835 · Typically dawn to dusk
Place of worship
4699 W Oakland Park Blvd · (954) 735-1500

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 rating3★
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 increased2.8%8.7%15.4%better
Long-stay residents who lose too much weight7.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%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 symptoms3.9%4.6%6.5%better
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 injury0.2%2.5%3.3%better
Long-stay residents whose ability to walk worsened1.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.7%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers6.4%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control0.8%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.9%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine97.6%94.7%79.4%better
Short-stay residents rehospitalized after admission29.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit9.2%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.362.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.961.151.80better

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.

37.2% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.2%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 80.0% 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 40 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 57% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 SNF37.2%CMS range 24.3–53.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.6–13.610.7%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 discharge80.0%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 discharge82.5%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 discharge60.0%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 identified100.0%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 setting97.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%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 hospitalization9.1%CMS range 6.0–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.361.02Oct 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

0.72
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.54
Total nurse hours/ resident / day
0.64
RN hoursweekends
16.7%
Total nursing turnover
10.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 114.6 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.25 hrs/resident/day on weekends vs 3.65 on weekdays — 11% thinner on weekends. RN hours go from 0.76 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below 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

10
deficiencies at the latest standard inspection (2024-10-24)
7
at the previous standard inspection (2023-08-17)

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.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2024-10-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike interior for 3 of 3 residential units (200, 300, and 400), the Skilled Therapy Department, the Main Dining Room, the Activity Room, and the Main Lobby. The findings included: During the tour conducted on 10/21-22/24, resident meal observations conducted on 10/21-23/24, routine resident observations conducted on 10/21-23/24, and the environment tours conducted on 10/23-24/24 accompanied with the Corporate Maintenance Director, the Maintenance Director, and the Director of Housekeeping, the following were noted: 200 Resident Unit: room [ROOM NUMBER]: Room windows soiled, and window screens torn and in disrepair. room [ROOM NUMBER]: Room windows soiled, and window screens torn and in disrepair. 300 Resident Unit: room [ROOM NUMBER]/#302/#304: main hallway outside of rooms and inside of rooms noted pervasive and offensive body…

    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 · Ecited before2024-10-24 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that its Cycle menus (#1, #2, #3, and #4) met the nutritional requirements for daily milk / dairy servings and that the approved menu was being followed for potentially 105 of 113 facility's residents. The findings included: 1. During the review of the current Cycle menu in use (Cycle #3) on 10/21/24, it was noted that only 8-ounces on milk / dairy was being served to residents on a daily basis. An interview conducted with the Corporate Dietary Manager (CDM) at the time of the review to review documentation of why the facility menus did not include the required 16-ounces of milk per day to the residents (55 years or older). The surveyor specifically requested the government tool utilized to develop the facility's cycle menu. On 10/22/24, the CDM submitted to the surveyor a nutritional tool utilized for the development of the menus to be nutritionally adequate, and stated that an approved government tool was not utilized. Further interview and review noted an Optima Solutions Menu Template Nutrition…

    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 · E2024-10-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses for 110 of 113 residents. The findings included: 1. During the initial tour of the Main Kitchen on 10/21/24 at 9:30 AM, and accompanied by the Dietary Director, CDM (Certified Dietary Manager), the following was observed and noted: a. The walk-in refrigerator contained 2 expired items. The Marmalade was dated 10/11/24. The Chicken Broth was dated 09/25/24. b. The dishwasher was a low temperature dishwasher. The rinse temperature reached 140' F. The sanitization of the dishware depended upon the adequacy of the sanitizing solution. The Dietary Director, CDM, was asked to perform a chlorine sanitizer test to determine if the sanitizing solution was adequate to sanitize the dishware. The first test strip was dipped into the dishwasher solution, and it did not change color. A second test strip trial was performed and again the test strip did not change…

    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 · E2024-10-24 · tag F0925 — failed to control pests — pattern
    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 observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pest (flies and roaches). The findings included: 1. During resident screenings and routine observations conducted on 10/21/24 through 10/24/24, numerous sightings of flying insects were noted by the surveyors that included the following: a. On 10/21/24 - Main Kitchen (7, 9 AM), 300 and 400 Units, and Main Dining Room (12:30 PM). Staff stated that flies and roaches are a common daily occurrence. b. On 10/22/24 - Main Dining Room (8 AM) and in resident Hallways (8 AM - 10 AM). Staff and residents stated that flies are a common daily occurrence. c. On 10/23/24 - Main kitchen (7 AM) and the resident Hallways (300 and 400 Unit). Staff stated that flies are a daily common occurrence. d. On 10/24//24 - Main Dining room [ROOM NUMBER] AM and 12 PM, the resident Common Areas, and the resident Hallways (200, 300, and 400 Units). Photographic Evidence Obtained of above. 2.…

    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 · D2024-10-24 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for 2 of 2 sampled residents, Residents #23 and #97, who were to receive the restorative dining program; and failed to maintain the residents' ability to communicate and to participate in activities of daily living (ADLs) for 1 of 1 sampled resident, Resident #82, The findings included: 1. Review of the clinical record of Resident #23 on 10/22-23/24 noted a readmission date of 07/30/24 with current diagnoses of Alzheimer's Disease and Dementia. Review of the current physician orders included: On 12/04/23, Mechanical Soft Diet / Fortified Foods and Med Pass 2.0 - 120 ml Every Day, and Restorative Dining Program - Breakfast & Lunch Meals 7 days per week. Review of the resident's weight history documented a current weight of 100 pounds, occurring weight loss, and a BMI (Body Mass Index) of 18.5, indicating the resident was underweight / malnourished. Review of the current care plan dated 10/01/24 documented:…

    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 · D2024-10-24 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 provide appropriate services to promote and maintain the highest practicable mental and psychosocial well-being for 1 of 1 sampled resident reviewed for Paranoid Schizophrenia (Resident #90). The findings included: Review of the facility's policy, titled, Behavioral Health Services, undated, included the following: Policy Interpretation and Implementation: 2. Residents who exhibit signs of emotional / psychosocial distress receive services and support that address their individual needs and goals for care. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] and re-admission on [DATE] with the following diagnoses: Paranoid Personality Disorder, Delusional Disorders, Anxiety Disorder, and Paranoid Schizophrenia. Review of Section C of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 3 of 6 sampled residents reviewed for psychotropic medications (Residents #90, #89, and #59). The findings included: Review of the facility's policy, titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, included the following: Policy Statement 1.The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 6.The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Management 1.The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly.…

    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 before2024-10-24 · 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 observation, interview and review of policy and procedure, the facility failed to ensure that residents medications were properly stored as evidenced by medications being left on the resident's night stand for 1 of 1 sampled residents, Resident #26; and one opened bottle of Mucus Relief and one opened box of acetaminophen suppositories, over the counter medications (OTC), observed in the medication room cabinet for 1 of 2 medication storage rooms. The findings included: Review of the facility's policy, titled, Medication Labeling and Storage, revised 02/2023, provided by the Regional Nurse, documented, in part, The facility stores all medications .in locked compartments .the nursing staff is responsible for maintaining medications storage .in a clean, safe and sanitary manner medications are stored in an orderly manner in cabinets, drawers, carts each resident's medications are assigned to an individual cubicle, drawer, or other holding area . 1. On 10/21/24 at 11:02 AM, during initial tour to the facility's south wing, an interview was conducted with Resident #26 who…

    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 before2024-10-24 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 prepare food in a pureed form designed to meet the needs of 2 sampled residents of 14 residents with physician ordered pureed diets, Residents #4 and #110. The census at the time of survey was 113 residents. The findings included: Record review of the Nutrition Service Policy and Procedure effective 07/01/23, described the pureed diet as able to be piped, layered, molded if able to retain shape, but should not require chewing if presented in this form. The weekly menus that were labeled Spring / Summer Menus Week 3, from the Optima Solutions Dietary Management System, listed a description of the pureed diet on each menu. It said: Holds shape on spoon; smooth texture; No separated liquid; not firm/sticky. In the dining room on 10/21/24 at 1:04 PM, Resident #4's lunch plate was observed with beef stroganoff that was supposed to be pureed according to the diet listed on the meal ticket. The beef had small lumps in it. The surveyor then went into the kitchen and spoke to the Dietary Manager. Observation revealed…

    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 · D2024-10-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, facility policies, and record reviews, the facility failed to encourage hand hygiene, provide hand hygiene supplies, and assist residents in performing hand hygiene before meals for 6 of sampled 6 residents, Residents #14, #64, #30, #74, #95, and #27. The findings included: Review of polciy, titled, SNF Clinic Handwashing/ Hand Hygiene - F880; Infection Control, submitted by the Administrator documented, in part, considers hand hygiene the primary means to prevent the spread of healthcare associated infection, and #6 explaining Residents are encouraged to practice hand hygiene. 1. Record review revealed Resident #14 was admitted on [DATE] with diagnoses that included Protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow causing difficulty of breathing), Muscle wasting and Atrophy (thinning of muscle). Record review of Minimum Data Set (MDS) assessment Section C dated 09/19/24,revealed a Brief Interview of Mental Status (BIMS)…

    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
Show the remaining 16 citations
  • Potential for harm · D2023-08-17 · 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 Based on review of policy and procedure, observation, interview and record review, the facility failed to maintain residents' privacy in a dignified manner for 3 of 24 sampled residents observed, Residents #103, #100, and #68. The findings included: Review of the facility policy and procedure on 08/16/23 at 2:45 PM, titled, Dignity, provided by the Director of Nursing (DON) revised February 2021, documented in part, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times 11. Staff promote, maintain and protect resident privacy, including bodily privacy . 1. Resident #103 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Peripheral Vascular Disease, Diabetes Mellitus Type 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-17 · 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 observations, interviews, and record review, the facility failed to provide the appropriate Activities of Daily Living (ADLs), regarding eating assistance, for 1 of 5 sampled residents reviewed for nutrition, Resident #23. The findings included: Review of the policy, titled, Activities of Daily Living, revised in March 2118, showed, in part, the following: appropriate care and services would be provided for residents who cannot carry out ADLs [Activities of Daily Living] independently by the plan of care, including support and assistance with dining. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Record review documented Resident #23 was readmitted to the facility on [DATE] with diagnoses to include Heart Disease and Dementia. Resident #23 had been placed under hospice services on 05/31/23. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognition…

    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 · D2023-08-17 · 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

    Based on observations, interviews, policy review, and record review, the facility failed to provide proper urinary catheter care, as evidenced by cleaning the catheter tubing from the outside to the insertion site, wiping the buttocks from the top downward into the perinium, lifting the catheter bag above the bladder level, lack of hand hygiene after touching unclean items, and allowing the catheter tubing to be kinked after care, for 1 of 1 sampled resident, Resident #68, reviewed for catheter care. The findings included: Review of the policy, titled, Catheter Care, Urinary, Level III, dated August 2022, revealed, in part, the following: Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. Use a washcloth to cleanse the labia-use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth and cleanse around the urethral meatus. With a clean washcloth,…

    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 before2023-08-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the correct tube feeding formulary and rate as per the physicians' orders for 1 of 2 sampled residents reviewed for tube feeding, Resident #100. The findings included: Review of the facility's policy, titled, Enteral Nutrition, revised in 2018, showed, in part, the following: The Nurse confirms that orders for enteral nutrition are complete. Complete orders include a. The enteral nutrition product; b. Delivery site (tip placement); The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; c. d. Administration method (continuous, bolus, intermittent); e. Volume and rate of administration; f. The volume/rate goals and recommendations for advancement toward these; and g. Instructions for flushing (solution, volume, frequency, timing, and 24-hour volume). Resident #100 was admitted on [DATE] and readmission on [DATE] with diagnoses of Hemiplegia and Muscle Wasting. Review of the physician orders dated 08/10/23…

    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 before2023-08-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to maintain medications, medication carts and treatment carts in a secure manner and during medication administration opportunities, as evidenced by medications left unattended at the bedside for Resident #100 and 22 and failed to dispose of expired medications and supplements properly on 1 of 2 units (the North Unit). The findings included: Review of the policy, titled, Storage of Medications, dated November 2020, revealed in part, the following: Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access. 1. During tour of the facility conducted on 08/14/23 at 9:24 AM, the surveyor observed an unlocked, unattended treatment cart on the North Hallway of the facility. The treatment cart contained various treatments and ointments. Photographic Evidence Obtained. Upon further observation, there were 2 pairs of scissors observed in the top drawer of the wound care cart. During this observation, multiple staff members were…

    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 before2023-08-17 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the food was prepared and appropriate to meet the residents' needs of 4 of 6 sampled residents observed during dining observations, Resident #23, Resident #36, Resident #98, and Resident #83. The findings included: Review of the facility policy, titled, Nutrition Service Policy and Procedures, under mechanical soft diet, dated 07/01/23, showed that this diet consists of moist, smooth textured, and quickly formed into a bolus. Most raw fruits and vegetables, seeds, nuts, and dried fruits are excluded. It further showed that vegetables should be soft, well cooked and less than ½ inch in size, and easily mashed with a fork. Review of the facility's spring-summer menu 2023, week 1, showed the following menus for Monday: under the regular diet: pork roast, parsley egg noodles, and one piece of parsley sprig. Under the mechanical soft diet, it showed: grounded pork roast, parsley egg noodles, and one piece of parsley sprig. 1.…

    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 · D2023-08-17 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 chart review, the facility failed to provide the correct diet orders and nutritional supplements, and failed to ensure accurate food allergies were followed, for 1 of 5 sampled residents, Resident #23, reviewed for nutrition. The findings included: An observation was conducted on 08/14/23 at 12:35 PM of Resident #23. The resident was observed in her room with her lunch tray. Closer observation revealed a tray of a mechanical soft diet with vanilla ice cream. There was no nutritional supplements noted on this lunch tray. Record review showed that Resident #23 was readmitted to the facility on [DATE] with diagnoses of Heart Disease and Dementia. Resident #23 was placed under hospice services on 05/31/23. The Minimum Data Set (MDS) dated [DATE] showed Resident #23 has a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The care plan revised on 08/03/23 documented that Resident #23 was at nutritional risk and to provide supplements as…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-14 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to follow the portion sizes for the approved regular menu for the lunch meal on 04/13/22 for 77 of 77 residents on regular diets, which affected 22 sampled residents (Residents #107, #20, #110, #32, #51, #73, #30, #76, #34, #86, #80, #91, #92, #57, #44, #168, #21, #16, #96, #40, #112 and #81). The findings included: Review of the approved lunch menu for regular diets for 04/13/22 showed that the items to be served included: 4 ounces Salisbury steak. During an observation of the lunch tray line conducted on 04/13/22 at 11:51 AM, Salisbury steak was being plated for the lunch meal. At the request of the surveyor, the Certified Dietary Manager (CDM) calibrated the facility's food scale and measured the weight of the Salisbury steak. The weight of the Salisbury steak was recorded at 3.5 ounces, which was 0.5 ounces below the portion size listed on the approved menu. As the CDM removed the steak from the scale, the calibration dial had shifted from 0 ounces to 0.5 ounces. The CDM acknowledged that the calibration…

    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 · D2022-04-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to update an advance directive in a timely manner and failed to update the advance directives care plan for 1 of 1 sampled resident, reviewed for advance directives, Resident #168. The findings included: Review of the facility's policy, titled, Advance Directives, revised in [DATE], documented, .the plan of care for each resident will be consistent with his or her documented .advance directives .changes .of a directive must be submitted in writing to the Administrator .the care plan team will be informed of such changes .so that appropriate changes can be made in the resident assessment Minimum Data Set (MDS) and care plan . Review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered, revised in [DATE], documented, .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Review of Resident #168's clinical record documented an admission 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-14 · 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 observations, records review, and interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment reflected the actual functional status of 1 of 5 sampled residents, Resident #102, reviewed for range of motion. The findings included: Observation and interview conducted on 04/11/22 at 10:44 AM revealed that Resident #102 was in bed with a visible right-hand contracture. A splint was observed on the bed next to the resident. Resident #102 reported that she needed assistance to put on the splint, after she was asked why she was not wearing it. Subsequent observations on 04/13/22 at 10:02 AM, 04/13/22 at 11:12 AM, and 04/14/22 at 12:42 PM revealed Resident #102 wearing the splint. During an interview with Resident # 02 on 04/14/22 at 12:43 PM, she reported that they do not always put the splint on for her. Resident #102 said that if was only this week that they put it on daily, since Monday April 11, 2022. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-14 · 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 observations, interviews, and record review, the facility failed to provide fingernail grooming for 2 of 4 sampled residents reviewed for activities of daily living (ADLs), Resident #17 and Resident #87. The findings included: Review of the facility's policy, titled, Care of Fingernails/Toenails, revised on October 2010, documented the following: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Review of the Certified Nursing Assistant (CNA) Job Description, revised on 01/01/15, documented that CNAs were to assist residents with nail care (clipping, trimming, and cleaning). 1. Review of the record documented that Resident #17 was re-admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Dementia, Muscle Weakness and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented that a Brief Interview for Mental Status…

    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 · D2022-04-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 records review, the facility failed to provide splints as per therapy recommendations to 2 of 5 sampled residents, Resident #102 and Resident #44. The findings included: 1. Review of the electronic clinical admission record revealed that Resident #44 was admitted to the facility on [DATE]. The most recent reentry date was on 03/31/20. Resident #44's diagnoses included, in part, Muscle Weakness (Generalized) as of 09/18/20, Aortic Aneurysm without Rupture Cardiovascular, and Coagulations 03/31/20, peripheral vascular disease. Review of the Minimum Data Set (MDS), section C (Cognitive Patterns), dated 02/08/22 revealed that Resident #44 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicating Resident #44's cognition was intact. Section G (Functional Status) revealed that Resident #44 required supervision for all ADLS except dressing for which she required limited assistance. Yet, she was totally dependent on staff for bathing. Review of the care plan (CP)…

    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 before2022-04-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to administer tube feeding as per Physician's Orders for 4 of 6 sampled residents reviewed for tube feeding, Resident #108, Resident #87, Resident #95, Resident #4. The findings included: Review of the facility's policy titled, Enteral Nutrition, revised on December 2008, documented the following: Adequate nutritional support through enteral feeding will be provided to residents as ordered. 1. Review of the record documented Resident #108 was re-admitted to the facility on [DATE] with diagnoses that included: Hemiplegia, Hemiparesis, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension and Dysphagia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #108 had a Brief Interview for Mental Status Score of 00, indicating he was severely cognitively impaired. Review of Section K of the MDS dated [DATE] documented that Resident #108 was on tube feeding. Review of the Physician's Orders documented that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 5 of 9 sampled residents reviewed during the controlled substance record review at the facility's north and south wings, for Residents #45, #51, #92, #112 and #168. The findings included: Review of the facility's policy, titled, Controlled Substances, revised in December 2016, documented controlled substances must be stored .in a locked container . The policy did not address documentation of reconciliation of the locked controlled substances once it is removed of a locked container. 1. Review of Resident #45's clinical record documented an admission to the facility on [DATE]. The resident's diagnoses included, in part, Cerebrovascular Disease with Hemiplegia and Hemiparesis, Metabolic Encephalopathy, and Seizures. On 04/13/22 10:03 AM, a side-by-side review of the facility's south wing-controlled substance records with Staff F, a Licensed Practical nurse (LPN), was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-14 · 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 observations, interviews and record review, the facility failed to obtain a physician's order for oxygen therapy for 1 of 1 sampled resident, Resident #168, as evidenced by the resident receiving oxygen therapy via a nasal cannula without a physician order. The findings included: Review of the facility's policy, titled, Physician Medication Orders, revised in April 2010, documented Medications shall be administered only upon the written order .drug and biological's orders must be recorded on the physician's order sheet in the resident's chart . Review of Resident #168's clinical record documented an admission on [DATE] and a readmission on [DATE], with diagnoses to include: Muscle Weakness, History of Falling, Lack Of Coordination, Unsteadiness on Feet, Chronic Osteomyelitis to Right Ankle and Foot, Difficulty in Walking, Chronic Obstructive Pulmonary Disease (COPD), Seizures Essential Hypertension, Emphysema, Anxiety Disorder, and Peripheral Vascular Disease. Review of Resident #168's Minimum Data Set…

    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
  • No harm found · B2026-04-30 · tag F0583 — failed to protect personal privacy — pattern
    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, interview and record review, the facility failed to protect private medical records for 1 of 1 sampled resident reviewed for privacy, Resident #36. The findings included: Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side, and Schizoaffective Disorder, Bipolar Type. Her Brief Interview for Mental Status was 6 on the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicating she was severely cognitively impaired.On 04/29/26 at 2:00 PM, a family member of the resident was interviewed. She stated she was given the wrong envelope when she took her mother to the doctor. She spoke with the Administrator and put in a grievance with the facility.Review of grievance dated 04/28/26 revealed the resident returned from an appointment and reported that the incorrect enveloped was given to the patient. Review of the Action taken documented 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

“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

$11,517 in federal fines across 1 penalty.

  • $11,517 — penalty dated 2024-10-24

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 FL SNF TRUST — 10 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 3 of 53.2-0.2 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 9 homes this chain runs (chain average 3.2★, 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
PALMS NURSING HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2023
FL MASTER OPCO HOLDCO II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2023
FL SNF TRUST IOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2023
FL SNF TRUST IIOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2023
SYLVERAIN, VANESSAIndividualW-2 MANAGING EMPLOYEEsince 08/01/2023
ELLENBOGEN, MOSSIndividualCORPORATE OFFICERsince 08/01/2023

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.6M
Net patient revenuemost recent cost report
+2.2%
Operating marginrevenue minus expenses
$10K
Related-party expense0% of expenses
Who pays — share of resident-days
Medicaid 85%Medicare 2%Other / private 13%

About 85% 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 $10K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$338per resident / day
operating cost
$10,261per month
≈ monthly operating cost
$345per 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 105336. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-24, 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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