St Johns Nursing Center
3075 NW 35th Ave, Lauderdale Lakes, FL 33311 · Non profit - Corporation · 181 certified beds · (954) 739-6233 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,155 in federal fines (most recent 2023-09-21)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.9% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.4% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.4% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.1% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.9% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.9% 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 64 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.0% 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 37 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.9%CMS range 33.5–56.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.1–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.0–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.02 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 181 beds and averages 164.6 residents a day — about 91% occupied, or roughly 16 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above 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 3.71 hrs/resident/day on weekends vs 4.18 on weekdays — 11% thinner on weekends. RN hours go from 0.94 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% 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
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.
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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2023-09-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Record review for Resident #137 revealed the resident was admitted to the facility on [DATE] with the following diagnoses that included: Chronic Systolic (Congestive) Heart Failure, Morbid (Severe) Obesity, and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) for Resident #137 dated 08/11/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment; In Section G for bed mobility, the resident had a self-performance of extensive assistance with support of one person assist, for dressing the resident had a self-performance of total dependence with support of two plus persons assist, and for eating the resident had a self-performance of extensive assistance with support of one person assist. Review of the Physician's orders for Resident #137 revealed an order dated 02/16/23 for regular thin liquids, special instructions none. Review of the Physician's orders for Resident #137 revealed an order dated 02/16/23 for Hydrochlorothiazide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-09-21 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow physicians' orders regarding tube feeding for 1 of 2 sampled residents, Resident #124. The findings included: Review of the facility's policy, titled, Enteral Nutrition Products, dated 08/22/22, showed in part the following: The facility supplies residents with enteral nutrition support as ordered by the Physician. It further showed that all enteral nutrition products must be labeled with the Resident's name, date it was prepared, product name, concentration, and volume. Resident #124 was admitted to the facility initially on 06/01/23 with diagnoses to include Hyperlipidemia, Dementia, and Left Hip Fracture. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #124 had a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the diet order, dated 09/01/23, noted for tube feeding, Jevity 1.5 (tube feeding formulary) at 65 milliliters (ml) an hour times 15 hours…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide food to residents in a safe and sanitary method. This had the potential to affect 154 residents. The findings included:A tour of the kitchen was conducted on 03/03/26 at 8:50 AM, accompanied by the Kitchen Supervisor upon entering the kitchen. At approximately 9:30 AM, the Kitchen Manager joined the surveyor and the Kitchen Supervisor. At approximately 10:30 AM, the Director of Food and Nutrition Services joined the surveyor, the Kitchen Supervisor, and the Kitchen Manager, on the tour of the kitchen. The following was observed: a. Upon entering the kitchen, a tall gray garbage bin close to the Vulcan stove had an open lid. The staff quickly closed the lid. Regulations mandate that the garbage should be maintained with a closed lid. During a later observation of the garbage bin with an open lid, the Director of Food and Nutrition Services was asked if the lid was left open for convenience. It was observed that there was no garbage bin close to the hand-washing area. The Director of Food and Nutrition Services said…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-12 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow the facility policy of documenting identified changes in the sacral skin condition for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #1.The findings included:Review of facility's policy, titled, Wound Prevention, Skin Observation, with an effective date of 10/19/05, and a revision date of 11/21/17, documented that 'the nurse would evaluate and document identified changes in the weekly skin check section of the electronic medical record.' Record review documented Resident #1 was admitted to the facility on [DATE] after a surgical operation of the right knee. The resident had history of Vancomycin induced Acute Kidney Injury, Atrial Fibrillation and Hypertension. The resident was discharged to a hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/02/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating he had good cognitive function.Section M revealed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 3 of 3 sampled residents during mealtime observations, Resident #140, Resident #75, and Resident #100; and failed to provide grooming for 1 of 1 sampled resident, Resident #139. The findings included: 1. In an observation conducted on 01/13/25 at 12:22 PM, Staff H, Certified Nursing Assistant (CNA), was passing the lunch tray on the 2nd floor South unit. She turned to another staff member on the unit and said, She is a feeder. A few minutes later, at 12:27 PM, Staff I, CNA, asked another staff member, How many feeders do we have? 2. Continued observation on the 2nd floor South unit at 12:30 PM revealed Staff I stated to another staff member, She is a feeder as well. She then turned to the surveyor and said, I need to wait with some of the trays in the meal cart because I need to finish feeding the other residents. 3. In an observation conducted on 01/13/25 at 12:22 PM, Resident #140's roommate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of 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 observations, interview and record review, the facility failed to ensure the residents' call devices were in reach for 3 of 33 sampled residents reviewed for call light accessibility, Residents #85, #153 and #51. The findings included: Review of the facility's policy, titled, Call Bells-Lights, effective date 08/12/19 and reviewed date 10/16/24, included the following: Call bells will be available to facilitate care and to enhance safety for all residents. Procedure: 1.Staff will ensure that call buttons are within the reach of the resident at all times. 1. Record review for Resident #85 revealed the resident was admitted to the facility on [DATE] with the diagnoses that included Gastrointestinal Hemorrhage, Dementia, Hypertension, History of Falling, and Diabetes Mellitus. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Review of Section GG of the same MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to honor 1 of 22 sampled residents, Resident #130's rights for self-determination, as evidenced by the facility's infringement on Resident #130's right to refuse and discontinue nursing home care services. The findings included: On 01/13/25 at 11:44 AM, Resident #130 stated he was asked in the month of October 2024 to come to the nursing home while his assisted living facility's (ALF) apartment was being renovated. He said that they told him that he would return to the ALF in two months. Yet, he has not heard from anyone, he does not know what is going on, and it has been three months. The resident stated they have ignored all his concerns. Resident #130's electronic record documented the following diagnoses: Chronic systolic heart failure; Hypertensive Heart disease; Bacteremia; Hyperlipidemia; presence of Cardiac Pace Maker; Glaucoma bilateral unspecified and gait abnormalities. On the Brief Interview of Mental Status (BIMS) Resident #130 obtained a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, records review, and interview, the facility failed to provide assistance with Activites of Daily Living (ADLs) for 1 of 22 sampled residents, Resident#139, related to removal of facial hair. The findings included: Review of Resident #139's facesheet and section A of the Minimum Data Set (MDS) assessement documented the resident's admission date to the facility to be 06/08/23.Review of on the Brief Interview for Mental Status (BIMS) for Resiident #139 noted a score of 3 of 15 indicating severe cognitive impairment. Section GG of the MDS. titled Functional Abilities and goals. documented the resident required total assistance for most ADLs. Review of the resident's ADL care plan (CP) dated 02/12/24 documented the resident has self-care deficits as evidenced by her decreased balance and endurance, safety awareness strength, and required maximum assistance with upper body dressing, total assistance with lower body dressing, total assistance with toilet transfer, total assistance with toileting hygiene, due to functional decline related to ADL dysfunction muscle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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, interviews and record reviews, the facility failed to follow Physician orders for urinary care for 1 of 1 sampled resident, Resident # 152, reviewed for urinary care. The findings included: Review of a document, titled, Foley Catheter Care, with policy # 2032, and reviewed on 08/22/22, revealed catheter care will be provided to all residents with indwelling catheters at least daily. An additional statement revealed the purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. Record review documented Resident #152 was admitted on [DATE] with diagnoses that included Atrial Fibrillation, Heart Failure, Benign Prostatic Hypertrophy, Chronic Urinary Retention, Diabetes Mellitus, Thyroid Disorder, Malnutrition, Sacral Wounds, and Asthma. Review of the Minimum Data Set (MDS) assessment, Section C, dated 01/05/25, revealed a Brief Interview for Mental Status (BIMS) score of 10 of 15 indicating…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to identify weight loss and provide nutritional interventions in a timely manner for 2 of 8 sampled residents reviewed for nutrition, Resident #7, and Resident #140. The findings included: Review of the facility's policy titled Nutrition Assessment and Monitoring, revised on 09/08/24, revealed the following: A systematic approach will be used to optimize a resident's nutritional status. The process includes identifying and assessing each Resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing the effectiveness, monitoring pertinent approaches and interventions, and revising them as necessary. Review of the facility's policy titled Resident Weights reviewed on 10/16/24 showed the following: The Weight Team will be responsible for weighing Residents and entering weight into the EMR. Weight Fluctuations shall be re-weighed and then reported to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow physicians orders for fluid restriction for 1 of 1 sampled resident, Resident #42, reviewed for Dialysis. The findings included: Review of the policy document provided, titled Dialysis Residents, with a policy #2008, and reviewed on 10/16/24, revealed the purpose is to ensure that all needs / services of residents on dialysis are met while at the Facility. Recor review revealed Resident #42 was admitted on [DATE] with diagnoses including End Stage Renal Disease on Dialysis, Anxiety Disorder, Anemia, and Hypertension. Review of quarterly Minimum Data Set (MDS) assessment, Section C, dated 12/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of physician orders dated 09/11/24 revealed to monitor intake every shift as per fluid overload prevention protocol: 24-hour fluid restriction in milliliters (ml). 1200 ml (nursing 480 ml and dietary 720 ml). The order documented: 120 ml…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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, interview, observation and record review, the facility failed to address social services responsibilities regarding missing personal items and clothing for 1 of 1 sampled resident, Resident #223. The findings included: Review of undated facility's licensed Social Worker job description on 01/16/25 at 11:17 AM provided by the Administrator documented, Summary & Objective: The Social Worker coordinates and provides medically related Social Services to attain or maintain the highest practicable, physical, mental, and psychosocial wellbeing of each resident . Essential Functions: Complete progress notes/assessments as required . Participates in daily management team meetings to discuss resident status, census changes, and resident complaints or concerns if applicable . Other Duties: Comply with all policies, local, state, and federal laws and regulations and Perform other duties as assigned . Review of the facility's policy and procedure, titled, Handling of Valuables,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2025-01-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to secure dispensed medications which were left unattended on a medication cart, and dispensed medications left at the bedside for a resident during initial observational tour, for 1 of 164 resiudents observed, Resident #374; failed to secure a treatment cart while unattended during wound care observation; and failed to secure an unlocked medication cart review in the facility's third floor wing. The findings included: Review of the facility's policy, titled, Drug Procurement/Storage/Inspection, effective date 12/03/04, reviewed date 10/24/24, included the following: Policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the facility. Procedure: Medications are stored in a secure manner. Lockable medication carts are used to store unit-of-use medications in the resident medication dose system. These carts will be locked when not attended. Review of the facility's policy, titled, Bedside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0806 — failed to honor food preferences — isolatedEnsure 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 review of policy and procedure, observation, interview and record review, the facility failed to ensure it honored the resident's food preferences during a lunch meal for 4 of 33 sampled residents observed, Resident #14, Resident# 151, and Resident #133. The findings included: Record review of the facility policy and procedure, titled, Nutritional Services Rounds, provided by the Administrator, reviewed 10/16/24, documented: Purpose: To determine resident's likes/dislikes and overall acceptance of meal service. Residents' cultural, religious and ethnic food preferences are honored when possible and when not contraindicated To identify any errors or deficiencies in the meal tray service. Policy: The Registered Dietician or Dietary Technician: Record as appropriate, nutrition information in the medical record on nutrition progress notes. 1. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnosis to included Gastroesophageal Reflux Disease (GERD). The current Minimum Date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 observations to the main kitchen. The findings included: In an initial tour of the central kitchen conducted on 01/13/25 at 9:00 AM, the following were noted: 1. The Food Service Director did not have a facial hair covering in the food production area. 2. A dirty used rag was noted in the food production counter that was not placed in a sanitation bucket. 3. One (1) light of 3 lights under the hood was not working. 4. A 16-ounce private plastic drinking cup was noted under the food production area. 5. A large bag of cooked pork in the walk-in refrigerator had a date of 01/04/25 with a used by date of 01/07/25. 6. A large metal container of pollo sauce in the walk-in refrigerator had a date of 01/07/25 with a used by date of 01/09/25. 7. A large metal container of Marinara sauce in the walk-in refrigerator had a date of 12/31/24 and a used-by date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-16 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to disinfect the vital signs machine between residents' usage for Residents #137, Resident #42 and Resident #428; and failed to follow droplet precaution protocol for residents' positive for Coronavirus Disease 2019 (COVID-19), for Resident #375. The findings included: Review of the facility document, titled, Guidelines for Isolation Precautions, policy #4022, dated 10/25/24, revealed standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections in hospitals. Page 5 of the policy revealed droplet transmission is a form of contact transmission, where droplets are generated from the source person primarily during coughing, sneezing, talking, and during the performance of suctioning and bronchoscopy. Isolation precautions are designed to prevent transmission of microorganisms in healthcare facilities. Since agents and host factors are more difficult to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assist with Activities of Daily Living (ADLs) regarding assistance during dining for 1 of 1 sampled resident, Resident #73. The findings included: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status and Heart Failure. The physician order dated 08/17/23 noted for a regular heart-healthy diet with thin liquids. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #73 has a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment. Section G of this MDS showed that for eating, Resident #73 needed extensive assistance from one person with her meals. In an observation conducted on 09/18/23 at 7:54 AM, the breakfast tray was taken into Resident #73's room and placed at her bedside table. At 8:00 AM, staff took the tray from the room and placed it on the meal cart outside in the hallway. Continued observation showed Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record and policy review, the facility failed to follow physician orders for discontinued medications for 1 of 3 sampled residents reviewed for medication storage on Floor 2 South wing medication cart, Resident #73. The findings included: The facility's policy, titled, Medications-Disposition, effective [DATE], revised [DATE] and reviewed [DATE] revealed, The nurse is responsible for the proper disposition of drugs no longer eligible for use, such as those that have expired, were stored improperly or were degraded and discontinued. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status and Heart Failure. The Minimum Data Set (MDS) dated [DATE] showed that Resident #73 has a Brief Interview of Mental Status (BIMS) score of 01, indicating severe cognitive impairment. On [DATE] at 11:13 AM, an observation of the medication cart on Floor 2 South wing was done with Staff L, Licensed practical nurse (LPN). During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 observation and interview the facility failed to provide dining in a dignified manner as evidenced by using disposable utensils and serving bowls as observed during lunch meals. The findings included: On 05/23/22 at 12:45 PM, observations were conducted of the lunch meal tray delivery on the South and East halls on the 3rd floor. Staff were observed delivering the lunch trays to residents and assisting with set up of the meal. At 1:05 PM, Resident #10 in room [ROOM NUMBER] was observed eating her lunch meal using a silverware fork for the chopped meat however only a white plastic teaspoon was available to eat the soup and dessert which were served in Styrofoam bowls. Resident #10 was observed to be having difficulty using the plastic teaspoon to get the soup to her mouth. At 1:08 PM, Resident #84 in room [ROOM NUMBER] was observed being fed by Certified Nursing Assistant (CNA) Staff L. She was sitting in a chair next to his gerichair feeding him his puree meal with a white plastic teaspoon. This lunch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, record review and review of policy and procedure, it was determined that the facility failed to ensure that it maintained a safe, clean, comfortable, homelike environment for 7 of 7 resident rooms identified during the initial environmental tour (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] for Resident #50 and room [ROOM NUMBER] for Resident #36.) The findings included: 1) During an observational room tour conducted on 05/23/22 at 9:32 AM, it was noted that Resident #50 was observed trying to clean the floor around her bed utilizing a paper towel on the end of her cane. Resident #50 in room [ROOM NUMBER] was originally admitted to the facility on [DATE] with diagnoses which included Dementia, Hypertension, Diabetes,, Glaucoma and Hypertensive Heart and Chronic Kidney Disease. She had a Brief Interview Mental Status (BIMS) score of 12 (moderately impaired). During a brief interview conducted on 05/23/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 develop a Baseline Care Plan for fall risk for 1 of 3 residents sampled for accidents (Resident #101). The findings included: A review of the facility's policy titled Interdisciplinary Team Care Assessments reviewed on 01/12/21 revealed the following: An interim plan of care is initiated within 48 hours of admission to the facility. The nursing admission assessment/observation is begun on the day of admission. Development and implementation of the plan of care begin with the completion of assessments and observations. Resident #101 was admitted to the facility from an acute hospital on [DATE] with diagnoses of Hypertension, Alzheimer's, and heart disease. He was later discharged to the hospital on [DATE] after a fall sustaining a right hip fractured. A review of the admission Fall Risk Evaluation, completed on 04/06/22 by the admitting nurse, revealed that an answer of no was marked for any history of falls for Resident #101. It further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide care and services in accordance with activities of daily living specifically nail grooming for 1 of 2 residents observed for Activities of Daily Living (ADL), Resident #26. The findings included: During an initial observational tour conducted on 05/23/22 at 11:23 AM, Resident #26 was observed with long, sharp, jagged, dirty, unkempt fingernails on both hands. (Photographic evidence obtained.) Resident #26 was originally admitted to the facility on [DATE] with diagnoses which included Diabetes, Hypertension and bilateral above the knee amputations. She had a Brief Interview Mental Status (BIMS) score of 12 (moderately impaired). On 05/23/22 at 11:29 AM, a brief interview was conducted with Resident #26 in which she was asked if she liked her nails long or if she would like them to be trimmed and she said that she wanted them to be trimmed down and she added that she does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide treatment and care for application of a hand splint to address the resident's positioning needs for 3 of 9 residents observed for splints/range of motion (ROM), (Resident #36, Resident #21, and Resident #84). The findings included: Review of the facility policy and procedure on Restorative and Nursing Services documented in part, 'Restorative Nursing Policy: The facility will ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. Procedure: Restorative Nursing Programs from the following categories may be implemented: 1. Range of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observation, interview and record review the facility failed to ensure indwelling Foley catheter perineal care was conducted in a manner to prevent the potential for infection for 1 of 1 residents observed for Foley catheter perineal care, Resident #75. The findings included: Review of the clinical record for Resident #75 revealed an admission date of 04/04/22 with pertinent diagnosis to include urinary tract infection and urinary retention requiring the use of an indwelling urinary Foley catheter. On 05/23/22 at 10:48 AM, Resident #75 was observed in his room in bed with the Foley catheter drainage bag covered with a privacy cover and the connected catheter tubing laying on the bed. The urine in the tubing looked cloudy with whitish sediment. An inquiry was made to the resident how long he has had the Foley catheter to which he could not say. An inquiry was made if he has had any recent urinary tract infections to which he also could not say. Review of the April 2022 Medication Administration Records…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status. It failed to provide nutritional interventions in a timely manner to prevent significant weight loss for 3 of 7 sampled residents for nutrition (Resident #101, Resident #73 and Resident #23). The findings included: A review of the facility's policy titled Nutrition Assessment and Monitoring reviewed on 04/02/22 showed the following: The Dietitian evaluates the resident when changes are noted that could affect the nutritional status. The Dietitian will document the evaluation and make the appropriate recommendation when necessary. It also showed that The Dietitian would ensure that the resident maintains acceptable parameters of nutritional status, such as body weight or desirable body range, unless the resident clinical condition demonstrates that this is not possible. A review of the facility's policy titled Resident Weights reviewed on 04/02/22 showed that all resident's weights…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to identify a resident on Dialysis; failed to obtain a physician order for Dialysis; and failed to monitor the Bruit (rumbling sound) and Thrill (rumbling sensation) for 1 of 1 residents reviewed for Dialysis (Resident #590). The findings included: A chart review showed that Resident #590 was admitted to the facility on [DATE] with diagnoses of End-stage renal disease, Anemia, and Hemiplegia. A review of the Physicians' Orders on admission did not show that an order for Dialysis was given for Resident #590. On 05/23/22 at 10:00 AM, observation showed that Resident #590 was not in his room. A review of the Entry Minimum Data Set (MDS) dated [DATE], under section O, did not show that Resident #590 was coded for Dialysis. Further review of the 5 day MDS dated [DATE], under section O, did not show that Resident #590 was on Dialysis. The Baseline Care Plan, which was started on 05/13/22, did not show that Resident #590 was on Dialysis, and 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.
- Potential for harm · Dcited before2022-05-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it secured seven (7) over-the-counter (OTC) medications for 4 of 31 residents observed, Resident #3, Resident #85, Resident #110, and Resident #96. And, failed to assess the residents for Self-Administration of Medications. The findings included: Review of facility policy and procedure for Bedside Medication Storage dated reviewed April 2022, documented in part, 'Policy: Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to dispose of the garage and refuse correctly. The findings included: In an observation conducted on 05/23/22 at 10:00 AM of the waste dumpster area, the following were noted: A pile of debris and garbage consisting of used gloves, plastic, and other unidentified matter. The waste was concentrated behind the caged dumpster bin with a foul odor (photographic evidence obtained). An interview conducted on 05/26/22 at 9:20 AM with the facility's Administrator stated that the primary garbage dumpster is picked up twice a week. She further acknowledged the findings.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$25,155 in federal fines across 1 penalty.
- $25,155 — penalty dated 2023-09-21
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ST JOHNS REHABILITATION HOSPITAL AND NURSING CENTER INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/06/2025 |
| ARCHDIOCESE OF MIAMI INC | Organization | DIRECT OWNERSHIP INTEREST; 5% OR GREATER INDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | 100% | since 08/09/1979 |
| FRICK, MARY | Individual | CORPORATE OFFICER | — | since 04/01/2024 |
| CATHOLIC HEALTH SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/04/1986 |
| BAILEY, ROSEMARIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/06/2025 |
| JULES, CLINTON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| WILSON, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2024 |
CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105371. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, 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.