No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Life Care Center At Inverrary

4300 Rock Island Road, Lauderhill, FL 33319 · For profit - Limited Liability company · 120 certified beds · (954) 485-6144 Medicare & Medicaid certified

Call the home — (954) 485-6144 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 22 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 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 quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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
5501 W Oakland Park Blvd · (954) 735-4628 · Call to confirm hours
Grocery
5588 W Oakland Park Blvd · (954) 306-6859 · Call to confirm hours
Park
4500 Monterey Dr · (954) 597-3620 · Typically dawn to dusk
Place of worship

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 5 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 4 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 rating4★
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 increased4.8%8.7%15.4%better
Long-stay residents who lose too much weight3.0%5.5%5.4%better
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 infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%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 injury0.8%2.5%3.3%better
Long-stay residents whose ability to walk worsened4.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.8%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control3.2%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 table7.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine96.7%94.7%79.4%better
Short-stay residents rehospitalized after admission31.4%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.982.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.171.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 173 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.4%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
85.7%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 85.7% 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 70 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 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.4%CMS range 43.6–59.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.3–14.610.7%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 discharge85.7%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 discharge81.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge80.0%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 identified99.3%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 setting100.0%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 worsened2.9%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 hospitalization6.9%CMS range 4.5–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.92
RN hours/ resident / day
0.66
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.67
RN hoursweekends
26.7%
Total nursing turnover
38.5%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 110.4 residents a day — about 92% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.92 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.46 hrs/resident/day on weekends vs 4.03 on weekdays — 14% thinner on weekends. RN hours go from 1.03 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

8
deficiencies at the latest standard inspection (2025-08-14)
5
at the previous standard inspection (2024-04-18)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Ecited before2025-08-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide double portions for 2 of 2 sampled residents (Resident #6 and #107) reviewed for dining observations, and for 1 of 1 tray line observations in the kitchen. This has the potential to affect 8 residents with double portions orders. The facility failed to provide fortified foods during observations in the kitchen, that has the potential to affect 12 residents who are to be served fortified foods. The findings include: 1. During an observation conducted in the main kitchen on 08/13/2025 at 12:00 PM, on three occasions, a Dietary Aid was seen reading the double portion meal ticket to the Cook, Staff A. During the observations, Staff S did not understand what double portion meant. This surveyor had to intervene, as the plate was already placed on the tray with single portions and ready to go on the cart. At the time of intervention, the CDM (Certified Dietary Manager) had to explain to Staff A that double portion meant two scoops 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-14 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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 reviews, the facility failed to provide the correct diet consistency for pureed diets, for 5 of 5 sampled residents (Resident #20, Resident #45, Resident #108, Resident #33 and Resident #15) observed on pureed diets. This has the potential to affect 10 residents receiving pureed diets. The findings include: 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Degenerative Disease of Nervous System and Encounter for palliative care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) revealed that Resident #20 was unable to conduct the interview. A review of Resident #20's orders dated 06/19/25 documented the following: Regular diet, Puree texture, Nectar/Mildly consistency, nectar fluids by teaspoon. In an observation conducted on 08/11/25 at 1:15 PM revealed Resident #20's meal ticket diet consistency read puree regular and nectar fluid. Further observation…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · 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 observation, record review and interview, the facility failed to provide a weekly menu to a resident on contact precautions for Clostridium Difficile (C. Diff) for 1 of 1 sampled resident reviewed for contact precautions for C. Diff (Resident #6). The findings include:Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included Malignant Neoplasm of Temporal Lobe, Malignant Neoplasm of Parietal Lobe, and Enterocolitis due to C. Diff. (C. diff infection is a serious bacterial infection that primarily affects the colon, often causing severe diarrhea and inflammation. C. Diff is highly contagious. A resident who has C. Diff is on contact precautions, which means whoever enters the room must wear a gown and gloves). His Brief Interview for Mental Status (BIMS) score was 11 on the admission Minimum Data Set (MDS) dated [DATE]. This indicated the resident had mild cognitive impairment. Further record review revealed on 07/01/2025, the resident weighed 174.4 pounds. On…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow physician orders for oxygen therapy care and management for 2 of 4 sampled residents (Resident #23 and Resident #40), and failed to follow its own policy to ensure the respiratory care and services are in accordance with professional standards of practice by: failing to properly disinfect and store nebulizing masks for 2 of 4 sampled residents (Resident #45 and Resident #100); failed to have an order for a required tracheostomy tube size, and failed to maintain sterility during tracheostomy care for 1 of 2 sampled residents (Resident #1). The facility also failed to provide a readily available tracheostomy inner canula for immediate care for 2 of 2 observations and for 1 out of 2 sampled residents reviewed for tracheostomy care (Resident #9). The findings included:Review of facility's policy titled, Oxygen Administration (Infection Control, Safety, & Storage, undated, revealed the following: Oxygen should be written for specific…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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 record reviews and interviews, the facility failed to follow the professional standards of practice and doctor's order regarding taking blood pressure (BP) on the dialysis access site for 1 of 1 sampled resident (Resident #5) reviewed for dialysis. The findings included:Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Acute Post Hemorrhagic Anemia, and Respiratory Tuberculosis. A review of the most recent Minimum Data Set (MDS) assessment, dated 06/08/25, under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 13 indicating Resident #5 had intact cognition. A review of physician orders dated 06/12/25, documented to not take BP on right arm with fistula/shunt. A further review of BP documentation on Point Click Care (PCC- electronic health record for Nursing Homes), revealed that Resident #5's BP measurements were taken on the right arm during the following dates and times: On 05/14/25 at 10:05…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's medication regimen for psychotropic (antipsychotic) medication was monitored appropriately, as evidenced of the lack of written documentation of behavior monitoring for 1 of 5 sampled (Resident #3) residents reviewed for Unnecessary medications. The findings included:Review of the facility policy provided by the Assistant Director of Nursing titled Psychotropic Medication Use revised on 09/15/24 documents .psychotropics medications are drugs that affect .behavior and include .antipsychotics.facility staff should monitor the resident's behavior pursuant to facility policy using behavioral monitoring chart.for residents receiving psychotropic medication.facility staff should monitor behavioral triggers, episodes and symptoms.Review of Resident #3's clinical record documents an admission to the facility on [DATE] with a readmission on [DATE]. Resident #3's diagnoses included Anoxic Brain, Cognitive Communication Deficit, Bipolar…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-14 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, for 3 out of 22 sampled residents observed during dining. (Resident #21, Resident #55, Resident #62).The findings included:1. A record review showed that Resident #21 was admitted on [DATE] with diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing and fracture of unspecified part of neck of right femur. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 14, which indicates no cognitive impairment.In an observation conducted on 08/11/2025 at 1:15 PM this surveyor observed that Resident #21 meal ticket consisted of Broccoli & Cauliflower under the Allergies and Dislikes section. Resident #21 tray consisted of a mix of vegetables including cauliflower and broccoli. Residents #21 ate everything on the plate except the mixed vegetables. Resident #21 stated that she is…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-14 · 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, and record reviews, the facility failed to follow their own policy for Clostridium Difficile Infection (CDI) regarding meal tray removal for 1 sampled resident (Resident #6) and failed to follow their policy for disinfection of machine and equipment after residents' use during 2 observations.The findings included:A record review of a policy titled, Clostridium Difficile (CDI) with the latest revision date of 02/22/21, it revealed meal trays should be bagged prior to removal from the room and are then placed on the tray cart (p.2, no.7).An additional record review of a policy titled, Cleaning and Disinfection of Non-Critical Patient Care Equipment, with the latest revision date of 08/22/22, revealed the following: Equipment will be cleaned and disinfected prior to storage (p. 2, no.1). Non-critical items require cleaning followed by either low or intermediate-level disinfection following manufacturers' instructions (Procedure no.1.) Disinfection should be performed with an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to follow physicians' orders for medication parameters for an antihypertensive medication; and for a vitamin supplement for 1 of 6 sampled residents, Resident #51, located on the [NAME] wing. The findings included: Review of the facility policy and procedure on 04/16/24 at 1:15 PM titled Administration of Medication provided by the Director of Nursing (DON) reviewed 08/24/23 documented in the Policy Statement: The facility will ensure that medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Review of the record revealed Resident #51 was readmitted to the facility on [DATE] with diagnoses that included Dementia, Hypertension, Atherosclerotic Heart Disease, Anxiety Disorder, Anemia, Depression and Bipolar Disorder. The record documented a Brief Interview Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 initiate care plans for the use of bed rails/side rails and accurately assess 5 of 5 sampled residents reviewed for the use of side rails, (Residents #25, #46, #89, #258 and #259); failed to honor a resident's representative declining the use of bed rails/side rails for 1 of 5 sampled residents reviewed for side rails/bed rails, (Resident #258); failed to obtain orders for the use of side rails/bed rails for 1 of 5 sampled residents reviewed for side rails/bed rails, (Resident #259); and failed to assess for the potential risks associated with the use of side rails for 5 of 5 sampled residents reviewed for side rails/bed rails, (Resdents #25, #46, #89, #258 and #259). The findings included: The facility's policy titled, 'Bed Rails - Safe and Effective Use of Bed Rails, most recently revised on 12/03/22, documented: Definitions Bed Rails - Also known as side [NAME], are adjustable metal or rigid plastic bars that attach to the bed .All…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2024-04-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview, observation, and records review, the facility failed to ensure that 1 of 5 sampled residents (Resident #42) was free from unnecessary medications by failing to timely relay recommendations made by the Consulting Pharmacist to decrease Resident #42's psychotropic medication, to Resident #42's Psychiatrist. The findings included: Record review revealed the Pre-admission Screening and Resident Review (PASARR) level I dated 1/15/2019 documented that Resident #42 had diagnoses of: Depressive Disorder; Bipolar Disorder, and Psychosis. The Resident had a primary diagnosis of Dementia. The record showed that the resident did not exhibit or have suspicion of serious mental illness or Intellectual Disability. On 4/17/2024 at 11:29 AM, Resident #42 was observed in her room. Her Private Duty Aide was present sitting a few feet away from the resident. Resident #42 had a dismissive behavior. She refused to participate an the interview. Review of the Physicians Orders revealed Resident #42 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 · Dcited before2024-04-18 · 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

    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 that it secured 1) over-the-counter (OTC), prescription pill medications; and 2) one (1) Nebulizer treatment medication solution for 1 of 6 sampled residents (Resident #51) observed during a Medication Administration Observation, in 1 of 3 units; the facility's Locked Dementia Unit. The findings included: Review of the facility policy and procedure titled, Long-Term Care (LTC) Facility's Pharmacy Services and Procedures Manual 5.3 Storage and Expiration Dating of Medications, Biologicals revised on 08/07/23, documented in the Policy Statement: Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. Procedure: 1. Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage…

    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 before2024-04-18 · 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, and record review, the facility failed to clean and disinfect the glucometer per manufacturer's instructions for 4 out of 4 sampled residents reviewed for blood glucose monitoring (Resident #29, #70, #80, and #93). The facility failed to properly perform hand hygiene during medication administration observation for 4 out of 6 sampled residents reviewed for medication administration (Resident #52, #76, #77, and #78). In addition, the facility failed to implement proper signage for Contact Precautions as per Physician's orders for 1 out of 2 sampled residents reviewed for Transmission-Based Precautions (Resident #311). The findings included: Review of the facility's policy titled, Cleaning and Disinfection of the Glucometer, dated 09/20/23, included the following: To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use. Glucometer Reference…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 observation, interview, and record review, the facility failed to store, prepare, serve, and distribute food in accordance with professional standards for food safety that include: ensure that the dish machine is sanitizing as per regulation, maintenance of ceiling panels to ensure food borne illness does not occur, cleaning of dish room walls to prevent mold growth, on-going preventive maintenance on refrigeration units, and ensure that food storage containers are being cleaned on a regular basis. The findings included: During the initial kitchen/food service observation tour conducted on 01/24/23 at 9 AM and accompanied with the Dietary Manager (DM), the following were noted: (a) Observation of the dish room noted that the dish machine was in use by facility staff. Interview with the DM at the time of the observation noted that the dish machine sanitizes resident dishware by the use of hot water (Final Rinse Minimum 180 degrees F (Fahrenheit) by regulation. Observation of the dish machine noted that the temperature gauges were broken and non-operational. The DM stated…

    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 · E2023-01-27 · 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 and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (Second Floor) of 2 resident living areas. The findings include: During the initial resident screenings conducted on 01/24/23 and the Environment Tour conducted on 01/25/23 at 1 PM accompanied with the Administrator and Director of Maintenance, the following concerns were noted: Second Floor: room [ROOM NUMBER] - Room wall noted to be in disrepair and numerous large black scuff marks; exterior of room chairs were heavily worn; and exterior of end table (A bed) was worn with exposed sharp wood. room [ROOM NUMBER] - Room floor heavily soiled with noted large black stain marks, and exterior of end table (A -bed) was in despair. room [ROOM NUMBER] - Privacy curtain (A-bed) noted to be heavily stained and soiled, exterior of room chair was heavily worn, and exterior of over-bed table (B-bed) was soiled. room [ROOM NUMBER] - Room walls noted…

    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 before2023-01-27 · 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, it was determined that the facility failed to follow the approved resident menu for physician ordered Pureed Diet, Mechanical Soft Diet, and Easy to Chew Diet for 31 residents that included 8 of 8 sampled residents (Resident #96, #83, #11, #42, #37, #60, #58 and #35). The findings included: 1) During the review of the approved menu for the lunch meal of 01/24/23, it was noted that a 2-ounce serving of Pureed Bread was to be served to residents receiving special diets, including (1) Pureed Diet, and (2) Mechanically Altered Diet. During the observation of the lunch meal in the main kitchen on 01/24/23 at 11:30 AM, it was noted that the tray line steam table did not contain prepared servings of Pureed bread. Interview with the Dietary Manager (DM) at the time of the observations noted that the Pureed Bread were not prepared as per the approved menu. It was further noted that the approved menu was not reviewed prior to the preparation of the lunch meal to ensure that all foods on the menu were prepared for the 01/24/23 lunch meal. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-27 · 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 observations, interviews and record review, the facility failed to treat residents with dignity during dining for 5 of 5 sampled residents (Resident #58, #67, #83, #96 and Resident #352); and failed to avoid the use of labels such as feeders when addressing residents. The findings included: Review of the facility's policy titled Dignity revised on 09/30/22 documented, Each resident has to be treated with dignity and respect .promoting resident independence and dignity while dining, such as Addressing residents by the name or pronoun of resident's choice, avoiding the use of labels for residents such as feeders . 1) Review of Resident #352's, clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included, Fracture of Right Femur, Bipolar Disorder, Legal Blindness, Heart Disease, Dementia and Depression. Review of Resident #352's admission baseline care plan documented Activities of Daily Living Assistance (ADL) .needed to maintain or attain…

    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 · D2023-01-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 address weight loss and provide nutritional interventions in a timely manner for 3 of 8 sampled residents reviewed for nutrition (Residents #96, #58, and #36). The findings included: A review of the facility's policy titled Nutrition Assessment, revised on 12/16/21, showed that 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 pertinent approaches, monitoring the effectiveness of interventions, and revising them as necessary. It further showed that the Director of Food and Nutrition Services/ designee provides follow-up visits at least quarterly for all residents or more often if necessary. The Resident's nutritional status is updated as it changes, but no less than quarterly. A review of the facility's policy titled…

    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 · D2023-01-27 · 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 chart review, the facility failed to follow the practitioner's orders for tube feeding for 1 of 2 sampled residents reviewed for tube feeding (Resident #4). The findings included: A review of the facility's policy titled, Enteral Nutrition's Therapy, revised on 08/25/22, showed the following: Verify the practitioner's order, including the patient's identifiers; prescribed route based on the enteral feeding tube tip's location; enteral feeding device; prescribed enteral formula; administration method, volume, and rate; and type, volume, and frequency of water flushes. A chart review showed that Resident #4 was readmitted to the facility on [DATE] with heart failure, Dysphagia, and Chronic Respiratory Failure diagnoses. An order dated 12/19/22 showed Jevity 1.0 (tube feeding formulary) at 75 ml (milliliters) times 20 hours on at Noon and off at 8:00 AM. The care plan dated 11/13/22 showed that Resident #4 depends on tube feeding and has a tracheostomy in place. In an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide Tracheostomy care using a sterile technique for 1 of 1 sampled residents (Resident #4) reviewed for Respiratory Care. The findings included: Review of the facility's policy/procedure provided by the Director of Nursing titled, Tracheostomy Tube Cannula and Stoma Care revised on 11/28/22 documented, .This procedure should be performed using sterile technique and includes cleaning the stoma, neck, cleaning or replacing the inner cannula .if you must replace the disposable inner cannula, open the package containing the new inner cannula while maintaining sterile technique . Review of Resident #4's clinical record documented an admission date to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Encounter for Attention To Tracheostomy, Encephalopathy, and Chronic Respiratory Failure. Review of Resident #4's physician orders dated 05/14/22 documented, Tracheostomy care every shift and as needed.…

    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 before2023-01-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to: 1) secure/lock the non-controlled substance e-kit located in the 2- [NAME] unit's medication storage room; 2) failed to remove an IV (intravenous) start kit with an expiration date on [DATE]; 3) failed to remove a Gastrostomy tube feeding with an expiration date of 09/2017 in the 1- [NAME] unit's medication storage room; and 4) failed to secure/lock 1 of 3 treatment carts located in the 2-East unit. The findings included: Review of the facility's policy provided by the Director of Nursing (DON) titled, Storage and Expiration Dating of Medications, Biologicals revised on [DATE] documented .facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room facility should destroy or return all .outdated, expired .medications and biologicals . 1) On [DATE] at 3:45 PM, a side by side review of the facility's 2-West Unit's medication storage room 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 · D2023-01-27 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it exercised due diligence with regard to not promptly addressing, reporting and following-up on the resident's dental concerns, in a timely manner for 1 of 2 sampled residents observed ( Resident #48). The findings included: Review of the facility policy and procedure, titled Dental Services, provided by the Director of Nursing (DON), reviewed 08/18/22, documented in the Policy Statement: The facility is responsible for assisting the patient in obtaining needed dental services, including routine dental services. The facility will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each patient Skilled Nursing Facilities must provide or obtain from an outside resource .routine and 24-hour emergency dental care/services to meet the needs of each resident Must if necessary, or if requested, assist the resident: In making appointments;…

    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

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 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 4 of 53.4+0.6 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
DEVELOPERS INVESTMENT COMPANY II, INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 06/14/2006
PRESTON, FORRESTIndividualDIRECT OWNERSHIP INTEREST; INDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 09/03/2002
OSTROW, SARAHIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2025
PRESTON, AARONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
QUINTALL, WENDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 12/06/2021
LAY, LISAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/09/2018
SWANKER, RICHARDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2022
CROSS, CINDYIndividualCORPORATE OFFICERsince 09/25/2002
HENRY, TERRYIndividualCORPORATE OFFICERsince 09/25/2002
THURMOND, JOANIndividualCORPORATE OFFICERsince 09/25/2002
INVERRARY MEDICAL INVESTORS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/30/2002
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2025
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
KOCH, HOWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2025
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024

CMS files one row per role, so the 28 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

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.

$13.5M
Net patient revenuemost recent cost report
+1.7%
Operating marginrevenue minus expenses
$2.1M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 11%Other / private 27%

This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$340per resident / day
operating cost
$10,321per 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 106047. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.

What to do next