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Lake Port Square Health Center

701 Lake Port Blvd, Leesburg, FL 34748 · For profit - Limited Liability company · 80 certified beds · (352) 728-3366 Medicare & Medicaid certified

Call the home — (352) 728-3366 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 28 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
Worth asking about
  • 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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1070 Flagler Ave Ste A · (352) 365-2550 · Call to confirm hours
Pharmacy
620 S Lake St Ste 4 · (352) 460-4030 · Call to confirm hours
Grocery
223 S Canal St · (352) 787-8333 · Call to confirm hours
Park
201 Mills St · (352) 728-9886 · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased24.3%8.7%15.4%worse
Long-stay residents who lose too much weight10.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.3%4.6%6.5%worse
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 injury2.0%2.5%3.3%better
Long-stay residents on antianxiety or hypnotic medication13.9%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers6.8%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control31.3%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.7%94.7%79.4%better
Short-stay residents rehospitalized after admission29.4%26.1%22.6%worse
Short-stay residents with an outpatient ER visit15.6%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.692.131.67typical
Long-stay outpatient ER visits per 1,000 resident days1.241.151.80better

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.

66.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 297 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.1%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
35.5%U.S. median 56.6%
Met the expected recovery
0.73U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.34hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 35.5% 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 138 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 0.73 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 39% 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 SNF66.1%CMS range 60.4–70.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 8.3–13.510.7%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 discharge35.5%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 discharge44.9%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 discharge18.1%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 identified99.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.3%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 stay0.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.1%CMS range 4.6–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 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

0.82
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.27
Aide hours/ resident / day
4.03
Total nurse hours/ resident / day
0.46
RN hoursweekends
51.2%
Total nursing turnover
68.4%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 74.9 residents a day — about 94% occupied, or roughly 5 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.65 hrs/resident/day on weekends vs 4.19 on weekdays — 13% thinner on weekends. RN hours go from 0.96 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as 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

9
deficiencies at the latest standard inspection (2026-06-11)
7
at the previous standard inspection (2025-02-13)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and, #15) of 9 residents reviewed. Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and #15) of 9 residents reviewed. Findings include: During an observation on 6/8/2026 at 10:28 AM, Resident #8 was sitting in her wheelchair self-propelling in her room. There were no observations of restraints. During an interview on 6/8/2026 at 10:28 AM, Resident #8 stated, I have no concerns with my care and do not use any restraints. During an observation on 6/9/2026 at 2:14 PM, Resident #8 was sitting in activity room participating in activities in a wheelchair. No restraints observed at this time. Review of Resident #8's physician orders did not document orders for restraints. Review of Resident #8's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-11 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments were updated following documentation of a new diagnosis for 2 Residents (Resident #4 and #9) out of 5 residents sampled for preadmission screening and resident reviews (PASARR). Findings include:Review of Resident #9's admission record shows resident was admitted on [DATE] and readmitted on [DATE] with diagnosis including but not limited to Brief psychotic disorder [onset date 11/14/2025] and major depressive disorder [onset date 3/17/2026].Review of Resident #9's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASSR) dated 11/11/2025 did not document mental illness.Review of Resident #9's physician orders dated 11/18/2026 read, Quetiapine Fumarate Oral Tablet 25 MG [milligram] give 1 tablet by mouth at bedtime for Brief Psychosis for agitation and sedation.Review of Resident #9's [Name of Psychology Provider] admission Note dated 11/26/2026 reads, History of Present Illness: He was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-06-11 · 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

    Based on observation, interview and record review the facility failed to administer correct dosage amount of medication to 1 (Resident #9) of 6 residents reviewed for medication administration and failed to provide intravenous device care as per nursing standards for 1 (Resident#15) of 2 residents reviewed for intravenous infusions. Findings include: During an observation on 6/10/2026 at 8:10 AM Staff B, Licensed Practical Nurse (LPN) was pouring medication for Resident #9. Staff B, LPN, poured one tablet of Methotrexate Sodium 2.5 mg into the medication cup. When Staff B, LPN was finished pouring all medications, Staff B entered Resident 9's room and administered the medications. Staff B, LPN then exited Resident #9's room and signed off on all the medications. Review of Resident #9 physician order dated 2/09/2026 read, Methotrexate Sodium Oral Tablet 2.5 MG [milligram] (Methotrexate Sodium) give 6 tablet by mouth one time a day every Wed [Wednesday] for rheumatoid arthritis 6 X 2.5 mg=15mg. During an interview on 6/10/2026 at 12: 25 PM, Staff B, LPN, stated, I should have given…

    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 plan of correction
  • Potential for harm · D2026-06-11 · 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

    Based on observation, interview and record review the facility failed to provide nutritional supplements as order for 1 (Resident #12) of 6 residents reviewed for nutritional services. Findings include:During an observation on 6/8/2026 at 12:03 PM, Resident #12 was having lunch in her room. The meal tray contained soup, iced tea, noodles, brussels sprouts, peaches, and chicken. There was no nutritional treat observed. [photographic evidence obtained]During an interview on 6/8/2026 at 12:03 PM, Resident #12 stated, I do not get any additional nutrition treat. Nothing that is frozen. During an observation on 6/9/2026 at 12:48 PM, Resident #12 eating in her room. The tray contained iced tea, dessert, rice, vegetables, and pork. There was no frozen nutritional treat on the meal tray. [photographic evidence obtained]Review of Resident #12's physician order dated 11/26/2025 read, Frozen nutritional treat with Lunch and dinner two times a day for at risk for malnutrition.Review of Resident #12's medical record shows documented weights on 5/23/2026 187.4 lbs [pounds], 4/13/2026 194.6 lbs,…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-11 · 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

    Based on observation, interview and record review the facility failed to ensure the oxygen delivery rate was specified for 1 resident, Resident #11, and failed to ensure nebulizer equipment was properly stored for 1 resident, Resident #85, of 3 residents reviewed for respiratory care. Findings include: During an observation on 6/9/2026 at 8:12 AM, Resident #11 was semi reclined in his bed in his room. Resident #11 was being administered oxygen from a concentrator via nasal cannula at 2 liters per minute. Review of Resident #11's care plan, initiated 1/2/2026, revealed Resident #11 was at risk for complications related to sleep apnea secondary to the need for continuous positive airway pressure with a history of refusing the continuous positive airway pressure. Resident #11's respiratory care plan interventions included oxygen as needed to Promote lung expansion and improve air exchange by positioning with proper body alignment (if tolerated, head at 45 degrees). Review of Resident #11's physician's orders showed Resident #11 had physician orders that included O2 [Oxygen]: Clean…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow standards of medication storage for 2 out of 6 halls reviewed for unattended medication.Findings include: During an observation on 6/8/2026 at 9:15 AM Resident #86 was lying in bed. Resident #86's wife was at bedside. There was a clear medication cup with cream inside. Medication cup was not labeled. There were two normal saline flush syringes on top on nightstand. During an interview on 6/8/2026 at 2:11 PM, Staff I Licensed Practical Nurse (LPN) stated, I am not aware of any cream or normal saline flushes. I have not done any of it. During an interview on 6/8/2026 at 2:13 PM, Resident #86's Representative stated, The staff came in and applied the cream when the changed him [Resident #86]. During an interview on 6/8/2026 at 2:16 PM, Staff G Certified Nursing Assistant (CNA) stated, The wound care nurse gave me the cream this morning; I left it in his [Resident #86] room and when I came back I applied it. During an observation on 6/8/2026 at 10:25 AM Resident #38 was lying in bed. There was a clear…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure food was stored in a safe manner in the main kitchen and in 1 of 2 nourishment rooms. Findings include: During the initial tour of the main facility kitchen on 6/8/2026 at 9:38 AM, there was no thermometer in the walk-in freezer. During an interview on 6/8/2026 beginning at 9:38 AM, the Kitchen Manager agreed there was no stand-alone thermometer in the walk-in freezer. During an observations on 6/8/2026 beginning at 9:48 AM, the thermometer in the 300 Hall nourishment room freezer registered 30 Fahrenheit degrees. There were 7 thawed ice cream bars stored in the 300 Hall nourishment room freezer. During interview on 6/8/2026 beginning at 9:48 AM, the Kitchen Manager reported the thermometer in the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit. She agreed the ice cream bars stored in the 300 Hall nourishment room freezer were thawed. Review of the policy titled Food & Beverage Standards of Excellence, last reviewed 1/22/2026, read 5. Food will be purchased, stored, prepared and served…

    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 plan of correction
  • Potential for harm · D2026-06-11 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure garbage and refuse was disposed of properly.Findings include: On 6/8/2026 at 9:51 AM, there was a large dumpster with no lid that contained exposed filled household style plastic garbage bags. The plastic garbage bags were not secured from pests or wildlife. There was 1 small dumpster in the area. The left side top lid of the small dumpster was open exposing the contents of the dumpster to pests and wildlife.During an interview on 6/8/2026 beginning at 9:51 AM, the Kitchen Manager reported the large dumpster with no lid should not contain garbage. She acknowledged the left side top lid of the small dumpster was open exposing the contents of the dumpster to pests and wildlife.During interview on 6/9/2026 at 9:09 AM, the Interim Certified Dietary Manager reported the large dumpster was a construction dumpster and should not contain facility trash. Review of the facility policy titled Sanitization, last reviewed 1/22/2026, read, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-06-11 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to document therapy sessions for 1 (Resident #38) out of 2 residents reviewed for rehabilitation services.Finding includes:During an interview on 6/9/2026 at 8:24 AM Resident #38 stated , I want to know if I am going to have therapy today. The guy who does my physical therapy has been on vacation and I have not gotten therapy in weeks.Review of Resident #38 physician order dated 4/21/2026 read, PT [physical therapy] recertification order for PT TX [treatment] QD [everyday]1 X/WK [week] x 60 days for thera ex, thera activity, Gait training, PT. /CG ed. TX DX R53. 1 one time for 60 Days.Review of Resident #38 Service Log Matrix for the Month of May 2026 there is no documentation for 5/19/2026 visit.Review of Resident #38 Service Log Matrix for the Month of April 2026 there is no documentation for 4/14/2026 and 4/28/2026 visits.During an interview on 6/10/2026 at 10:18 AM with the Director of Therapy stated, He[Resident #38] did missed on April 14. There is no documentation. He is on the assignment board for functional…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1(Resident #20) of 3 residents reviewed for nutrition. Findings include: During an observation on 2/12/2025 at 5:48 AM, Staff I, Licensed Practical Nurse (LPN), entered Resident #20's room and administered medications to Resident #20 via gastric tube. Review of Resident #20's quarterly MDS dated [DATE] showed the resident did not have a feeding tube while a resident in the facility under Section K- Swallowing/Nutritional Status. Review of Resident #20's physician order dated 12/6/2024 showed it read, G-tube [gastric tube] Enteral feedings- Monitor for adverse reactions check residuals with Bolus feedings every shift for Dysphagia. Review of Resident #20's physician order dated 12/6/2024 showed it read, Jevity 1.2 55 ml/hr x 20 hours= 1100 ML [55 milliliters per hour times 20 hours equals 1100 milliliters] total up at 4 pm (afternoon) & down at 12P [PM] or until volume is delivered in the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-02-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 (Resident #26) of 5 residents reviewed for medication administration, and 2 (Resident #265 and Resident #266) of 4 residents reviewed for respiratory services. Findings include: 1) Review of Resident #26's admission record showed the resident was admitted on [DATE] with diagnoses to include atherosclerotic heart disease, cardiac pacemaker, prosthetic heart valve and atrial fibrillation (abnormal heartbeat). Review of Resident #26's physician order dated 1/18/2025 showed it read, Eliquis Oral Tablet 5 mg [milligrams] (Apixaban), Give 1 tablet by mouth two times a day for afib [atrial fibrillation]. Review of Resident #26's Medication Administration Record (MAR) for January and February 2025 showed the resident received Eliquis oral tablet 5 mg (Apixaban) as ordered. Review of Residents #26's care plan did not show a focus area or interventions for anticoagulant medication or a-fib. During 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · 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, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 (Resident #265) of 4 residents reviewed for respiratory services. Findings include: During an observation on 2/10/2025 at 9:10 AM, Resident #265 was sitting on left side of the bed dressed in gown. CPAP [Continuous Positive Airway Pressure] nose piece was attached to tubing and was resting on top of the bedside table. During an interview on 2/10/2025 at 9:10 AM, Resident #265 stated, I use the CPAP to breath better at night. During an observation on 2/10/2025 at 9:30 AM, Resident #265 was walking with walker in her room. CPAP nose piece was attached to tubing and was resting on top of the bedside table. During an observation on 2/12/2025 at 8:25 AM, Resident #265's CPAP nose piece was attached to tubing and was resting on top of the bedside table. Review of Resident #265's admission record showed the resident was admitted on [DATE] with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · 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

    2) During an observation on 2/10/2025 at 9:18 AM, Resident #43 was sitting in his room in a chair. There was one bottle of Latanoprost 0.005% eye drops on top of the bedside table (Photographic evidence obtained). During an interview on 2/10/2025 at 9:18 AM, Resident #43 stated, Someone brought it [eye drops] one night and left it behind. I think it needs to be thrown out. During an interview on 2/13/2025 at 9:10 AM, the Director of Nursing stated, [Resident #43's name] is not able to self-administer medications and medication should not be left unattended in the residents room. Review of the facility policy and procedures titled Medication Labeling and Storage with the last review date of 12/2/2024 showed it read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure food was safely and properly stored, labeled, or discarded in the areas of the kitchen walk-in cooler, and failed to ensure all areas were cleaned and free of debris. Findings include: A walk-through tour of the kitchen was conducted on 2/10/2025 at 9:12 AM with the Certified Dietary Manager (CDM)/Assistant Dining Manager. An observation was made of several containers of open food condiments [salad dressing, mustard, and sauces] in the reach-in cooler without an open date. An observation was made of numerous trash paper items and debris on the freezer floor and open box flaps exposing food items. An observation was made of a male staff member [Staff F, Dietary Aide] with no hair covering or beard guard. During an interview on 2/10/2025 at 9:28 AM, Staff F, Dietary Aide, confirmed he had not put on a hair net or beard guard when starting his job assignment. During an interview on 2/10/2025 at 9:19 AM, the CDM stated he was unaware of condiment containers in the reach-in cooler needing an open date. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 3 (Resident #26, #27, and #163) of 6 residents reviewed for medication administration. Findings include: 1) Review of Resident #27's physician order dated 1/30/2025 read, Amlodipine Besylate Oral Tablet 2.5 MG (milligram) (Amlodipine Besylate) Give 1 tablet by mouth at bedtime for htn (hypertension). Review of Resident #27's physician order dated 1/30/2025 read, Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth at bedtime for htn. Review of Resident #27's physician order 1/31/2025 read, Metoprolol Tartrate Tablet Give 12.5 mg by mouth one time a day for HTN Review of Resident #27's Medication Administrator Record (MAR) for the month of February 2025 documented Amlodipine Besylate 2.5mg was coded a 4 [vital sign outside of parameter] on 2/4 at 2100 [9:00 PM] no blood pressure or pulse documented and 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · 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

    Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to help prevent the spread and transmission of communicable diseases and follow infection control standards of practice for hand hygiene during 1 of 5 medication administration observations, 2 (Resident #265 and #266) of 10 residents reviewed for respiratory care equipment, 2 (Resident #20 and #167) of 4 residents reviewed for enhanced barrier precautions and 1(Resident #15) of 1 resident reviewed for transmission based precautions. Findings include: 1) During an observation on 2/10/2025 at 10:14 AM Resident #167's room had an enhanced barrier sign posted on the right side of the door entrance and personal protective equipment was observed upon entering the room. Staff G Certified Nursing Assistant (CNA) entered Resident #167's room with a towel and gown in her hand. Staff G donned a pair of gloves and began to assist Resident #167 to undress without donning personal protective equipment of a gown. Review of Resident #167's physician order dated 2/9/2025 read,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-11 · 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

    Based on observation, interview, and record review, the facility failed to ensure central venous catheter dressing was changed in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #3 and #4. Findings include: 1. Review of Resident #3's admission record showed the resident was admitted to the facility with the diagnoses including unspecified fracture of left forearm, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, arthritis due to other bacteria left elbow, atrial fibrillation, and pneumonia. During an observation on 4/11/2024 at 9:10 AM, Resident #3 was in bed with a right upper extremity peripherally inserted central catheter (PICC) line with a net stocking over the insertion site. The resident rolled down the netting. There was a gauze under a transparent dressing that was covering the insertion site. The transparent dressing was dated 4/1/2024. The dressing was curling up at the edges and the insertion site remained covered. During an interview on 4/11/2024 at 9:12 AM, Resident #3…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    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

    Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as prescribed by the physician for 2 of 4 residents reviewed for oxygen administration (Residents #20 and #64). Findings include: 1. Review of Resident #20's physician order dated 10/9/2023 showed oxygen to be administered at 2 liters per minute via nasal cannula for shortness of breath every shift. During an observation on 10/22/2023 at 9:33 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 3.5 liters per minute. During an observation on 10/23/2023 at 8:17 AM, Resident #20 was lying in her bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. During an observation on 10/24/2023 at 8:23 AM accompanied with the Weekend Supervisor Registered Nurse, Resident #20 was being administered oxygen via nasal cannula at 2.5 liters per minute. During an interview on 10/24/2023 at 8:23 AM, the Weekend Supervisor Registered Nurse confirmed Resident #20 was being administered oxygen at 2.5 liters per minute. He stated he was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-25 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 ensure the consulting pharmacist reported any irregularities to the attending physician and director of nursing, and these reports were acted upon for 3 of 5 residents reviewed for unnecessary medications (Residents #1, #36 and #59). Findings include: 1. Review of Resident #1's admission record showed the resident was admitted initially on 11/27/2014 and most recently on 10/14/2023 with diagnoses including unstable angina, anxiety disorder, type II diabetes mellitus, dementia, bipolar disorder, and muscle weakness. Review of the consulting pharmacist's recommendations for Resident #1 dated 7/13/2023 showed the recommendation for adding Sitagliptin 100 mg daily for diabetes was accepted by the physician. Review of Resident #1's medical records revealed no record for addition of Sitagliptin 100 mg daily for diabetes. 2. Review of Resident #36's admission record showed the resident was admitted initially on 9/30/2016 and most recently on 3/19/2023 with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 1 of 3 residents reviewed for communication/sensory services (Resident #23), 1 of 1 resident reviewed for hospice services (Resident #15), 2 of 6 residents reviewed for nutrition (Residents #6 and #21), and 1 of 4 residents reviewed for respiratory care (Resident #35). Findings include: 1. Review of Resident #23's inventory of personal effects downloaded on 7/28/2023 revealed the resident was admitted to the facility with right and left side hearing aids. Review of Resident #23's admission Medicare 5-Day MDS assessment dated [DATE] showed Section B. Hearing, Speech and Vision, B0300. Hearing Aid had been documented as No to indicate Resident #23 did not use a hearing aid or other hearing appliance. During an interview on 10/24/2023 at 10:34 AM, the MDS Coordinator stated Resident #23's admission 5-day MDS had been coded incorrectly related to use of hearing aids. 2. Review of Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for oxygen therapy (Resident #35) and failed to implement weight orders for 1 of 6 residents reviewed for nutrition (Resident #48). Findings include: 1. Review of Resident #35's physician order dated 6/22/2023 reads, Oxygen administration 4 LPM [liters per minute] PRN [as needed] for sats [oxygen saturation] below 90% as needed for low oxygen level. Order Status: Active. Review of Resident #35's care plan did not show the resident was care planned for oxygen administration. During an interview on 10/24/2023 at 10:37 AM, the MDS (Minimum Data Set) Coordinator stated, I oversee care plans. I do not think that [Resident #35's name] has a care plan focus for oxygen. 2. Review of Resident #48's physician order dated 4/17/2023 reads, Weekly weight. Order Status: Active. Review of Resident #48's care plan initiated on 4/17/2023 reads, [Resident #48's name] is at increased nutritional risk r/t [related to] hx [history of] dx [diagnosis] protein calorie malnutrition,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to treat pressure ulcers for 1 of 3 residents reviewed for skin conditions (Resident #54). Findings include: Review of Resident #54's Wound Evaluation and Management Summary dated 10/17/2023 revealed the resident had a stage 3 pressure wound of left distal lateral calf and a stage 4 pressure wound of the right heel. The wounds were assessed as not at goal. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse L [left] distal lateral calf with NS [normal saline], apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse right heel with NS, pat dry and apply collagen powder followed by santyl and cover with dry protective dressing every day shift for wound care. During an observation on 10/22/2023 at 11:11 AM, Resident #54 was lying in bed with her feet offloaded on top of a pillow with a dressing dated 10/20/2023 on left…

    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 · D2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as is possible and each resident received adequate supervision while being transferred utilizing a mechanical lift for 1 of 2 residents reviewed for accidents (Resident #17). Findings include: During an observation on 10/22/2023 at 10:00 AM, Staff C, Restorative Specialist, was using a mechanical lift and sling independently to weigh Resident #17 above his bed. Review of Resident #17's admission records showed the resident was admitted initially on 11/1/2013 and most recently on 10/7/2022 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic obstructive pulmonary disease. Review of Resident #17's physician order sated 2/13/2023 reads, Total mechanical lift with large sling. Order Status: Active. Review of Resident #17's care plan dated 5/21/2020 reads, Focus: [Resident #17's Name] has an ADL [Activities of Daily Living)] Self Care Performance Deficit. Activity Intolerance,…

    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 before2023-10-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts and failed to ensure the medication were secured in 1 of 2 units. Findings include: During an observation of the Blue Medication Cart (300 Hall) on 10/22/2023 at 9:28 AM with Staff D, License Practical Nurse (LPN), there was one opened Novolog insulin pen with no opened or expiration dates. During an interview on 10/22/2023 at 9:31 AM, Staff D, LPN, stated, I do not see an opened date. Once we open an insulin pen, it should be labeled with the open and expiration date. During an observation of the Medication Cart 1-2 (400 Hall) on 10/22/2023 at 9:33 AM with Staff E ,LPN, there was one opened Systane Comp (complete) 0.6% eye drops with no opened or expiration dates, one opened Humulin N insulin pen with no opened or expiation dates, and one Fluoromethol 0.1% ophthalmic drops with no opened and expiration dates. During an interview on 10/22/2023…

    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 · D2023-10-25 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide laboratory services for the monitoring of Valproic Acid levels for 3 of 7 residents reviewed for mood and behavior (Residents #6, #17, and #25). Findings include: 1. Review of Resident #6's physician order dated 4/4/2023 reads, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG [milligram] (Divalproex Sodium). Give 2 capsule by mouth two times a day for mood disorder. Order Status: Active. Review of Resident #6's physician order dated 6/2/2023 reads, Depakote level every night shift every 3 month(s) starting on the 2nd for 1 day(s). Order Status: Active. Review of Resident #6's Lab Results Report dated 6/3/2023 showed the result for Valproic Acid (Depakote) as 26 ug/ml [micrograms per milliliter], flagged for low. Review of Resident #6's laboratory records showed no Valproic Acid labs completed in September 2023. 2. Review of Resident #25's physician order dated 5/30/2023 reads, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, Give 1 capsule by mouth three times a day for mood disorder.…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure treatment of pressure ulcers was accurately documented for 1 of 3 residents reviewed for skin conditions (Resident #54). Findings include: Review of Resident #54's physician order dated 10/17/2023 reads, cleanse L [left] distal lateral calf with NS [normal saline], apply collagen sheet and cover with dry protective dressing every day shift for wound care. Review of Resident #54's physician order dated 10/17/2023 reads, cleanse right heel with NS, pat dry and apply collagen powder followed by santyl and cover with dry protective dressing every day shift for wound care. During an observation on 10/22/2023 at 11:11 AM, Resident #54 was lying in bed with her feet offloaded on top of a pillow with a dressing dated 10/20/2023 on left distal lateral calf. Review of Resident #54's Treatment Administration Record (TAR) for October 2023 showed the wound care for left distal lateral calf was provided on 10/21/2023. During an observation on 10/23/2023 at 11:05 AM, Resident #54 was sitting in a wheelchair in her…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-25 · 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

    Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, during wound care for 1 of 3 residents reviewed for wound care (Resident #54), and during providing direct care to Resident #64. Findings include: 1. During an observation on 10/24/2023 at 8:29 AM, Staff F, Registered Nurse (RN), performed hand hygiene with hand sanitizer and began to prepare medication for Resident #26. Staff F opened the lower drawer of the medication cart and poured 30 milliliters of Prostat into a medication cup. Staff F did not don gloves. Staff F grabbed two Acidophlilus capsules with his hands and placed them in the medication cup. Staff F used the mouse and keyboard to type the reason why Norvasc was being held. Staff F grabbed 2 Arimidex, Ascorbic Acid, Baclofen, Bumex and Clopidogrel with his hands and placed them in a medication cup. Staff F touched the computer mouse in between preparing medications. Staff F used hand sanitizer and poured Pepcid without touching the medication. Then, Staff F, without donning…

    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
  • No harm found · C2023-10-25 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation on 10/22/2023 at 9:23 AM, the posted nurse staffing information showed the information for 10/20/2023. During an interview on 10/22/2023 at 9:28 AM, the Weekend Supervisor Registered Nurse stated, I believe the Staffing Coordinator is responsible for posting the weekend staffing numbers, possibly even me. During an interview on 10/22/2023 at 10:51 AM, the Administrator stated, The Weekend Supervisor is supposed to display the correct day [staffing for the day]. The nurse staffing information was completed in advance and the Weekend Supervisor was supposed to make any staffing changes daily and post accurate staffing data. Review of the facility policy titled Procedure on Required Daily Staff Posting reads, Purpose: To comply with the requirement of posting the daily staffing. Procedure: The facility Staffing Coordinator will prepare the Daily Staffing Posting daily for the following day and place in 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.

    Nursing and Physician Services 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 HEALTHPEAK PROPERTIES, INC. — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.5-0.5 vs chain
Health inspection 3 of 53.1-0.1 vs chain
Staffing 3 of 54.3-1.3 vs chain
Quality measures 3 of 53.9-0.9 vs chain
The other 14 homes this chain runs (chain average 3.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
CCRC OPCO VENTURES, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/29/2014
HCP MA3 GP HOLDING, LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/19/2026
HCP VENTURES II TRS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/19/2026
JANUS LIVING TRS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/19/2026
JANUS LIVING OP LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 03/19/2026
CHENG, PATRICKIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2022
MOHADEO, TRISTANIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/05/2026
RUSSO, FRANKIndividualMANAGING CONTROL - GOVERNING BODYsince 01/31/2022
LIFE CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2020
BUETTNER, MARKUSIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/31/2025
MARTINEZ IRIZARRY, AXELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
VALLEJO AGUDELO, ANDRESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2026
HCP MA3, LPOrganizationLIMITED PARTNERSHIP INTEREST; ADP OF THE SNFsince 03/19/2026
HCP PARTNERS LPOrganizationLIMITED PARTNERSHIP INTEREST; ADP OF THE SNFsince 03/19/2026
BLACKROCK INCOrganizationADP OF THE SNFsince 03/19/2026
CCRC PROPCO VENTURES, LLCOrganizationADP OF THE SNFsince 03/19/2026
HCP S-H 2014 MEMBER LLCOrganizationADP OF THE SNFsince 02/01/2020
HCP VENTURES II PARTNER LLCOrganizationADP OF THE SNFsince 03/19/2026
HCP/LS 2011 REIT, LLCOrganizationADP OF THE SNFsince 03/19/2026
HEALTHPEAK OP LLCOrganizationADP OF THE SNFsince 02/10/2023
HEALTHPEAK PROPERTIES INCOrganizationADP OF THE SNFsince 02/01/2020
JANUS LIVING, INC.OrganizationADP OF THE SNFsince 03/19/2026
JANUS MEMBER, LLCOrganizationADP OF THE SNFsince 03/19/2026
OCEAN ACQUISITION I LLCOrganizationADP OF THE SNFsince 03/19/2026
STATE STREET CORPORATIONOrganizationADP OF THE SNFsince 03/19/2026
VANGUARD GROUP INCOrganizationADP OF THE SNFsince 03/19/2026

CMS files one row per role, so the 34 rows in the source record cover these 26 parties — each is shown once here with every role it holds. Nothing is omitted.

20 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.

$11.4M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 16%Medicare 23%Other / private 61%

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

$927per resident / day
operating cost
$28,195per month
≈ monthly operating cost
$328per 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 105705. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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