South Campus Care Center And Rehab
715 E Dixie Ave, Leesburg, FL 34748 · For profit - Limited Liability company · 120 certified beds · (352) 728-3020 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (56%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.4% | 4.6% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.1% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 0.0% | 14.4% | 18.9% | check this* — see note marked star below the table |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 1.7% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 78.0% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 34.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.6% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.30 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.52 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.6% 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 109 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 45.5% 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 121 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.6%CMS range 35.5–52.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.3–14.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 45.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 31.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 92.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 55.8% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 59.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.8–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.28 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 113.6 residents a day — about 95% occupied, or roughly 6 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 3.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 3.27 hrs/resident/day on weekends vs 3.75 on weekdays — 13% thinner on weekends. RN hours go from 0.47 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · D2026-04-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 interview and record review the facility failed to inform the resident representative of discharge for one (Resident #2) of 3 residents reviewed for discharge. Findings include: Review of Resident #2's census data showed Resident #2 was admitted to the facility on [DATE] with the payor source hospice respite private. Review of Resident #2's Discharge Return not Anticipated minimum data assessment, dated 3/21/2026, showed Resident #2's cognitive summary score to be 7 [severe problems with memory and thinking]. Review of Resident #2's admission record showed his spouse was listed as emergency contact #1 and diagnoses that included vascular dementia with agitation. Review of Resident #2's progress note, dated 3/19/2026, read Patient admitted for a 5-day respite stay through [Name of Hospice Provider] with a diagnosis of cerebral atherosclerosis. Resident is A&Ox2 [alert and oriented times 2]. Review of the facility grievances showed Resident #2's spouse filed a grievance with the facility on 3/21/2026 that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a homelike physical environment when access to the pull cords for the lighting fixtures behind the resident's beds were unavailable for residents for one of three hallways.Findings include: During an interview on 1/5/2026 at 9:40 AM, Resident #128 stated, Since I have been here, I cannot turn on my over-the-bed light because there is no string to pull. It has been like this since I was admitted . I have told nursing. During an observation on 1/5/26 at 9:40 AM, the light was off behind Resident #128's bed and there was no cord attached to the pull chain that would enable the resident to turn the light on himself. During an interview on 1/5/26 at 10:45 AM, Resident #125 stated, 'The environment needs repair. I cannot access the light cord behind the bed.During an observation on 1/5/26 at 10:45 AM, the light cord for light behind Resident #125's bed was not long enough for her to control the light.During an interview on 1/6/26 at 8:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident # 0) of 8 residents reviewed. Findings include:During an interview on 1/5/2025 at 11:08 AM, Resident #50 stated, The port was when I was getting chemotherapy.During an observation on 1/5/2026 at 11:08 AM, Resident #50 had a venous access port (a small, implanted device placed under the skin to provide long term access to a vein for medications, fluids, and blood draws) near her left shoulder with a dressing covering it. The dressing is dated 12/5/2025. Photographic evidence obtained on 1/5/2025 at 11:08 AM. During record review of Resident #50's resident centered plan of care, there is no care plan for Resident #50's venous access port.During interview on 1/7/2026 at 10:10 AM, [NAME] Unit Manager, Licensed Practical Nurse (LPN) stated, I do not see a care plan for the resident for her access port. There should have been a plan of care for her venous access port.Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, receive the necessary services to maintain good grooming and clean clothing for 1 of 7 residents (Resident #33) reviewed for activities of daily living.Findings include:On 1/5/26 at 11:04 AM, Resident #33 was observed in a visibly soiled jacket and pants, facial hair unkept in appearance and had a sour body odor. Resident was pleasantly confused, standing at the doorway to his room.On 1/6/26 at 9:58 AM, Resident #33 was observed in the same visibly soiled jacket and pants, partially fallen due to missing belt loops, facial hair unkept in appearance, and a foul/sour body odor. Resident is observed standing in the hallway next to the door of his room.On 1/7/26 at 8:52 AM, Resident #33 was observed in the same visibly soiled jacket and pants, partially fallen due to missing belt loops, facial hair unkept in appearance, and a foul/sour body odor. Resident #33 is observed walking the hallway in the unit.Review of Resident #33's admission record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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 adhere to professional standards of practice for the care and maintenance of a venous access catheter port for 1 (Resident #50) of 2 residents reviewed.Findings include:Review of the medical record for Resident #50, documented tunneled venous access catheter was in place for the administration of chemotherapy for cancer. During an interview on 1/5/2026 at 11:05 AM, Resident #50, stated I had the port placed for chemotherapy. They are not using it now. During an observation on 1/5/2026 at 11:05 AM, Resident #50 has a venous access port (implanted device to provide long term access for medications) near her left shoulder with a dressing covering it. The dressing is dated 12/5/2025. (Photographic evidence obtained) During an interview on 1/7/2026 at 10:10 AM, the [NAME] Unit Manager/Licensed Practical Nurse (UMLPN) stated, Our policy is an access port needs to have weekly changes of the Huber needle and dressing. The dressing should have been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for 1 (Resident #117) of 3 residents reviewed for advance directives and respiratory services.Findings include:Review of the admission record for Resident #117 documented an initial admission date of 12/2/25 and a re-admission date of 1/3/26.On 1/5/25 at 10:50 AM, Resident #117 was observed wearing oxygen (O2) via nasal cannula on 2 liters with the oxygen concentrator.During an interview on 1/5/26 at 10:50 AM, Resident #117's significant other, who was at resident's bedside, stated [Resident #117's Name] was hospitalized for Respiratory Syncytial Virus (RSV) and was brought back to facility on Saturday after the hospital said she was stable to return. The cough has been persistent since diagnosis of RSV and has improved. [Resident #117's Name] being on oxygen is new and never [had] been on oxygen prior to this episode. On 1/6/26 at 3:24 PM, Resident #117 was observed in bed wearing O2 on 2 liters with the oxygen concentrator, resident is being repositioned by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observations and interviews, the facility failed to provide a clean homelike environment for 2 of 9 residents, Residents #1 and #7, reviewed for environment. Findings include: 1) During an observation on 4/29/2025 at 10:39 AM of Resident #1's room and bathroom there were tiles noted to be missing along the wall of the sink and toilet, these were located along the baseboard of the wall. The bathtub does have a rust colored discoloration near the faucet and brown staining on the tile along the wall. (Photographic evidence obtained) During an interview on 4/29/2025 at 3:20 PM the Regional Plan Operator stated, The condition of the tiles and bathtub were not acceptable and needed to be fixed. During an interview on 4/29/2025 at 3:40 PM the EVS (Environmental Services) Manager stated, The bathtub discoloration is not to his expectations for cleanliness. 2) During an observation on 4/29/2025 at 9:15 AM of Resident #7's room there was a loose baseboard with dry wall debris that spans the length of Resident #7's bed. (Photographic evidence obtained) During an interview on 4/29/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews the facility failed to document blood glucose levels and administration of insulin for one of 3 residents, Resident #1, reviewed for medication administration, and 1 of 3 residents, Resident #1, reviewed for wound care. Findings include: 1) Review of Resident #1's medical record documented a medical diagnosis of diabetes mellitus (DM) type 2. Review of the physician order dated 2/20/2025 for Resident #1 read, Insulin Lispro subcutaneous solution pen 100 unit/ml (milliliter), inject 4 units subcutaneously before meals for DM and Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml, inject 15 units subcutaneously at bedtime for DM. Review of the physician order dated 2/21/2025 for Resident #1 read, Glucose monitoring before meals and at bedtime for DM. Review of the medication administration record for April 2025 for Resident #1 did not provide documentation of the administration for Insulin Lispro for April 27th at 4:30 PM, Insulin Glargine for April 27th at 9:00 PM, and did not provide documentation of Resident #1's blood…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to ensure food was stored, covered, labeled, or discarded in the kitchen walk-in coolers and dry storage areas and maintained standards of practice for cleaning and sanitary conditions in the dietary department. Findings included: An initial walk-through of the kitchen was conducted on 7/21/24 at 9:00 AM with the Dietary Manager (DM). An observation was made at 9:08 AM of two large full containers of cottage cheese with an expiration date of 7/14/24. An observation was made in the walk-in cooler of a large metal bowl of a fruit type mixture with no identifying label or date. An observation was made in the kitchen of a dirty cloth and a dirty metal scrubby left on the sink and not in a Santi-container or solution. An observation was made in the dish room of 3 large 5-gallon containers of chemicals for the dish machine stored on the floor. (photographic evidence obtained) An interview was conducted with the Dietary Manager (DM) at 9:15 AM. The DM confirmed he observed the two large cottage cheese containers 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.
- Potential for harm · D2024-07-24 · tag F0641 — isolatedEnsure 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 assessments accurately reflect the resident's status for 1 (Resident #109) of 3 residents reviewed for range of motion and 1 (Resident #20) of 2 residents reviewed for gastrostomies. Findings include: 1. During an observation on 7/21/2024 at 10:05 AM, Resident #109 was lying in bed guarding his right arm with his left hand. During an interview on 7/21/2024 at 10:05 AM, Resident #109 was asked if he was able to move both arms without limitations, he nodded No and touched his right hand. When asked if he was able to move both lower extremities without limitation he nodded No. Review of Resident #109's admission record documented resident was admitted on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and muscle weakness. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], documented in Section GG titled Functional Abilities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2024-07-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who needed assistance to perform activities of daily living (ADLs) received assistance for 1 of 3 residents reviewed for ADL care, Resident #367. Findings include: Review of Resident #367's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, difficulty in walking, need for assistance with personal care, other abnormalities of gait and mobility, muscle weakness, hyperlipidemia, constipation, essential (primary) hypertension, low back pain, gout, opioid dependence, personal history of malignant neoplasm of prostate, gastrointestinal hemorrhage, headache, obstructive sleep apnea, hypo-osmolality and hyponatremia, chronic diastolic (congestive) heart failure, chronic kidney disease, and anemia. During an observation 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.
- Potential for harm · Dcited before2024-07-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 interview and record review, the facility failed to ensure the residents received medication per physician orders for 1 (Resident #37) of 7 residents reviewed for medication administration. Findings include: Review of Resident #37's physician's order, dated 1/14/2024, read Acetaminophen Tablet 325mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain, level 1-3, related to pain, unspecified (R52) not to exceed 3gm (grams)/3000mg per 24 hours . Review of Resident #37's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen Tablet 325mg on June 2 at 0429 [4:29 AM] for a pain level of 4, June 3 at 0500 [5:00 AM] for a pain level of 5, June 6 at 0929 [9:29 AM] for a pain level of 7, June 7 at 0053 [12:53 AM] for a pain level of 7, June 13 at 1423 [2:23 PM] for a pain level of 4, June 14 at 0447 [4:47 AM] for a pain level of 4, June 15 at 1907 [7:07 PM] for a pain level of 10, June 16 at 0500 [5:00 AM] for a pain level of 5, June 26 at 0101 [1:01 AM] for a pain level of 7, June 27 at 0050 [12:50 AM] for a pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record review, and interview, the facility failed to ensure residents received oxygen according to physician order for 1 of 3 residents sampled for respiratory care, Resident #366. Findings include: Review of Resident #366's admission record showed the resident was admitted on [DATE] with the diagnoses including diabetes mellitus due to underlying condition, chronic obstructive pulmonary disease, overreactive bladder, nondisplaced fracture of lateral malleolus of right fibula, chronic systolic (congestive) heart failure, depression, dementia, obstructive sleep apnea, atherosclerotic heart disease, repeated falls, muscle weakness, essential (primary) hypertension, morbid (severe) obesity due to excess calories, and anxiety disorder. During an observation on 7/21/2024 at 9:50 AM, Resident #366 was in bed, receiving oxygen through nasal cannula at 3.5 liters per minute (LPM). During an interview on 7/21/2024 at 9:51 AM, Resident #366 stated, I need oxygen at 2 liters 24/7. 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.
- Potential for harm · D2024-07-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for unattended medications in 1 unit of 3 units. Findings Include: During an observation on 7/21/2024 at 9:25 AM in Resident #109's room, there was one unopened packet of zinc oxide formula barrier cream on top of the room drawer. [photographic evidence obtained] Review of Resident #109's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:37 AM of Resident #38's room, there was one unopened packet of zinc oxide formula barrier cream on top of resident's bedside table. [photographic evidence obtained] Review of Resident #38's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:38 AM of Resident #78's room, there were two packets of unopened oxide formula barrier cream on top of resident's television table. [photographic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing dining services and failed to ensure staff used appropriate personal protective equipment while providing high contact direct care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Findings include: 1. During an observation on 7/22/2024 at 12:00 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #105's room and delivered a meal tray. Staff A exited the room and returned with a drink. Staff A exited the room and did not perform hand hygiene. Staff A walked down the hall and entered another resident's room and quickly exited the room. Staff A entered Resident #12's room and without performing hand hygiene started to assist the resident with lunch meal. Staff A stood at the room doorway and went back into the room. Staff A lifted Resident #20's plate cover and asked if the resident was hungry and wanted to eat. Staff A, without performing hand hygiene, returned to Resident #12'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.
- Potential for harm · Dcited before2023-11-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to maintain accurate and complete medical records for 2 of 3 residents reviewed for documentation, Residents #1 and #10. Findings include: 1. Review of Resident #1's admission record revealed the resident was admitted to the facility with the diagnoses including unspecified right femur fracture, respiratory failure, type 2 diabetes mellitus, anemia, chronic pain, right knee, left knee right hand contracture, unspecified atrial fibrillation, adult failure to thrive, atherosclerosis of coronary artery bypass grafts without angina pectoris, unspecified heart failure, unspecified seizures, status post colostomy, presence of cardiac pacemaker, and essential hypertension. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left inner ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's Treatment Administration Record (TAR) for October 2023 showed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-15 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process to monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained for the concerns identified with documentation of wound care. Findings include: Review of the policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 reads, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain documentation and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 services consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen administration, Residents #84, #227, and #321, in a total sample of 52 residents. Findings include: 1. During an observation on 3/12/2023 at 1:01 PM, Resident #321 was lying in bed with oxygen running at 3.5 liters per minute via nasal cannula. During an observation on 3/13/2023 at 8:43 AM, Resident #321 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. Review of Resident #321's admission records revealed the resident was admitted to the facility on [DATE] with the diagnoses including contracture on right knee, right hand, and left knee, other muscle spasm, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, unspecified atrial fibrillation, adult failure to thrive, sick sinus syndrome, heart failure, peripheral vascular disease, unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accommodate resident needs were accommodated by failing to have functioning call light system for 1 of 3 residents reviewed for falls, Resident #102. Findings include: During an observation on 3/12/2023 at 9:57 AM, Resident #102 was in bed with a bell noted on top of the bedside table. During an interview on 3/13/2023 at 9:57 AM, Resident #102 stated, My call light has not been working for four months now. Maintenance came in and the part they brought did not work. That was months ago. The staff will not answer when I ring the bell. They never come. During an interview on 3/13/2023 at 9:58 AM, Resident #30 stated, I will turn my light on when he needs help. During an observation on 3/13/2023 at 10:00 AM, Resident #102 pressed the call light. The light did not turn on outside of the room. During an observation on 3/14/2023 at 10:35 AM, Resident #102 was ringing the bell. Staff I, Licensed Practical Nurse (LPN), was in the hallway.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-15 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for 7 of 12 residents reviewed for resident assessments, Residents #22, #37, #68, #79, #88, #110, and #112, in a total sample of 52 residents. Findings include: Review of the Minimum Data Set (MDS) with the MDS Coordinator revealed the following: Resident #22: Assessment Type: Quarterly, Assessment Reference Date: 2/8/2023, Status: 35 days overdue; Resident #37: Assessment Type: Quarterly, Assessment Reference Date: 2/13/2023, Status: 30 days overdue; Resident #68: Assessment Type: Quarterly, Assessment Reference Date: 2/8/2023, Status: 35 days overdue; Resident #79: Assessment Type: Quarterly, Assessment Reference Date: 1/26/2023, Status: 44 days overdue; Resident #88: Assessment Type: Quarterly, Assessment Reference Date: 2/15/2023, Status: 28 days overdue; Resident #110: Assessment Type: Quarterly, Assessment Reference Date: 2/12/2023, Status: 31 days overdue; Resident #112: Assessment Type: Quarterly, Assessment Reference Date:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, interview, and record review, the facility failed to implement a comprehensive person-centered care for 2 of 3 residents reviewed for comprehensive care plans, Residents #19 and #116, in a total sample of 52 residents. Findings include: 1. Review of the admission record for Resident #116 documented the diagnoses including encounter for other orthopedic aftercare, unspecified dementia, anemia, unspecified atrial fibrillation, dysphasia oral pharyngeal phase, essential primary hypertension, unspecified protein calorie malnutrition, iron deficiency anemia secondary to blood loss, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of other venous thrombosis and embolism, thrombocytopenia, and unspecified malignant neoplasm of skin. During an observation on 3/13/2023 at 8:05 AM, Resident #116 was in bed on a low air loss mattress lying on back. During an observation on 3/14/2023 at 8:51 AM, Resident #116 was on a low air mattress in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 medications were administered in a timely manner for 3 of 7 residents observed for medication administration, Residents #79, # 371, and #30, and failed to ensure physician ordered bed rail adaptations were in place 1 of 6 residents reviewed for safety, Resident #83. Findings include: 1. During an observation on 3/14/2023 at 10:12 AM, Staff H, License Practical Nurse (LPN), entered Resident #79's room and informed the resident the medication was late and asked if she would like to take her medication. Resident #79 agreed to take her medication. Staff H administered one tablet of Aspirin 325 milligrams (mg), one tablet of Amlodipine Besylate 10 mg and 120 milliliters (ml) of Med Pass 2.0. During an interview on 3/14/2023 at 10:20 AM, Staff H, LPN, stated, Medications are late due to facility not allowing medication pass when food is being delivered or when residents are eating. Review of Resident #79's Medication Administration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents received the necessary services for personal hygiene for 2 of 2 residents sampled for activities of daily living, Residents #25 and #87, in a total of 52 residents. Findings include: During an interview on 3/12/2023 at 10:38 AM, Resident #25 stated, I do not get a shower sometimes because they do not have enough linens and towels to do it. When I get a bed bath or shower, it is often late in the day due to waiting for linens and I like to get up in my wheelchair in the mornings. Review of Resident #25's admission record revealed the resident was admitted to facility on 9/24/2016 with diagnoses including osteoarthritis, major depressive disorder, multiple sclerosis, chronic fatigue, pain, contracture left hand, abnormal posture, and muscle weakness. Review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] denoted the resident as total dependence for bathing with two persons physical assistance. During an observation 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.
- Potential for harm · Dcited before2023-03-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106. Findings include: During an observation on 3/14/2023 at 7:41 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #106's room to administer a normal saline flush (used before and after medication administration to prevent mixing of medication). Staff C administered 10 milliliters of normal saline intravenously. Staff C did not check for line patency via blood return, (the procedure used to determine line patency, to verify the line is opened and not blocked), prior to administering the normal saline flush. During an observation on 3/14/2023 at 8:42 AM, Staff C, LPN, administered Cefepime (an antibiotic) IV (intravenous) to Resident #106. Staff C did not administer a normal saline flush or check PICC (peripherally inserted central catheter) line patency prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-15 · tag F0770 — failed to provide lab services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide laboratory services to meet the needs of 1 of 6 residents reviewed for Medication Regimen, Resident #29. Findings include: Review of Resident #29's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, unspecified protein-calorie malnutrition, anxiety disorder, anemia, other seizures, essential hypertension, unspecified atrial fibrillation, cardiomegaly, chronic kidney disease, major depressive disorder, and chronic obstructive pulmonary disease. Review of the physician order dated 3/7/2021 for Resident #29 reads, Keppra level every night shift every 90 day(s). Review of Resident #29's medical records did not reveal a Keppra lab result for the month or February 2023 or March 2023. Review of Resident #29's Treatment Administration Record for February 2023 revealed Keppra level was completed on 2/25/2023. Review of the Treatment Administration Record for March 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.
- Potential for harm · Dcited before2023-03-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106, in a total sample of 52 residents. Findings include: During an observation on 3/14/2023 at 7:41 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #106 's room to administer a normal saline flush. Staff C did not perform hand hygiene, donned gloves and removed the peripherally inserted central catheter (PICC) line from a mesh stockinette on Resident #106's right upper arm. Staff C removed a green cap off the hub of the insertion site, turned to retrieve the normal saline flush, dropped the PICC line resulting in the hub resting on the skin of Resident #106's right arm. Staff C did not clean the needleless connector, administered 10 milliliters of normal saline intravenously and reapplied the same green cap to the hub. During an observation on 3/14/2023 at 8:42…
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.
- No harm found · C2024-07-24 · tag F0732 — widespreadPost 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 7/21/2024 at 9:04 AM, the nurse staffing information posted at the entrance lobby was dated 7/19/2024. During an interview on 7/21/2024 at 9:04 AM, Staff J, Licensed Practical Nurse (LPN) Supervisor, confirmed that the staffing information posted at the entrance lobby was dated 7/19/2024 and it had not been updated. During an interview on 7/22/2024 at 3:02 PM, the Administrator stated, The Staffing Coordinator is responsible for preparing the weekend staffing information and the receptionist is responsible for displaying it. The information was prepared but not displayed. Review of the facility policy and procedure titled Staff Postings issued on 4/1/2022 and last reviewed on 11/29/2023, read, Policy: It will be the policy of this facility to display staff posting information for visitors, families, residents and staff to be able to see. Procedure: 1. Nurse Staffing Information: (1) Data requirements. 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GOLD FL TRUST II — 36 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SOUTH CAMPUS NURSING HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| FL SNF TRUST I | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| FL SNF TRUST II | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/27/2022 |
| WAGONER, JOSHUA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105375. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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.