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Luxe At Lutz Rehabilitation Center (the)

19091 N Dale Mabry Hwy, Lutz, FL 33548 · For profit - Limited Liability company · 120 certified beds · (813) 751-0557 Medicare & Medicaid certified

Call the home — (813) 751-0557 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20231 actual-harm citation$50,225 in federal fines
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $50,225 in federal fines (most recent 2025-05-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • about 17% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
19021 N Dale Mabry Hwy · (813) 961-5201 · Call to confirm hours
Pharmacy
1040 Dale Mabry Hwy · (813) 435-2934 · Call to confirm hours
Grocery
Publix0.4 mi
19221 N Dale Mabry Hwy · (813) 949-3882 · Call to confirm hours
Park
766 W Lutz Lake Fern Rd · Typically dawn to dusk
Place of worship
18932 Dale Mabry Hwy N · (813) 909-2166

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 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 fell from 3 to 2 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 rating2★
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 increased11.2%8.7%15.4%better
Long-stay residents who lose too much weight7.4%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%2.5%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened10.7%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.7%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine96.6%99.2%95.3%typical
Long-stay residents with pressure ulcers3.2%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control24.1%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 table7.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine88.6%94.7%79.4%better
Short-stay residents rehospitalized after admission27.0%26.1%22.6%worse
Short-stay residents with an outpatient ER visit7.6%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.502.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.171.151.80better

* 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.

46.1% 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 304 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.1%U.S. median 51.5%
Got home and stayed home
13.9%U.S. median 10.7%
Went back to hospital
31.0%U.S. median 56.6%
Met the expected recovery

Met the expected recovery: 31.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 226 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.

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 SNF46.1%CMS range 41.6–51.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.9%CMS range 11.5–17.110.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge31.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge31.0%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 discharge27.9%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 identified97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.3%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 discharge99.3%98.7%Oct 2024–Sep 2025CMS 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 stay1.2%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 worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 6.5–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

7
deficiencies at the latest standard inspection (2024-04-18)
7
at the previous standard inspection (2022-02-04)

Deficiencies are unchanged from the previous inspection. 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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2025-05-07 · 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 interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization. Findings included: 1. Review of the admission record showed Resident #18 was originally admitted to the facility 2/22/24 and readmitted on [DATE] with diagnoses of acute bronchiolitis due to respiratory syncytial virus, acute chronic respiratory failure with hypoxia, and Chronic obstructive pulmonary disease (COPD). Review of a hospital History and Physicals for Resident #18 dated 5/5/25 revealed under history of presenting complaint, This is an [AGE] year-old male resident of an extended care facility with a history of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure urinary catheter care was provided in accordance with standards of care for one resident (#1) out of 3 residents sampled for catheter care.Findings included: A review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include benign prostatic hyperplasia, malignant neoplasm of prostate, and obstructive uropathy.A review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 3008) dated 10/3/2025 revealed in Section P. Health Status-Foley (urinary) catheter checked yes.A review of Resident #1's order summary report was absent of an order for a urinary catheter upon admission.Review of Resident #1's October 2025 Treatment Administration Record revealed the following treatment order: Indwelling urinary catheter care Q-shit [every] and PRN [as needed] with a start date of 10/20/2025.Review of Resident #1's Care Plan revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-07 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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, staff interview and policy and procedure review, the facility did not ensure resident medical records and confidential medical information were safeguarded in a confidential manner that would prevent unauthorized access on two (100 and 200) of two halls toured. Findings included: A tour of the 200 hall was conducted on 5/5/25 at 9: 32 a.m. A two-tiered rack was observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway to include residents, family members, vendors and visitors. Subsequent tours of the 200 hall were conducted on 5/5/25 at 4: 45 p.m. and 5/6/25 at 10: 44 a.m. The two-tiered rack containing white binders with room numbers and resident specific information and the DNR book were observed to remain in the hallway during these times,easily accessible to anyone walking down the hallway. Upon opening one of the white binders it was observed to contain a Resident Face…

    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 · Ecited before2025-05-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and policy review, the facility failed to ensure proper infection control practices were in place for two (100 and 200) out of two halls related to use and availability of personal protective equipment (PPE) and performing hand hygiene. Findings included: On 05/05/25 at 9:33 a.m. an empty PPE supply cart was observed located outside of room [ROOM NUMBER]. room [ROOM NUMBER] was observed with a contact isolation sign present. The observation revealed the facility staff did not have readily available PPE to provide care for a resident on contact isolation. An observation of lunch service on 5/5/2025 at 12:36 p.m., room [ROOM NUMBER] revealed a contact precautionsign hanging above door. Staff A, Certified Nursing Assitant (CNA), was observed entering the room without performing hand hygiene prior to entering the room. Staff A, CNA was observed putting on the gown at bedside. Staff A, CNA proceeded to touch the resident with bare hands, positioned the resident for meal and proceeded…

    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 before2025-05-07 · 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 interview and record review, the facility failed to ensure a post fall care plan was updated and interventions were implemented in a timely manner for one (#21) of two residents reviewed for falls. Findings included: On 5/7/25 at 12:02 p.m. Resident #21 was observed sitting in his wheelchair outside his room. He stated he fell in his room a few days ago. He said, I stumbled and fell in my room. I was trying to get to the bed. The resident stated the bed was high and he could not sit on it. He stated he was hurt and went to the hospital. The resident was observed with an open area on his right arm close to the elbow and stiches to his forehead. The resident stated at the moment he was not in pain. Resident #21 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, unspecified dementia, other secondary Parkinsonism, muscle weakness and difficulty in walking. Review of a progress note for Resident #21 dated 5/5/25 at 2:45 p.m. showed pt (patient) found on the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility did not ensure wound care orders were put in place and completed timely for one resident (#1) and did not ensure medications were administered appropriately for two residents (#10 and #22) out of twenty-two sampled residents. Findings included: 1. Review of admission Record showed Resident #1 was admitted on [DATE] with diagnoses including hereditary and idiopathic neuropathy, chronic pain syndrome, morbid obesity, and primary generalized (osteo)arthritis. Review of Resident #1's Weekly Skin checks showed resident had clear skin on 4/9/25. The Weekly Skin check on 4/16/25 documented Left toe-open ulcer with current treatment in place. Review of Resident #1's physician orders showed an order for Mupirocin External Ointment 2%. Apply to left 2nd toe topically every day shift for rash. Start date 2/19/25. Discontinued 4/29/25. Review of Resident #1's provider notes showed the resident went to an outside foot specialist on 4/8/25. The Assessment/Plan…

    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 before2024-04-18 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure it had an effective infection control program related to hand hygiene on 2 of 4 units (TCU, Lakeview) , sharps containers, and use of Personal Protective Equipment (PPE) for one of one residents on Transmission Based Precautions (room [ROOM NUMBER]). Findings included: 1. Observations of meal distributions on TCU unit from 04/15/24 at 12:48 PM revealed that the meal cart arrived on the unit. Continued observations at this time revealed that that Staff I entered random rooms to deliver meal trays. Staff I was not observed to sanitize or wash his hands. Additional observations revealed the following: -04/15/24 at 12:52 PM Staff I entered room [ROOM NUMBER] (enhanced barrier room) and delivered a meal tray. No hand sanitizing or washing noted before entering the room or after exiting the room. -04/15/24 at 12:48 PM Staff I delivered meal tray to room [ROOM NUMBER]. No hand sanitizing or hand washing noted before entering the room or…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure the resident's right to privacy was upheld related to staff and visitors knocking at resident doors prior to entering for 3 of 36 (#51, #38 #55) sampled residents and 6 of 12 (Rooms 122, 123, 124, 127, 129, 130) random resident rooms on TCU unit. Findings included: 1. During an interview with Resident #51 in her room on 04/16/24 at 09:01 AM Staff G, Certified Nursing Assistant (CNA) was observed to enter the resident's room without knocking. During an interview with Staff G at this time she reported that she usually knocks but because the room door was open, and she knows the resident is in the room she thought that it was ok. Review of Resident #51's electronic record revealed that she was admitted to the facility on [DATE] for orthopedic aftercare. Review of the residents Minimum Data Set (MDS) Brief Interview For Mental Status (BIMS) dated 3/19/24 revealed a score of 14 (Cognitively intact). 2. During an interview 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 ensure the physician and resident representative was informed of medications not given as well as weights not performed for one of 40 sampled residents (#56). Findings included: Resident #56 was admitted on [DATE] and discharged to the hospital on [DATE]. Review of the admission record showed diagnoses included but were not limited to acute respiratory failure, pneumonitis due to inhalation of food and vomit, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertensive heart disease with heart failure, malignant neoplasm of thyroid gland, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of lymph node, obesity, muscle weakness, and anxiety disorder. Record review of the admission Minimum Data Set, dated [DATE] showed Section C, Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the physician orders 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · 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 2. A review of the admission Record showed Resident #2 was initially admitted to the facility on [DATE] with diagnoses of anxiety disorder and bipolar disorder. The admission Record revealed a new diagnoses of adjustment disorder with anxiety on 06/22/20, major depressive disorder on 01/04/21, and persistent mood disorder on 06/01/21. Review of Resident #2's PASRR Level I Screen dated 04/03/24 and completed by the Assistant Director of Nursing (ADON) only showed a qualifying diagnosis of anxiety disorder and indicated no PASRR Level II was required. On 04/18/24 at 11:42 a.m., the ADON reported they started doing audits on PASRRs because there were a lot of diagnoses not listed on the PASRRs. She confirmed she completed the PASRR for Resident #2 during the audit. She confirmed that all her current diagnoses were not listed on the PASRR. She stated she only looked at physician orders to complete the PASRR and not the list of diagnoses. On 04/18/24 at 1:30 p.m., the Director of Nursing (DON) reported that PASRRs…

    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 · D2024-04-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to provide Activities Of Daily Living (ADL) for 2 of 3 (#10, #55) residents sampled for ADL care related to personal hygiene. Findings included: 1. Observations of Resident #55 on 04/16/24 at 12:52 PM the resident was observed sitting up in her bed eating her midday meal. The resident was noted with gray facial hair on her chin. Interview with Resident #55 at this time revealed that she does not like having the hair on her face and that no one has offered to assist her with removing the facial hair. Observations on 04/17/24 at 09:08 AM revealed Resident #55 sitting up in her bed. The resident indicated that it's still there! as she wiped her hand over her chin. The resident reported that they still have not shaved her. Review of Resident #55's electronic record revealed that she was admitted to the facility on [DATE] with diagnosis that included muscle weakness, Osteoarthritis, and Spinal stenosis. Review of the residents Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2024-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure 2 of 39 (#340, #389) sampled residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings. Findings included: Review of the facility policy titled Wound Care and Treatment with an issue date of 03/2020 and a revised date of 01/2024 revealed the following: 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initial, time, and date and apply to dressing. 1. Review of Resident #340's record revealed that this resident was admitted to the facility on [DATE] with diagnosis that included: hemiplegia and hemiparesis following cerebral infraction affecting right side. Review of the residents physician orders revealed orders with a start date of 4/15/24 and an end date of 4/16/24 for [bloodwork/labdraws]in AM every night shift for 1 day Observations of Resident #340 on 04/16/24 at 09:12 AM revealed the resident lying in bed. Attempt 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Forty-four medication administration opportunities were observed and fourteen errors were identified for three residents (#42, #241, #24) of eight residents observed. These errors constituted a 25% medication error rate. Findings include: On 4/17/24 at 8:45 a.m., medication administration observations were made with Staff J, Licensed Practical Nurse (LPN) for Resident # 42. The staff member dispensed the following medications: -Amiodarone 200 milligram (mg) one tablet -Plavix 75 mg one tablet -Lasix 20 mg one tablet -Potassium chloride 10 milliequivalent (mEq) one tablet -Ferrous Sulfate 325 mg one tablet During observation and interview, Staff J, LPN stated the resident has Metoprolol 12.5 mg and Eliquis 2.5 mg due but there were none available in the medication cart. Staff J, LPN wrote on a notepad the two missing medications and administered the medication pulled above to the resident and informed the resident two medications are not available…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag 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 interview and record review, the facility failed to implement the Comprehensive Resident-Centered Care Plan related to administering medications and performing weights for one of 40 sampled residents (#56). Findings included: Review of Resident #56's care plans showed he had altered cardiovascular status related to Congestive Heart Failure (CHF), Hypertension, pneumonia and obesity. The Care plan was initiated on 03/18/2024. The goal was for the resident to be free from complications of cardiac problems. Interventions included but were not limited to Monitor vital signs / weights as ordered/ PRN (as needed). Notify MD [medical doctor] of significant abnormalities/changes as ordered/indicated. Administer medications per MD order. Monitor/document/report PRN any changes in lung sounds on auscultation, edema and changes in weight. Resident #56 was admitted on [DATE] and discharged to the hospital on [DATE]. Review of the admission record showed diagnoses included but were not limited to acute respiratory…

    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 · D2023-11-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to implement policies and procedures for ensuring the reporting of resident neglect related to an elopement for one resident (#4) out of three residents sampled for elopement risk. Findings included: An interview was conducted on 11/13/23 at 1:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN stated around 5:00 a.m. on 10/20/2023 she was in a resident room with the door shut and she heard an alarm going off for about a minute and a half. She stated, when she was able, she stopped what she was doing and walked into the hall. She said Staff E, Certified Nursing Assistant (CNA) also came into the hall from another resident room. Staff D, LPN said she did not see any residents and Staff E, CNA told her she did not see any either. She stated they shut an alarm off, at a door to the service hall, because they thought a staff member may not have shut the door all the way. She stated once the alarm was shut off, another alarm was still beeping.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-14 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to implement an effective discharge planning process by not ensuring medical follow-up related to home health care was initiated for one resident (#1) of two residents sampled for discharge. Findings included: A review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of right femur, history of falling, need for assistance with personal care, muscle weakness, and difficulty in walking. The record revealed Resident #1 was discharged from the facility on 10/07/2023. A review of the Minimum Data Set, dated [DATE], revealed a Brief Interview For Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of Resident #1's progress notes revealed the following: -9/25/2023 1:10 p.m. Discharge planning, SSD (Social Service Director) spoke with resident and [family member] to discuss discharge plan. Resident will return home alone. Resident will remain…

    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 before2022-02-04 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring equipment is maintained in a clean manner and free from debris, related to 3 of 4 (Kitchen, Fern Unit, TCU Unit) ice machines, dish machine, and kitchen walls. Findings included: During an initial tour of the kitchen on 02/01/22 at 10:40 a.m. revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. -Debris was noted on top of the dish machine and its surrounding area. -Black substance was noted on backsplash behind the dish machine table. Observation of the kitchen 02/03/22 at 08:06 a.m. of the morning meal tray line revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. (Photographic Evidence Obtained) -Debris was noted on top of the dish machine 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 date of correction
  • Potential for harm · Ecited before2022-02-04 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 related to: 1) not ensuring 2 staff members (K and P) disposed of Personal Protective Equipment (PPE) in the recommended manner when exiting one of nine rooms on the COVID positive unit and one (#179) of rooms where two resident (#282 and #289) were under Enhanced Barrier Precautions for COVID-19 and 2) not ensuring one staff members (N) complied with the wearing of required PPE when entering one (#177) out of thirteen rooms posted for Enhanced Barrier precautions. Findings included: An observation, on 2/1/22 at 11:05 a.m., was made of Staff Member K, Licensed Practical Nurse (LPN), in the hallway of the COVID positive unit, which housed nine positive residents, rolling up a yellow disposable gown and threw it away in the trash can located in the hallway. Staff…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-02-04 · tag F0885 — failed to notify residents/families about COVID-19 — pattern
    Report COVID19 data to residents and families.
    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 notify residents, resident representatives, and staff members of the positive COVID-19 test results in a timely manner. Findings included: During an interview, on 2/3/22 at 12:57 p.m., Resident #4 reported that she had not been notified when a resident or staff member had tested positive for COVID-19. The Annual Minimum Data Set, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. The admission Record for Resident #4 indicated the resident was own responsible party and did have a health care surrogate. An observation on 2/1/22 at 11:05 a.m., identified nine residents who had tested positive for COVID-19. The listing of positive COVID-19 staff members and residents identified the following: - 3 staff members tested positive on 1/15/22. - 1 staff member tested positive on 1/28/22. The facility provided January notifications which indicated that after staff members had tested positive…

    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 · E2022-02-04 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and interview the facility failed to maintain its kitchen equipment in a safe operating condition, related to a 6 burner stove. Findings included: Observations during the initial tour of the facilities kitchen on 02/01/22 at 10:40 AM revealed that the kitchen housed a 6 burner stove which was located in the center of the kitchen. Inspection of the stove with Staff A, cook, and Staff B, Certified Dietary Manager (CDM) present revealed that the right front burner did not light when the knob was placed to the on position. The cook was noted to light a piece of paper towel from a lit burner and light the front right burner with the lit paper towel. Observations of the 6 burner stove during the comprehensive tour of the kitchen on 02/03/22 at 08:06 AM revealed that pilot light on the top left burner and the bottom right burner were out. Attempts of Staff A:, cook lighting the burners by turning on the knobs were unsuccessful. Interview with the CDM on 02/03/22 at 11:15 AM revealed that she will address the issues right away and include maintenance 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure skin conditions were addressed and assessed for 3 (Resident #69, #294 and #27) of three sampled residents. Findings included: On 02/01/22 at 10:00 a.m. ,during the initial tour, an observation was made of Resident #27. Resident #27 was noted with excessive skin discoloration on both arms (dark purple to black coloring). Resident #27 was asked if he knew the cause of the skin discoloration, he reported he did not know, and he has had it for some time. When asked if the facility had addressed the purple deep black color markings on his arms, he reported no one has come in to talk about it. Resident #27 is alert and oriented with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. A medical record review was conducted for Resident #27 which revealed he was admitted to the facility on [DATE] with multiple diagnoses, including but not limited to, COPD (chronic obstructive pulmonary disease), chronic…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-02-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure weight variances were addressed for two (#4 and #40) out of thirty-eight sampled residents. Findings included: Resident #4 was admitted on [DATE]. The admission Record for the resident identified diagnoses not limited to unspecified systolic (congestive) heart failure, unspecified viral hepatitis without hepatic coma, and hypertensive heart disease with heart failure. An observation and interview was conducted, on 2/3/22 at 12:57 p.m., with Resident #4. The resident reported a weight loss and that no one from the facility had talked to her about it. The resident stated, don't worry about it, I have enough. A review of Resident #4's Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS Section K - Swallowing/Nutritional Status indicated the resident weighed 152 pounds and a loss or gain of 5% or more in the last month…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-02-04 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and three errors were identified for three (#296, #295 and #69) of five residents observed. These errors constituted a 10.34% medication error rate. Findings included: 1. On 2/2/22 at 12:18 p.m., an observation of medication administration with Staff Member Q, Licensed Practical Nurse (LPN), was conducted with Resident #296. The staff member was observed dispensing and administering the following medication: - Admelog Solostar insulin pen - 2 units. The staff member identified a blood glucose level of 170 was previously obtained for Resident #296. Staff Q applied a needle to the Solostar pen and dialed the pen to 2 units. As the staff member was walking to the residents room, holding the pen slightly perpendicular to the floor, she was observed turning the dosage selector again. The staff member stated she had to make sure the pen worked, she confirmed that she had primed the pen with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-10-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and record review, the facility did not ensure the kitchen and cooking equipment were maintained in a clean and sanitary manner related to the dishwashing machine not reaching the required hot water temperature which had the potential to negatively impact 75 of the 77 residents in the facility. Findings included: On 10/27/20 at 9:45 AM, a tour of the kitchen was conducted with the Dining Manager and the Registered Dietician (RD). On 10/27/20 at 10:00 AM, Staff B, Dishwasher, was observed running the last load of breakfast dishes on the dishwashing machine. Staff B was requested to run the cycle again. The temperature gauge was noted rising to 122 degrees. The Dining Manager confirmed that the temperature of 122 degrees on a wash cycle was below the minimum requirement of 155 degrees. (photographic evidence obtained). During the observation, the Dining Manager intervened and stated the washer was working okay this morning. The temperature log was reviewed. A reading of 157 degrees for the wash and 185 for the rinse were documented for the 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-10-30 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed administered and two errors were identified for one (Resident #356) of four residents observed. These errors constituted a medication error rate of 7.41 percent. Findings included: An observation of medication administration on 10/29/2020 at 9:15 a.m., resulted in Staff D (LPN), not giving Resident #356 two (2) medications of Fluticasone Suspension 50 MCG/ACT and Ivabradine HCL Tablet Give 5 mg. During the observation Staff D (LPN) indicated she was running late on medication administration, and did not say or provide further information when asked, as to why her medications were late. On 10/29/2020 at 11:21 a.m., a record review was conducted of Resident #356's medications that were administered at 09:00 a.m. During the record review it was observed that Staff D (LPN) did not give Resident #356 his physician ordered medications of…

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

    Pharmacy Service 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

$50,225 in federal fines across 1 penalty.

  • $50,225 — penalty dated 2025-05-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
LUTZ REHAB HOLDING PARTNERS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/13/2020
GUTMAN, SAMUELIndividualINDIRECT OWNERSHIP INTERESTsince 08/13/2020
WILDES, DONNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
CYR, DANIELLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
FLEURANTIN, MARIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/27/2026
HASHMI, HASEEBIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2026
PARKS, BAILEYIndividualOPERATIONAL/MANAGERIAL CONTROLNO DATE PROVIDED
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2022

CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$15.9M
Net patient revenuemost recent cost report
+5.5%
Operating marginrevenue minus expenses
$2.6M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 28%Other / private 38%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$375per resident / day
operating cost
$11,397per month
≈ monthly operating cost
$397per 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 106093. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-18, 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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