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Pruitthealth-North Tampa, LLC

18940 Sunlake Blvd, Lutz, FL 33558 · For profit - Limited Liability company · 90 certified beds · (678) 533-6300 Medicare & Medicaid certified

Call the home — (678) 533-6300 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0610) — cited Oct 2024$32,812 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 (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $32,812 in federal fines (most recent 2025-06-19)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • about 30% of its spending goes to commonly-owned related companies

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.

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

Worth a closer look. This home's quality-measure rating runs 4 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
18928 N Dale Mabry Hwy Ste 101 · (813) 909-1146 · Call to confirm hours
Pharmacy
Walgreens1.8 mi
3890 Van Dyke Rd · (813) 269-2814 · Call to confirm hours
Grocery
Publix0.8 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
18908 Sunlake Blvd · (813) 949-9248

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-10 to 2026-06, this home’s CMS overall rating held steady at 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 increased5.9%8.7%15.4%better
Long-stay residents who lose too much weight3.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.7%0.7%2.0%worse 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 injury1.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened4.7%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.4%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control5.7%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 table13.1%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.1%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.2%94.7%79.4%better
Short-stay residents rehospitalized after admission21.4%26.1%22.6%typical
Short-stay residents with an outpatient ER visit7.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.742.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.961.151.80better

* 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.

64.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 461 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

64.9%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
49.5%U.S. median 56.6%
Met the expected recovery
0.65U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.34hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 49.5% 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 222 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF64.9%CMS range 59.5–69.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 9.4–13.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge49.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge47.3%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 discharge50.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.0%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 setting99.4%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 discharge96.3%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 stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%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 hospitalization8.3%CMS range 5.5–10.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.65
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.67
Total nurse hours/ resident / day
0.26
RN hoursweekends
51.7%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 84.2 residents a day — about 94% 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.09 hrs/resident/day on weekends vs 3.90 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.81 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

15
deficiencies at the latest standard inspection (2025-06-19)
0
at the previous standard inspection (2023-03-15)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Potential for harm · D2025-09-24 · tag F0729 — isolated
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure Certified Nursing Assistant (CNA) registry verification and competency evaluation for one staff member (Staff E) of five staff reviewed. Findings included: On 09/24/2025 at 8:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA), he stated the facility had no Personal Care Assistant (PCA) program, nor did the facility use Personal Care Assistants (PCAs). A review of the facility's employee list obtained on 09/24/2025, listed Staff E with a job title of Certified Nursing Assistant (CNA) with a position start date of 01/19/2025. On 09/24/2025 a review of Staff E's personnel file was conducted. The file revealed no evidence of the staff member being a licensed CNA. On 09/24/25 at 10:51 a.m., a Background Screening for Staff E was reviewed on the Clearinghouse Screening Management system. The screening revealed Staff E's Level II eligibility determination was a status of Agency Review Required. The licensure…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 reviews the facility failed to ensure wound care was done in a timely manner and dressings were dated for three residents (#182, #277, #51) out of four residents reviewed for non-pressure skin conditions. Findings included: An observation and interview was conducted on 6/16/25 at 12:38 p.m. with Resident #182. The resident was observed to have a bandage on his throat area dated 6/11/25. The resident said the bandage covered a stoma (an artificial opening) from having a tracheostomy (trach). He said he had been in the facility for two days and nothing had been done with the dressing. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis and pneumonia due to klebsiella pneumoniae. Review of Resident #182's admission Minimum Data Set (MDS), Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure pain was controlled for three residents (#185, #379, #182) out of three reviewed for pain management. Findings included: An interview was conducted on 6/18/25 at 2:15 p.m. with Resident #182. The resident said he had been in the facility for four days and did not have any pain medication for the first two days. The resident said pain had gotten to a 10 out of 10 on the pain scale during that time. The resident said he refused tube feedings because they caused stomach cramps and he couldn't handle any more pain. The resident said he was starting to feel better again after having his medication for the last two days. Resident #182 said the pain was so bad on Sunday, 6/15/25 that he almost left the facility. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis, cutaneous abscess of abdominal wall, spondylosis, and pain, unspecified. Review of Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-19 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. During an interview on 06/16/25 at 11:42 a.m. Resident #29 stated she was getting weaker due to no one at the facility assists her with walking. She stated therapy instructed her to ensure someone was supervising her while walking. During a follow up interview on 06/18/25 at 09:41 a.m. Resident #29 stated having lost endurance since discharging from therapy as no one was available to supervise except when family visits. During an interview on 06/17/25 at 12:13 p.m. Staff V, CNA stated, it is hard sometimes we don't have as many CNAs as needed. Many of the residents are total care and the distance from room to room. Staff V, stated having to cover around corners makes the job tasks even harder to get basic care completed, but certainly at meal times. She stated they did not have time for the extras if asked. During an interview on 06/18/25 at 10:53 a.m., Staff B, CNA stated not having time to complete Range of Motion(ROM) or walking residents around if requested and stated usually the restorative aide completes the task. Staff B stated they don't really need to worry about not…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not ensure medications for new admissions were available timely for four residents (#182, #185, #379, #228) out of four sampled for admission orders. Findings included: 1. An interview was conducted on 6/18/25 at 2:15 p.m. with Resident #182. The resident said he had been in the facility for four days and did not have any pain medication for the first two days. The resident said pain had gotten to a 10 out of 10 on the pain scale during that time. The resident said he refused tube feedings because they caused stomach cramps and he couldn't handle any more pain. The resident said he was starting to feel better again after having his medication for the last two days. Resident #182 said the pain was so bad on Sunday, 6/15/25 that he almost left the facility. Review of Resident #182's admission Record showed the resident was admitted on [DATE] with diagnoses including gram-negative sepsis, cutaneous abscess of abdominal wall, spondylosis, and pain, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    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 did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#228, #51 and #29) of three residents sampled. Findings included: Review of the admission Agreement dated 06/13/25 revealed Resident #228 electronically signed all documents personally, and the appointed representative was not present. On page 44 of the electronic admission agreement, it showed the Arbitration Agreement was signed by Resident #228 accepting the terms of Arbitration Agreement. Review of the admission Record for Resident #228 revealed an admission date of 06/10/25 with diagnoses to include ground level fall resulting in a displaced femur fracture and surgical repair on 06/04/25, hypertension, vascular dementia and other co-morbidities. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) for Resident #228 dated 06/10/25 revealed Resident #228 required a healthcare surrogate to make…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · 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 During an initial on 06/16/25 at 10:21 a.m. Resident #229's door had an 8 ½ by 11 (letter size) CDC Contact Isolation Precautions sign printed in color showing two large fonts STOP signs in all capital letters and the following Contact Precautions written between the two signs. The next line revealed in all capital letters Everyone Must: Clean their hands, including before entering and when leaving the room.The following line in all capital letters showed: Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. During this tour the PPE cabinet in the hallway outside Resident #229's door revealed only gloves were available and a roll of trash bags at the bottom drawer. On 06/16/25 at 11:30 a.m. Staff W, Occupational Therapist (OT)…

    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 · E2025-06-19 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 an antibiotic stewardship program including developing a system to monitor use of antibiotic-resistant organisms for one resident (#378) out of two residents reviewed for antibiotic stewardship with potential to impact the entire facility. Findings included: Review of the admission Record revealed Resident #378 was admitted to the facility on [DATE] with diagnoses to include other Staphylococcus as the disease classified elsewhere. Review of the June 2025 Medication Administration Record (MAR) for Resident #378 showed the resident was receiving Vancomycin recon 1.25 grams; IV (intravenous), dated 5/29/25 to 6/18/25. The review of the MAR did not show why the resident was on Vancomycin and it was not specified what type of infection she was being treated for. The MAR did not show a specified diagnosis. The review pf physicin orders for Resident #378 showed there was no order for contact precautions and there was no McGreer's Criteria (a 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · 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

    Based on observation, interview, and policy review the facility failed to ensure dignity was maintained for residents during dining in one dining room (between 400 & 500 halls) out of three dining rooms. Findings included: On 6/17/2025 at 11:45 a.m. an observation of the lunch meal service occurred in the dining room between the 400 and 500 hallways. The dining room was full of multiple residents (a total of 14) and several family members/visitors. Multiple staff members were observed assisting with passing out trays from the tray cart. One of the tables had three residents seated, two residents were served their meals and started eating, while the third resident did not have their meal. Another table had three residents seated, one resident was served their meal, the other two residents did not receive their meals at that time. Staff L, Certified Nursing Assistant (CNA), was observed delivering the tray to one resident who needed assistance. The staff member sat down and proceeded to assist the resident with eating. Staff L, CNA did not remove the food items from the tray and 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#5) of one resident reviewed. Findings included: Review of Resident #5's face sheet, showed an admission date of 6/15/25, with diagnoses to include metabolic encephalopathy, mood disorder, anxiety disorder, difficulty in walking, cognitive communication deficit, left hip osteoarthritis, cognitive impairment, and fall. Review of Resident #5's medical certification for Medicaid long-term care services and patient transfer form (3008), undated Showed the following Section B. Hearing is impaired, Section E. Medical Conditions generalized weakness, urinary tract infection (UTI) and lactic acidosis, Section G. Patient risk alerts is falls, Section O. Vitals Signs dated 6/15/25 at 7:55 A.M., Section P. Patient Health Status the resident is incontinent, Section S. physical function required two assistants to transfer, Section T. Skin Care - resident has a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-06-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to revise an Activity of Daily Living (ADL) care plan to reflect a resident's condition for one resident (#29) out of eight residents reviewed. Finding included: During an interview on 06/16/25 at 11:42 a.m. Resident #29 stated she was getting weaker due to no one at the facility assists her with walking. She stated therapy instructed her to ensure someone is supervising her while walking. During a follow up interview on 06/18/25 at 09:41 a.m. the resident stated loosing endurance since being discharged from therapy as no one was available to supervise except when family visits. Review of the admission Record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses to include: Parkinson's disease without dyskinesia, hypertension, Difficulty in walking, anxiety disorder, and other co-morbidities. Review of Resident #29's Minimum Data Set (MDS) dated [DATE] revealed Resident #29 is cognitively intact. Review of Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · 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 observation, record review and interview, the facility failed to provide meal assistance for one resident (#43) out of two residents sampled. Findings Included: During an interview and observation on 06/16/2025 at 12:20 p.m. Resident #53 was observed scooping mashed potatoes onto a spoon feeding Resident #43. Resident #53 stated I am feeding my [family member] (Resident #43). I feed her and try to eat my food in-between. If I don't feed, her then no one helps her. Review of Resident #43's admission record revealed an admission date of 09/21/2023. Resident #43 was admitted to the facility with diagnosis to include need for assistance with personal care, Muscle weakness (generalized), Mild protein-calorie malnutrition, Other specified joint disorders, right hand, other lack of coordination, Aphasia, Aphasia following cerebral infarction, Dysphagia, oropharyngeal phase. Review of Resident #43's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive Patterns a Brief Interview Mental…

    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 · D2025-06-19 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record reviews, the facility failed to provide nephrostomy care and services consistent with professional standards of practice for one resident (#328) out of one sampled resident. Findings included: A review of Resident #328's Face Sheet revealed admissions dated 6/4/2025 to the facility with diagnoses included but not limited to obstructive and reflux uropathy, chronic kidney disease, bladder-neck obstruction, hydronephrosis, neuromuscular dysfunction of bladder, and urinary tract infection. On 6/19/25 at 10:16 A.M. an observation and interview was conducted. Resident #328's nephrostomy insertion site dressing was not intact and dated 6/3/25. Resident #328 said the dressing was last changed before I left the hospital. The urine appears serosanguinous (contains blood). Resident #238 said she asked a nurse to change the dressing and was told there were no orders to change the nephrostomy site dressing. (Photographic Evidence Obtained). A review of Residents #328's Minimum…

    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 · D2025-06-19 · 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%. Twenty-five medication opportunities were observed, and two errors were identified resulting in an error rate of 8.0%. Findings Included: During a medication administration observation on 6/17/25 at 8:41 A.M. for Resident #6, Staff F, Registered Nurse (RN), prepared vitamin B-12 (1 tablet), multiple vitamin with minerals (1 tablet), and Gabapentin 300 mg (milligram) capsule (1 capsule) by crushing the medications and administering with applesauce. Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed Gabapentin tablet should not be crushed. On 6/17/25 at 8:48 A.M. during a medication administration observation Staff F, RN prepared and administered the following medications to Resident #53, aspirin 81 mg, calcium carbonate 1500 mg, brimonidine-timolol-one drop in each eye, buspirone 15 mg, vitamin D3 (1 tablet), and nifedipine 30 mg extended-release…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews facility failed to ensure medication was stored appropriately on three halls (100, 200, 500) out of five halls related to unlocked medication/treatment carts, unattended medication, dirty medication carts, and controlled drugs not stored in a permanently affixed compartment. Findings included: An observation was conducted on 6/16/25 at 9:35 a.m. of an unlocked treatment cart containing prescription medications on the 500 hall. No staff were observed in sight. An observation was conducted on 6/16/25 at 10:22 a.m. on the 100 unit of an unlocked medication cart left unattended in the hall. There was a resident in the hall and no staff members were present. An observation was conducted on 6/17/25 at 10:16 a.m. of the 500 hall medication storage room with Staff F, Registered Nurse (RN). A metal box in the refrigerator contained an emergency drug kit with a controlled drugs. The metal box was not permanently affixed. Staff A said she did not know why it was not affixed or if it was supposed to be. An observation was conducted on 6/17/25 at 12:09 p.m.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the annual survey conducted 6/19/25 regarding a medication error rate of greater than 5.0% and infection control during medication administration. Findings included: 1. On 6/17/25 during a recertification survey deficient practice was identified during medication administration and F759 was cited with a scope and severity of D. During a medication administration observation on 6/17/25 at 8:41 A.M. for Resident #6, Staff F, Registered Nurse (RN), prepared vitamin B-12 (1 tablet), multiple vitamin with minerals (1 tablet), and Gabapentin 300 mg (milligram) capsule (1 capsule) by crushing the medications and administering with applesauce.Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-18 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 surgical wounds were monitored for signs of infection and surgical sutures were removed per physician orders for two residents (#1 and #7) of three residents sampled for wound care. Findings included: 1. Review of Resident #1's entry record, dated 9/17/24, revealed the resident was admitted on [DATE]. The Minimum Data Set (MDS) records revealed the resident was admitted on [DATE], discharged on 9/23/24, and re-admitted on [DATE]. Further review of the clinical record revealed the resident was hospitalized from [DATE] to 10/11/24. Review of Resident #1's MDS discharge assessment, dated 9/23/24, revealed the resident had a fall in the last month prior to admission, had a fall in the prior 2-6 months to admission, and did not have a fracture related to a fall in the 6 months prior to admission. The assessment showed the resident's primary medical condition was Medically Complex Conditions. Review of Resident #1's MDS scheduled 5-day…

    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 before2024-10-18 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 interviews, the facility failed to provide sufficient nursing staff to meet the needs of three residents (#8, #9, & #13) out of seven sampled residents related to answering call lights timely and provide activities of daily living. Findings included: On 10/17/24 at 10:06 a.m., an interview was conducted with Resident #9. Resident #9 stated, The call bell has not worked since I got here (almost a week). It's been terrible. Finally, the facility provided me with this little bell (a round metal table bell, with the activating lever in the top middle of the bell) after I told them no one was assisting me but still no one comes when I ring it. I'm not sure what I would do if I fell or something. I don't really feel that safe. Although, the therapy is great! That is why I stay. Review of Resident #9's medical record revealed an admission date of 10/15/2024. Review of Resident #9's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to maintain a functioning nurse call system to respond to resident needs during two days (10/17/24, 10/18/24) of two days observed during survey. Findings included: On 10/17/24 at 10:06 a.m., an interview and observation was conducted with Resident #9. Resident #9 stated, The call bell has not worked since I got here (almost a week). It's been terrible. Finally, the facility provided me with this little bell (a round metal table bell, with the activating lever in the top middle of the bell) after I told them no one was assisting me but still no one comes when I ring it. A table bell was observed on the resident's nightstand. On 10/17/24 at 10:36 a.m. and 1:10 p.m., an interview and observation was conducted with Resident #8's resident representative in Resident #8's room. Resident #8's representative stated that the call light stopped working for her. Resident #8's representative stated the facility gave Resident #8 a bell (a round metal…

    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 · D2024-10-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to complete an investigation for a fracture of unknown origin for one resident (#1) out of thirteen sampled residents. Findings included: Review of admission Records showed Resident #1 was admitted from the hospital on 9/17/24 with diagnoses including urinary tract infection, vascular dementia, gout, muscle weakness, and history of transient ischemic attack, and cerebral infarction without residual deficits. Review of Resident #1's admission Observation, dated 9/17/24, showed an assessment of his musculoskeletal system revealed no contractures, paralysis or flaccidity, extremity weakness, history of joint replacement, weight bearing limitation, requirement of assistive devices, or amputations/prosthetics. The assessment also showed no impairment for functional limitation in range of motion for lower extremities. Review of Resident #1's Physical Therapy (PT) Evaluation, dated 9/17/24, showed a musculoskeletal system assessment of the resident's lower extremity range of motion within functional limits (WFL). Review of Resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 competent nursing care staff, related to care of one unresponsive Resident (#10), and wound monitoring for two Residents (#1 and #7) was provided out of thirteen resident sampled. Findings included: 1. Review of admission Records showed Resident #10 was admitted on [DATE] with diagnoses including fracture of right femur, subsequent encounter for closed fracture with routine healing. Review of Resident #10's admission Observation, dated [DATE], showed the resident was oriented, generally to person, place and time, understands and had clear comprehension, intact memory and clear, organized thinking. Review of Resident #10's care plan showed she had an Activities of Daily Living (ADL) decline related to a recent hospitalization due to fall with right hip fracture and surgical repair. Interventions included 1-person assist for transfer/toileting. Resident #10 also had a care plan for being a fall risk related to assistance being required for…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · 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 interviews and record review the facility failed to follow the Person-Centered Comprehensive Care Plan for one resident (#2) out of four sampled residents related to performing weights as ordered and medication administration as ordered. Findings included: Resident #2 was admitted on [DATE] and discharged on 06/16/2023. Record review showed diagnoses, included but were not limited to, urinary tract infection, diabetes hypertension, hypertension with chronic kidney disease with Congestive Heart Failure (CHF), atrial fibrillation (A-fib), hypothyroidism, pulmonary hypertension, and metabolic encephalopathy. Review of the admission Minimum Data Set (MDS), dated [DATE], showed he had Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). He required extensive assistance of two for bed mobility, transfers and toileting. Section J showed he had shortness of breath on exertion. A record review of the care plans showed risk for decreased cardiac output related to CHF, Coronary Artery…

    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

“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

$32,812 in federal fines across 6 penalties.

  • $9,474 — penalty dated 2025-06-19
  • $13,813 — penalty dated 2025-06-19
  • $2,470 — penalty dated 2023-10-17
  • $2,117 — penalty dated 2023-10-10
  • $1,764 — penalty dated 2023-10-02
  • $3,174 — penalty dated 2023-09-11

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.

Part of a chain

This home belongs to PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.9-0.9 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 53.6+1.4 vs chain
The other 94 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Oaks - Athens Skilled Nursing, TheAthens, GA 1 of 5PruittHealth - Holly Hill, LLCValdosta, GA 1 of 5PruittHealth - LilburnLilburn, GA 1 of 5PruittHealth- AikenAiken, SC 1 of 5PruittHealth- ColumbiaColumbia, SC 1 of 5PruittHealth- Rock HillRock Hill, SC 1 of 5PruittHealth-Carolina PointDurham, NC 1 of 5PruittHealth-DurhamDurham, NC 1 of 5PruittHealth-TrentNew Bern, NC 1 of 5PruittHealth-Union PointeMonroe, NC 1 of 5Pruitthealth - AustellAustell, GA 1 of 5Pruitthealth - Lakehaven, LLCValdosta, GA 1 of 5Pruitthealth - MaconMacon, GA 1 of 5Pruitthealth - Magnolia ManorMoultrie, GA 1 of 5Pruitthealth - Old CapitolLouisville, GA 1 of 5Pruitthealth - PalmyraAlbany, GA 1 of 5Pruitthealth - SwainsboroSwainsboro, GA 1 of 5Pruitthealth - ToccoaToccoa, GA 1 of 5Pruitthealth - West AtlantaAtlanta, GA 2 of 5NC State Veterans Home-KinstonKinston, NC 2 of 5PruittHealth - AugustaAugusta, GA 2 of 5PruittHealth- BambergBamberg, SC 2 of 5PruittHealth- DillonDillon, SC 2 of 5PruittHealth- EstillEstill, SC 2 of 5PruittHealth- Moncks CornerMoncks Corner, SC 2 of 5PruittHealth- RidgewayRidgeway, SC 2 of 5PruittHealth-NeuseNew Bern, NC 2 of 5Pruitthealth - BrookhavenAtlanta, GA 2 of 5Pruitthealth - CreeksideAugusta, GA 2 of 5Pruitthealth - DecaturDecatur, GA 2 of 5Pruitthealth - FairburnFairburn, GA 2 of 5Pruitthealth - Fleming IslandFleming Island, FL 2 of 5Pruitthealth - ForsythForsyth, GA 2 of 5Pruitthealth - GriffinGriffin, GA 2 of 5Pruitthealth - Richmond, LLCAugusta, GA 2 of 5Pruitthealth - RomeRome, GA 2 of 5Pruitthealth - SavannahSavannah, GA 2 of 5Pruitthealth - Valdosta, LLCValdosta, GA 2 of 5The Oaks-BrevardBrevard, NC 3 of 5Christian City Rehabilitation CenterUnion City, GA

Showing 40 of 94; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
PRUITTHEALTH CENTRAL FLORIDA LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST99%since 10/16/2014
UNITED HEALTH SERVICES OF FLORIDA, INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST99%since 10/16/2014
PRUITT, NEILIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/16/2014
FITTS, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/12/2022

CMS files one row per role, so the 5 rows in the source record cover these 4 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.

$6.2M
Net patient revenuemost recent cost report
-51.9%
Operating marginrevenue minus expenses
$2.9M
Related-party expense30% of expenses
Who pays — share of resident-days
Medicaid 11%Medicare 61%Other / private 28%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 30% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$752per resident / day
operating cost
$22,867per month
≈ monthly operating cost
$495per 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 106150. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-19, 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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