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Avante At Melbourne INC

1420 South Oak Street, Melbourne, FL 32901 · For profit - Corporation · 110 certified beds · (321) 723-3215 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 20253 immediate-jeopardy citations$87,952 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (38) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $87,952 in federal fines (most recent 2025-04-10)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
400 E Strawbridge Ave · (321) 676-3101 · Call to confirm hours
Pharmacy
15 E New Haven Ave · (321) 409-3941 · Call to confirm hours
Grocery
1616 Babcock St S · (321) 479-0321 · Call to confirm hours
Park
2101 Oak St · (321) 255-4400 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased3.7%8.7%15.4%better
Long-stay residents who lose too much weight4.4%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.9%2.5%3.3%better
Long-stay residents whose ability to walk worsened1.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.8%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers7.2%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control2.9%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 table5.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine92.7%94.7%79.4%better
Short-stay residents rehospitalized after admission15.7%26.1%22.6%better
Short-stay residents with an outpatient ER visit12.0%9.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.942.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.831.151.80better

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

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

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

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

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

50.0% 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 93 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.0%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 50 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF50.0%CMS range 38.5–59.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.9–14.810.7%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 discharge50.0%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 discharge48.0%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 discharge26.0%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 identified95.1%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 setting98.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 5.0–12.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

0.46
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.18
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.27
RN hoursweekends
36.0%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 110 beds and averages 91.2 residents a day — about 83% occupied, or roughly 19 beds typically open. It usually has some room. 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.28 hrs/resident/day on weekends vs 3.73 on weekdays — 12% thinner on weekends. RN hours go from 0.53 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

12
deficiencies at the latest standard inspection (2025-02-14)
9
at the previous standard inspection (2023-06-15)

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.

38 citations, most serious first. The 15 most serious are shown; the remaining 23 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2023-11-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 protect the resident's right to be free from neglect by not ensuring staff fully processed and implemented physician's orders for immediate care and ensure provision of necessary care and services and failed to complete a thorough investigation for possible neglect for 2 of 6 residents, reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-11-17 · tag F0635 — isolated
    Provide doctor's orders for the resident's immediate care at the time the resident was 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 observation, interview, and record review, the facility failed to ensure physician orders for immediate care were fully processed and implemented to ensure provision of necessary care and services for 2 of 6 residents reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-11-17 · 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 observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and competent with skill sets to fully process physician orders for immediate care of a post hospitalized resident with high risk health conditions for 2 of 6 vulnerable residents of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 neglected to ensure pre-operative testing was completed timely and per physician's orders for scheduled surgical removal of a musculoskeletal (muscle/bone) device (external fixator) for 1 of 1 resident reviewed for neglect, of a total sample of 4 residents, (#1). External fixators are metal devices attached to the bones of the arm, leg or foot with pins or wires from outside the body. Threaded pins or wires pass through the skin and muscles and are inserted into the bone, (retrieved from International Center for Limb Lengthening at limblength.org on 4/11/2025). Infection after fracture fixation (IAFF) in orthopedic surgery is a dreaded complication, leading to non-union, loss of function, and even amputation, (retrieved from pmc.ncbi.nlm.nih.gov on 4/11/2025). Findings: Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on 1/03/25 with diagnoses that included subsequent encounter of right knee…

    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
  • Actual harm · G2025-04-10 · tag F0840 — isolated
    Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
    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 timely assist and provide post-operative follow up transportation for 1 of 3 residents reviewed for Administration, of a total sample of 4 residents, (#1). Findings: Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on 1/03/25 with diagnoses including subsequent encounter of right knee dislocation/reduction, type 2 diabetes mellitus, adjustment disorder with depressed mood, and anxiety disorder. Additional diagnoses after admission to the facility included leukocytosis (high white blood cells/infection response), right leg wound infection, right Achilles (ankle) tendon (connects muscle to bone) contracture (tightening), and right peroneal (lower leg) nerve palsy (paralysis/weakness). The Minimum Data Set Comprehensive admission Assessment with an Assessment Reference Date of 1/09/25 noted during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-28 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services per standards of practice and plan of care for 3 of 3 residents reviewed for IV care, (#4, #5, and #6), of a total sample of 9 residents. Findings: A midline catheter is put into a vein by the bend in the elbow or the upper arm .a midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments, (retrieved on 8/08/25 from www.drugs.com). A peripherally inserted central catheter (PICC) is a long, thin tube that's inserted through a vein in the arm. The tube is passed through to the larger veins near the heart. It is often referred to as a PICC line. A PICC line gives your healthcare professional access to the large central veins near the heart. It's generally used to give medicines or liquid nutrition, (retrieved on 8/08/25 from www.mayoclinic.org). 1. Resident #4 was admitted to the facility from an acute care hospital on 7/16/25 with diagnoses that included cellulitis…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate documentation for Intravenous (IV) catheter dressing change for 1 out of 3 sampled residents with IV lines, (#5), of a total sample of 9 residents.Findings:Resident #5 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included encounter for surgical aftercare venous insufficiency, cardiac arrest, seizures, major depressive disorder and muscle weakness. Resident #5 had a peripherally inserted central catheter (PICC) IV line in his left upper arm for administration of antibiotics. The physician's orders indicated resident #5 received 1 gram of Ertapenem Sodium Solution Reconstituted intravenously daily for infection and he would continue to receive the medication until 7/30/25. The physician also ordered the PICC line dressing to be changed every seven days and as needed using sterile technique. A PICC IV is a long, thin tube that's inserted through a vein in the arm. It is often…

    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 · Fcited before2025-02-14 · tag F0806 — failed to honor food preferences — widespread
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food to accommodate residents' preferences for 4 of 43 sampled residents, (#77, #403, #34, and #59). Findings: 1. Resident #77 was admitted to the facility on [DATE] with the diagnoses of right tibia fracture, muscle weakness, major depressive disorder, and chronic lung disease. Her physician orders revealed a regular diet was prescribed. On 2/11/25 at 9:01 AM, resident #77 stated she was not going to eat her breakfast of a small donut and sausage because she considered these foods to be unhealthy. She added she had been at the facility for three months and was not aware she could request menu items for her meals. Resident #77 explained she had just found out she could eat outside of her room after she had wandered around one morning about a month after she had arrived. She stated no one had asked her what foods she liked to eat or what foods she disliked. On 2/12/25 at 11:16 AM, the Dietetic Technician, Registered (DTR) reviewed…

    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 · F2025-02-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to serve food items in accordance with professional standards for food service safety. Specifically, potentially hazardous food items were held and served while in the temperature danger zone having the potential to affect 95 of the 98 residents at the facility. Findings: On 2/12/25 at 4:40 PM, the dinner tray line was in process when tuna salad sandwiches were noted to be stacked in a full, deep sheet pan sitting in one of the wells of the steam table being used to plate hot entrees. The heating element for the steamtable well which held the sandwiches along with the well directly adjacent to it, were turned off but were warm to the touch as heat radiated from the other heated wells further down on the table. The Dietary Services Regional Manager took the temperatures of the sandwiches which recorded at 50 degrees Fahrenheit (F). The evening (PM) cook removed the tuna sandwiches from the tray line and put them in the freezer to re-chill. The Regional Manager removed a 2nd deep full-size steamtable pan of tuna salad sandwiches…

    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 · F2025-02-14 · tag F0847 — widespread
    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

    Based on interview, and record review, the facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it for 18 of 102 current residents who signed arbitration agreements. Findings: Review of the log provided by the facility revealed 18 of the current 102 residents signed the facility's arbitration agreement. On 2/13/25 at 1:59 PM, the Internal Admissions staff person verified she completed most of the admission packets with residents or their representatives within 48 hours of admission. She stated she usually read the Voluntary Binging Arbitration Agreement to the resident or their representative. She confirmed the agreement was not a requirement for admission. She explained the resident or their representative could change their mind after signing but was not sure of the time frame. The Internal Admissions staff person reviewed the arbitration agreement and confirmed it gave the resident or their representative 30 calendars of the resident's date 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-14 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI)/Quality Assurance and Assessment (QAA) activities which could affect facility wide processes impacting quality of care and quality of life for all residents. Findings: On 2/14/25 at 8:43 AM, in a joint interview with the Director of Nursing (DON) and Regional Director of Clinical Services, the Director said she initiated a Performance Improvement Plan (PIP) approximately one month prior for Pre-admission Screening and Resident Review (PASARR). She stated in regards to resident PASARRs, I would say maybe 25% have been looked at and some were redone. She said she had to locate the documentation and audits to clarify. On 2/14/25 at 10:08 AM, the Regional Director of Clinical Services explained she was unable to locate any records for the PIPs and stated, they're not on record and not organized. On 2/14/25 at 11:59 AM, the Nursing Home Administrator (NHA) said she had been the NHA since 1/14/25. She explained she had conducted…

    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 · E2025-02-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility failed to provide a homelike environment for residents who ate in the dining rooms on the two (North and South) nursing units. This affected all residents who chose to eat in the nursing unit's dining areas, which varied from approximately 8-20 residents per meal of the 98 residents at the facility. Findings: On 2/10/25 at 12:35 PM, four staff were observed serving trays to residents on the North unit from the food cart. There were seven residents sitting at tables in the North unit dining room waiting to be served. There were no tablecloths or centerpieces on the tables and the dishes were left on the serving trays. On 2/10/25 at 1:38 PM, lunch was provided to approximately thirteen residents in the South unit dining room. There were no tablecloths or centerpieces on the tables. All the dishes, flatware, cups and food items were left on the resident's trays while they ate. On 2/10/25 at 5:59 PM, residents were observed eating in the South unit room dining room from their trays. The undecorated tables held newspapers and pieces 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-14 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 conduct medication self-administration assessments to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 43 residents (#49, and #305). Findings: 1. Resident #49 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertensive urgency, encephalopathy, and malignant neoplasm of the bladder. A review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 12/24/24 revealed resident #49 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he was cognitively intact. On 2/10/25 at 12:27 PM, resident #49 was observed sitting upright in bed. His bedside table was over his lap, with personal items, including a 30-ounce jar of herbal blend [NAME] Neuro Ease, Vitamin D3-K2, Elderberry capsule 1000 milligrams (mg), Vitamin C tablet 400 mg, Zinc tablet 10 mg, Sea Moss, Turmeric-Curcumin capsule 1500 mg,…

    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 · D2025-02-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a call light device was within reach for 1 of 3 residents reviewed for accommodation of needs, of a total sample of 43 residents, (#52). Findings: Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status. Staff assessed the resident had short term and long term memory problems, was severely cognitively impaired, had continuous inattention 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 · Dcited before2025-02-14 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a new Preadmission Screening and Resident Review (PASSAR) level I screen to ensure additional mental health services were not required for 1 of 5 residents reviewed for PASSAR, of a total sample of 43 residents, (#62). Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication disorder, generalized anxiety disorder, and insomnia. Other diagnoses were added later and included Schizophreniform disorder on 9/14/23, persistent mood disorder on 10/02/23, and major depressive disorder on 8/01/24. Resident #62's Quarterly Minimum Data Set assessment dated [DATE], revealed he was severely cognitively impaired and required substantial to maximum assistance for activities of daily living. Review of resident #62's medical record revealed a PASSAR Level I had been completed on 8/08/23 with diagnosis of anxiety disorder listed. The facility could not provide evidence of a new…

    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 23 citations
  • Potential for harm · D2025-02-14 · 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 observation, interview, and record review, facility failed to ensure nurses followed physician's orders to monitor fingerstick blood glucose for 1 of 1 resident reviewed for change of condition, of a total sample of 43 residents, (#93). Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included, hemiplegia and hemiparesis (partial paralysis), generalized anxiety disorder, dysphagia (difficulty swallowing), hypertension (high blood pressure), gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic,…

    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 · D2025-02-14 · 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 observation, interview, and record review, the facility failed to monitor identified weight loss and impaired nutrition risk for 2 residents (#52, #15); and failed to properly monitor the clinical condition for 1 resident, (#34), out of 7 residents reviewed for nutrition, of a total sample of 43 residents. Findings: 1. Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed the 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 · Dcited before2025-02-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide emergency equipment available for accidental extubation for a resident on mechanical ventilation with a tracheostomy (trach) per nursing standards of practice for 1 of 1 residents reviewed for tracheostomy, of a total sample of 40 residents, (#22). Findings: Resident #22 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (low oxygen), anoxic brain damage, dysphagia (trouble swallowing), hypertensive heart disease, and tracheostomy status. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube or obturator) rather than through 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 · Dcited before2025-02-14 · tag F0755 — failed to provide safe pharmacy services — isolated
    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 observation, interview, and record review, the facility failed to obtain insulin medications timely for 1 of 26 residents reviewed for medication administration, of a total sample of 43 residents, (#93). Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included unspecified fall, generalized anxiety disorder, dysphagia (difficulty swallowing), high blood pressure, gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic, antianxiety, antidepressant, anticoagulant (blood thinner), opioid, hypoglycemic…

    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 before2024-06-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure respiratory therapy was provided as per physician orders for 1 of 2 residents reviewed for respiratory care, of a total sample of 5 residents, (#4). Findings: Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included acute and chronic respiratory failure, epilepsy, anoxic brain damage, dysphagia, and attention to tracheostomy. A tracheostomy is a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing (retrieved on 6/14/24 from https://www.mayoclinic.org). On 6/06/24 at 10:55 AM, resident #4 was observed lying in bed, she was nonverbal with her eyes open. Her oxygen was connected to her tracheostomy (trach) collar and the tubing was connected to an oxygen concentrator next to her bed set on a flow rate of 0 liters per minute (LPM). On 6/06/24 at 11:13 AM, the resident was observed similarly to prior observation…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a vulnerable, cognitively impaired resident had adequate supervision for outside medical appointments, to prevent the potential for accidents, and elopement for 1 of 3 residents reviewed for accidents of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, Diabetes type II, repeated falls, and pain. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted 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 · D2024-01-09 · 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 resident's representative was notified of a change in condition pertaining to multiple falls for 1 of 2 residents reviewed for falls of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, Diabetes type II, repeated falls, and pain. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted the resident had two or more falls since his admission or prior…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure medical records were complete and accurate for 1 of 2 residents reviewed for resident to resident abuse of a total sample of 6 residents, (#9). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, falls and persistent mood disorders. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. Resident #9 was admitted to the facility on [DATE]. His diagnoses included altered mental status, opioid dependence, and alcohol abuse. Review of the resident's admission MDS assessment with ARD of 12/03/23 revealed the resident's cognition was intact with a BIMS score of 15 out 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · 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 interview and record review, the facility failed to timely report possible neglect for 1 of 6 residents reviewed for Administration of a total sample of 6 residents, (#1). Findings: Review of resident #1's Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with an ARD of [DATE] revealed no assessment was completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). She had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The Comprehensive Care 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and identify possible neglect for 1 of 6 residents reviewed for Administration, of a total sample of 6 residents, (#1). Findings: Review of resident #1's Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed no assessment was completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). She had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, and had 2 unstageable pressure ulcers. The assessment noted the resident did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a 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 · Dcited before2023-11-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    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 observation, interview and record review, the facility failed to ensure critical medications were obtained for 2 of 6 residents reviewed for Quality of Care and Treatment, of a total sample of 6 residents, (#1, #6). Findings: 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of brain bleed, encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension (high blood pressure), deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and re-admitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure with history of mechanical ventilation (breathing machine) dependence, health care associated pneumonia, heart failure, pressure ulcer, and epilepsy. Review of the Minimum Data Set (MDS) Death in facility tracking record…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-15 · tag F0657 — failed to keep the care plan current — pattern
    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, interview, and record review, the facility failed to review or revise the individualized smoking safety plan of care for 2 out of 4 residents reviewed for care plans, from a total sample of 35 residents, (#18, #21). Findings: 1. Review of the medical record revealed resident #18 was admitted to the facility from an acute care hospital on 6/24/2019 and had diagnoses that included nicotine cigarette dependence, borderline intellectual functioning, schizoaffective disorder, bipolar disorder, dementia, epilepsy, chronic obstructive pulmonary disease (impaired lung functioning), and muscle weakness. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/29/2023 noted the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), that indicated he was cognitively impaired. The assessment noted the resident showed indicators of psychosis with hallucinations and delusions, required staff assistance to complete Activities of Daily Living (ADL), and received antipsychotic…

    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 · D2023-06-15 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    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 involve resident in Care Plan Meetings for 1 of 1 resident out of a total sample of 35 residents, (#22). Findings: Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke), type 2 diabetes, bipolar disorder and unspecified dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/04/23 revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 13/15. The assessment noted resident #1's hearing was adequate, he had clear speech, made himself understood, and had clear comprehension. The assessment noted his vision was severely impaired. The assessment indicated the resident participated in the assessment. On 6/15/23 at 10:15 AM, the MDS coordinator confirmed resident #1 had not been invited to his care plan meeting. She stated resident #22's Power of Attorney (POA) was invited to the care 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the process to ensure resident's wishes related to advance directives were accurately recorded for 1 of 1 sampled residents out of a total sample of 35 residents, (#22). Findings: Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of stroke, type 2 diabetes, bipolar disorder, and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 13/15. The assessment noted resident #1's hearing was adequate, his speech was clear and he made himself understood with clear comprehension. The assessment noted his vision was severely impaired. On [DATE] at 10:19 AM, resident #22 stated he wanted to be resuscitated and everything to be done if his heart stopped beating or he stopped breathing. He explained he told the nurse his wishes when he came…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for newly evident possible Serious Mental Illness (SMI) for 2 of 2 sampled residents from a total sample of 35 residents, (#81, #7). Findings: 1. Review of resident #81's medical record revealed the resident was admitted to the facility on [DATE] from a rehabilitation hospital and had diagnoses that included metabolic encephalopathy (brain function abnormality), depression, atrial fibrillation (heart dysfunction), and abnormal liver chemistry. Diagnoses of paranoid personality disorder, cognitive communication deficit, need for assistance with personal care, dysphagia (swallowing difficulty) and malnutrition were added to the resident's plan of care after he was admitted . The medical record revealed a PASRR was completed on 4/11/2023 by acute care hospital staff. Section I noted there were no suspected or Mental Illness (MI) present. The record showed the diagnosis of paranoid personality…

    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 · D2023-06-15 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Pre-admission Screen and Resident Review (PASRR) was completed prior to admission or as soon as identified after admission for 1 of 3 residents reviewed for Pre-admission Screen and Resident Review out of a total sample of 35 residents, (#2) Findings: Review of the medical record for resident #2 revealed she was admitted to the facility on [DATE] from another facility with diagnoses of paranoid schizophrenia, hypothyroidism, drug induced subacute dyskinesia, and depressive disorder. Review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 5/24/23 showed no PASRR screening and noted the resident had moderate cognitive impairment with a Brief Interview for Mental Status score of 8 out of 15. The medical record contained a PASRR screening form with no date, and blank pages except for resident #2's name, age, social security number and date of birth . On 6/14/23 at 10:23 AM, the Director of Nursing (DON) stated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0675 — failed to support quality of life — isolated
    Honor each resident's preferences, choices, values and beliefs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement orthopedic follow up care and services for 1 of 2 residents reviewed for rehabilitation and restorative from a total sample of 35 residents, (#90). Findings: Review of the medical record revealed resident #90 was admitted to the facility on [DATE] from an acute care hospital after a fall resulting in a fracture to his left upper arm. The resident's diagnoses included fracture of left humerus (upper arm), muscle weakness, history of falls, and depression. The Minimum Data Set admission assessment with Assessment Reference Date 6/5/2023 noted the resident scored 10 out of 15 on the Brief Interview for Mental Status which indicated he had moderate cognitive impairment. The assessment showed the resident did not have any behavioral symptoms and did not reject of care or evaluation. The assessment noted the resident required partial to moderate assistance from staff to complete Activities of Daily Living (ADL), had range of motion…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care out of total 35 sampled residents, (#445). Findings: Resident # 445's medical record revealed he was initially admitted to the facility on [DATE] with diagnoses to include osteomyelitis, sepsis, and acute kidney failure. Review of the Minimum Data Set (MDS) Modification of admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated resident #445 had severe cognitive impairment. Review of the medical record for resident #445 revealed physician orders dated 6/02/23 that read, PICC (Peripherally Inserted Central Catheter) Midline right arm, monitor for signs and symptoms of infection, swelling, color change, pain, drainage every shift and as needed (PRN). If present notify physician. An additional order dated 6/02/23 read, PICC Midline change…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor resident preferences and follow dietary orders for 1 of 3 residents reviewed for food concerns from a total sample of 35 residents, (#23). Findings: Resident #23 was admitted to the facility from the hospital on 4/21/23 for therapy and nursing services. His admission diagnoses included a recent laparoscopic cholecystectomy (gallbaldder removal) procedure, diabetes mellitus, anxiety, and depression. On 6/12/23 at 12:35 PM, resident #23 said he had gallbladder removal surgery and was told this morning at breakfast that staff on the unit told him they no longer have 2% milk for his cereal. He reported he had requested 2% milk as a preference with his cereal because regular milk caused him diarrhea since his gall bladder removal and the 1% milk tasted like water. Review of resident #1's diet order dated 5/11/23 revealed he was to receive a regular textured consistent carbohydrate diet (CCD) diet with thin liquids. The order also…

    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 · D2023-06-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper disposal of sharps in a puncture-resistant sharps container for 1 of 1 resident out of a total sample of 35 (#29). Findings: Resident #29 was readmitted to the facility on [DATE] with a previous admission on [DATE] from the hospital with diagnoses of complete traumatic amputation, oral phase dysphagia, type 2 diabetes, depressive, anxiety disorder, and basal cell carcinoma of the skin. On 6/12/23 at 11:25 AM, after observation of a point of care testing for blood sugar monitoring of insulin administration with Licensed Practical Nurse (LPN) G, the LPN G placed the soiled blood lancet into a water cup, doffed her gloves and placed them inside the same water cup. She then walked over to the trash can next to the sink in resident #29's room and placed the water cup with the soiled blood lancet and doffed gloves into the trash can. Observation revealed a sharps containers readily accessible in front of LPN G to the right of 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-29 · 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 and interview, the facility failed to provide nail care for 1 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care of a total sample of 34 residents, (#442). Findings: Resident #442 was admitted to the facility on [DATE]. Her diagnoses included displaced fracture of left femur, generalized weakness, dementia, and diabetes type II. The Medicare 5 days Minimum Data Set (MDS) assessment with assessment reference date (ARD) 7/15/21, showed the resident's Brief Interview of Mental Status (BIMS) score was 03 out of 15 which indicated severe cognitive impairment. The assessment showed the resident required extensive assistance for dressing, and personal hygiene. Observations on 07/26/21 at 12:05 PM, on 7/27/21 at 11:06 AM and on 7/28/21 at 11:22 AM, showed resident #442's fingernails of bilateral hands untrimmed, with a dark substance underneath the nails. The resident could not recall when her nails were last trimmed. She said they could do with some cutting. On 07/27/21 at…

    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 before2021-07-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen (O2) therapy was administered as per physician orders for 1 of 3 residents and failed to obtain a physician's order for 1 of 3 residents reviewed for oxygen in a total sample of 34 residents, (#441 & #5). Findings: 1. Resident #441 was admitted to the facility on [DATE] with diagnoses of Respiratory Syncytial Virus (RSV), diabetes type II, and acute respiratory failure. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 7/23/21, showed the resident was on oxygen 3 Liters (L) continuous. Physician orders dated 7/23/21 included oxygen (O2) continuous at 3 liters per minute (LPM) via nasal cannula (N/C) for acute respiratory failure. Observation on 7/27/21 at 11:10 AM, showed resident #441 received O2 via N/C at 4 LPM. The resident could not say what his O2 rate should be. On 07/27/21 at 4:18 PM, Registered Nurse (RN) B stated resident #441 had diagnoses of RSV, and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-29 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR) was accurately completed for 1 of 5 residents reviewed for unnecessary medications of a total of 34 sampled residents, (#10). Findings: Resident #10 was admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), bipolar disorder, heart failure, anxiety disorder, major depressive disorder, and aftercare following joint replacement. Physician orders showed the resident's medications included Lamotrigine 100 milligram (mg) twice daily (BID) for Bipolar, Gabapentin 300 mg BID, Morphine Sulfate 15 mg three times daily (TID) for pain, Baclofen 5 mg TID for pain, and Mucinex 600 mg BID for cough/congestion inhale every 8 hours as needed for shortness of breath, Senna 8.6 mg BID for constipation. Record review of the resident's MAR for July 2021 showed blank spaces on 7/11/21 for the resident's 9 PM medications listed above. There was no documentation/signature/…

    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

$87,952 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $46,176 — penalty dated 2025-04-10
  • $41,776 — penalty dated 2023-11-17
  • Medicare payment denial — starting 2023-12-28 for 34 days

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 AVANTE CENTERS — 11 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 52.5-0.5 vs chain
Health inspection 1 of 52.2-1.2 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 10 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
AG HOLDINGS, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/17/2000
DEBBIE KLURMAN 1994 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 06/20/1989
DEENA KLURMAN KRANZ 2000 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 06/20/1989
MONA MIZRACHI 1994 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 06/20/1989
SISEL KLURMAN 2001 REVOCABLE TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 04/09/2010
BIEGASIEWICZ, KIMBERLYIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/04/2022
HORNACK, JOHNIndividualCORPORATE OFFICERsince 04/24/2019
CAIATI, DENISEIndividualADP OF THE SNFsince 04/01/2026
CHOPRA, SHAWNIndividualADP OF THE SNFsince 04/01/2026

CMS files one row per role, so the 11 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.2M
Net patient revenuemost recent cost report
-0.4%
Operating marginrevenue minus expenses
$1.3M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 11%Other / private 31%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$324per resident / day
operating cost
$9,849per month
≈ monthly operating cost
$323per 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 105671. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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