No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Melbourne Healthcare And Rehabilitation Center

1415 S Hickory St, Melbourne, FL 32901 · For profit - Individual · 138 certified beds · (321) 723-1321 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$40,132 in federal fines
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 Nov 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $40,132 in federal fines (most recent 2024-11-22)
  • 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.

1/5
CMS overall
1 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 3 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, 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
1402 Oak St · (321) 722-3288 · Call to confirm hours
Pharmacy
1350 Hickory St · (321) 434-7373 · Call to confirm hours
Grocery
Publix0.4 mi
1411 S Babcock St · (321) 727-8085 · Call to confirm hours
Park
635 Hibiscus Blvd E · (321) 608-7400 · Typically dawn to dusk
Place of worship
311 E Hibiscus Blvd · (321) 725-9445

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.2%8.7%15.4%better
Long-stay residents who lose too much weight7.2%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.5%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 injury2.7%2.5%3.3%better
Long-stay residents whose ability to walk worsened2.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication8.8%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers7.3%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control4.8%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 table12.2%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.8%94.7%79.4%better
Short-stay residents rehospitalized after admission26.2%26.1%22.6%worse
Short-stay residents with an outpatient ER visit12.7%9.1%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.482.131.67better
Long-stay outpatient ER visits per 1,000 resident days1.671.151.80typical

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.

41.0% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.0%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
62.1%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 62.1% 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 66 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.0%CMS range 29.4–55.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 8.0–15.610.7%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 discharge62.1%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 discharge68.2%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 discharge56.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting92.5%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 discharge95.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%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 hospitalization6.9%CMS range 3.4–12.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.65
RN hours/ resident / day
0.46
LPN hours/ resident / day
2.32
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.62
RN hoursweekends
40.9%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 138 beds and averages 126.6 residents a day — about 92% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 3.29 hrs/resident/day on weekends vs 3.49 on weekdays — 6% thinner on weekends. RN hours go from 0.67 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

10
deficiencies at the latest standard inspection (2025-03-06)
7
at the previous standard inspection (2023-06-22)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Immediate jeopardy · J2024-11-22 · 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 implemented measures to mitigate risks to prevent elopement for 1 of 5 residents reviewed for elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, harm, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died. On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road…

    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 · J2024-11-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 5 residents reviewed for Elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious life-threatening injury, harm, or even death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died. On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-06 · 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 store food in accordance with professional standards for food service safety and failed to follow proper sanitation practices to prevent the outbreak of foodborne illness. This had the potential to affect all residents at the facility who eat food prepared in the kitchen. Findings: 1. On 3/03/25 at 10:00 AM, during the initial kitchen tour with the Assistant Dietary Manager I, observations in the walk-in found there were four, one-third steamtable pans of leftover food items including mechanical soft pork dated 3/1 and use by 3/07/25, sweet potatoes dated 3/2 and use by 3/08/25, corn dated 3/1 use by 3/07/25, and mashed potatoes dated 3/2 use by 3/08/25. Assistant Dietary Manager I stated their policy was to keep leftover fish, meat, and poultry for three days after prepared, and vegetables for five days. She could not explain why it was written to keep all these food items for six days each. There were two packages of hard-boiled eggs, unsealed and left open to the air, and undated; and a carton of whole eggs was open and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-06 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    3. Review of resident #25's record revealed an admission date of 11/23/23. His diagnoses include unspecified atrial fibrillation, acquired absence of right leg below knee, and acquired absence of left leg below knee. His quarterly 11/29/24 Minimum Data Set included a Brief Interview of Mental Status score of 15/15, which indicated intact cognition. On 3/03/25 at 11:05 AM, resident #25 said he had a skin growth on the left side of his nose since his admission to the facility in 2023. He explained in October 2024 he requested help from the facility's Business Office Manager to recertify his health insurance, Medicaid. He said the dermatology group that visited the facility did not take the type of Medicaid he had when he attempted to be seen by them last year; so, he waited for a dermatology visit to be arranged with an outside provider who took his insurance. He said he found out in last December 2024 from the outside dermatology appointment he did not have any active health insurance. He said he has missed a specialty appointment for another skin issue below his right eye, after he…

    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 · E2025-03-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment by failing to de-emphasize the institutional character of the dining room for one of one dining room reviewed for dining and failed to maintain a sanitary and comfortable interior of the resident rooms for 3 of 3 residents rooms reviewed for cleanliness, (#13, #20, and #62). Findings: 1. On 3/03/25 at 12:24 PM, in the main dining room, 36 residents were observed eating lunch. There were no table cloths, no centerpieces on the tables and there was no music playing to create a homelike atmosphere for dining. At 12:33 PM, loud country music was started. On 3/05/25 between 10:25 AM and 12:00 PM, residents were observed eating morning snacks at the dining tables in the dining room. A short time later a couple of tables were moved so residents could exercise in an open area of the dining room. Later, the tables were moved back so residents could eat lunch, but no dining room table additions such as tablecloths or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-06 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to post the nursing staffing hours daily, which identified the number of staff working in the facility on the form posted. Findings: On 3/03/05 at 10:24 AM, 3/04/25 at 10:15 AM, 3/05/25 at 8:34 AM, and 3/06/25 at 8:37 AM, the daily Nurse Staffing Form located by the receptionist in the lobby failed to identify the number and type of nursing staff working in the facility on the form posted. On 3/06/25 at 9:53 AM, the Staffing coordinator stated she was responsible for posting the form. The Staffing Coordinator acknowledged that the facility name was not on the Nurse Staffing Form, and that the form did not identify the number and type of staff working. The Coordinator stated the company was undergoing changes, so she was not sure what company name to put on the sheet. ON 3/06/25 at 1:03 PM, the Administrator stated there was a staffing meeting at about 11:00 AM daily. The Administrator explained that last week, the facility received a call that their name was changing, so we stopped putting the facility name on…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-06 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to establish a system for the prevention of communicable diseases by failing to ensure all residents were offered and encouraged to perform hand hygiene before meals for all residents eating meals in the dining room. Findings: On 3/04/25 at 12:00 PM, in the main dining room, approximately 28 residents were observed eating lunch. Several of the residents stated they were not offered a way to clean their hands prior to meals while one resident stated he was only offered a napkin. On 3/05/25 at 10:25 AM, approximately ten residents were observed finishing a morning snack in the main dining room, after which they proceeded to move to the front of the dining room for morning exercise. A short time later at 11:00 AM, 12 residents were observed participating in exercises to music while sitting in their wheelchairs, after which most of these residents moved to the dining tables to eat lunch. None of these residents, nor others who joined the dining room afterwards, were offered a means to clean their hands before 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 · D2025-03-06 · 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 a medication self-administration assessment to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 62 residents, (#44, and #92). Findings: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, emphysema, and general anxiety disorder. A review of the Minimum Data Set (MDS) admission assessment, with an assessment reference date of 12/09/24, revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. On 3/03/25 at 4:12 PM, resident #44 was observed with an Albuterol Tartrate HFA inhaler on her overbed table. The resident stated she took it as needed. On 3/3/25 at 4:33 PM, primary care nurse, License Practical Nurse (LPN) C observed and acknowledged the resident's inhaler at her bedside. LPN C stated the resident had physician orders that she may have…

    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 before2025-03-06 · 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 2. Resident #26 was initially admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy. She was discharged from the facility on 4/26/24 and readmitted on [DATE] following a right hip fracture. The admission Record or face sheet listed diagnoses including dementia with behavioral disturbances, insomnia, depression, and psychotic disorder with delusions due to known physiological condition, and anxiety. A psychiatry consult from 6/26/24 revealed that resident #26 was admitted with medications for diagnoses of dementia and insomnia. Resident #26 was started on Depakote sprinkles 250 milligrams (mg) two times a day for psychotic disorder on 1/02/24. Resident #26's care plan initiated on 7/12/24 indicated the resident had impaired cognition which affected communication, functional abilities, decision making, and judgement related to psychosis and dementia. The resident's PASARR forms dated 11/03/23 and 6/24/24 were completed by prior to admission to the facility. The form had no diagnosis…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents reviewed for choices, of a total sample of 62 residents, (#93). Findings: Resident # 93 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Parkinsonism, anemia, syncope and collapse, and hypertensive heart disease without heart failure. Her most recent Minimum Data Set (MDS) showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which meant she had no impairment in cognition. On 3/03/25 at 4:47 PM, resident #93 explained she and facility staff were very careful with her blood pressure because she passed out a few times and so she spent most of the day at the therapy gym. Review of the physician orders included Vital signs every shift and Midodrine HCL oral tablet 10 milligrams (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · 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 respiratory care and services were provided in accordance with professional standards of practice, and per physician orders for 2 out of 2 residents reviewed for respiratory care, of a total sample of 62 residents, (#35, & #85). Findings: 1. Resident #35 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, unspecified ulcerative colitis, celiac disease, pulmonary embolism (PE) and history of breast cancer. A review of the annual Minimum Data Set (MDS) assessment with reference date 2/12/25 revealed resident #35 had no cognitive impairment, no behaviors, no rejection nor refusal of care and required the use of oxygen. The physician orders for oxygen read continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Resident #35 had a plan of care for shortness of breath related to COPD, recent pneumonia and PE with interventions…

    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 · D2025-03-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Pharmacist recommendations were addressed by the physician for 1 of 5 resident reviewed for unnecessary medications, of a total sample of 62 residents, (#57). Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral brain hemorrhage, muscle weakness, abnormalities of gait and mobility, moderate protein-calorie malnutrition, anxiety, depression, and hypertension. The resident's Care Plan dated 12/16/24 stated the resident was at risk for falls due to weakness and adverse effects of psychotropic medications with intervention to watch for signs and symptoms such as gait disturbance, sedation, lightheadedness, dizziness and change in mental status, mentation, and mood. Review of the medical record revealed on 1/13/25, the pharmacist submitted a recommendation for the physician to evaluate the order for the antidepressant, Mirtazapine (Remeron), and to consider tapering the dose from 15…

    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
Show the remaining 10 citations
  • Potential for harm · D2024-12-03 · 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 ensure an allegation of neglect was reported to the relevant State Agencies within the regulatory timeframe for 1 of 2 resident reviewed for Abuse and Neglect, (#1). Findings: Resident #1, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease, hypertension, dysphagia (difficulty swallowing), anxiety disorder, and dementia. Review of the resident's quarterly Minimum Data Set assessment dated [DATE], revealed the resident was rarely/never understood, and was dependent on staff assistance for her activities of daily living (ADLs). Review of the facility's incident log reflected the resident had a fall on 11/01/24, and review of the reportable log revealed an entry for resident #1 dated 11/01/24, classified as neglect. On 12/02/24 at 1:40 PM, the entries for the resident on the facility's incident and reportable logs were discussed with the Director of Nursing (DON). She recalled that on 11/01/24…

    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 · E2024-11-22 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, and interview, the facility's administration failed to implement it's resources to maintain effective elopement prevention measures to ensure the safety of residents known to be at high risk of elopement. On 10/26/24 at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of 35 miles per hour. The route along the way had uneven terrain and curbs. Approximately 0.1 miles from the facility was a large lake, and approximately 0.4 miles, there was a high speed railroad crossing. The facility was unaware of the resident's elopement until a Registered Nurse (RN) realized he was missing but they failed to search for him for approximately 90 minutes. At approximately 9:50 PM, staff located the resident in the parking lot of a shopping…

    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 · D2023-06-22 · 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 interview, and record review, the facility failed to ensure a Do Not Resuscitate Order (DNRO) form was signed and properly completed for 1 of 1 resident reviewed for advanced directives from a total sample of 36 residents, (#52). Findings: Review of medical record revealed resident #52 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of heart and circulatory disease, stroke, speech and language deficits, malnutrition, and dysphagia (difficulty swallowing), schizoaffective disorder and moderate dementia with behavioral disturbance. The record showed the resident was placed under Hospice care and services on 11/07/2022. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date 5/21/2023 noted staff assessed the resident was rarely or never understood, had cognitive skills for decision making that were severely impaired, disorganized thinking was continually present, inattention was present and fluctuated, and the resident had not rejected…

    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 · D2023-06-22 · 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 (PASARR) for a later identified Mental Illness (MI) for 1 of 1 resident reviewed for PASARR from a total sample of 36 residents, (#52). Findings: Review of resident #52's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including metabolic encephalopathy (brain function abnormality), rhabdomyolysis (muscle injury), and stroke. Diagnoses of other schizoaffective disorders, adjustment disorder with mixed anxiety, anxiety disorder, moderate dementia with behavioral disturbance, speech and language deficits, malnutrition, and dysphagia (difficulty swallowing) were added to the resident's plan of care after he was admitted . The medical record showed a PASARR screen was completed on 1/25/2021 by acute care hospital staff. Section I noted there was no Mental Illness (MI) present or suspected. The diagnosis of other schizoaffective…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-22 · 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 interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) level I for possible Serious Mental Illness (SMI) for 1 of 1 resident from a total sample of 36 residents (#55). Findings: Review of resident #55's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include schizoaffective disorder, major depressive disorder, psychotic disorder with delusions, unspecified dementia. A level I PASARR screen was completed on 2/11/2022 by acute care hospital staff. Section I inaccurately noted there was no Mental Illness (MI) present or suspected. The medical record revealed all the above diagnoses to be present on admission. Review of physician orders included Lexapro for depressive disorder with a start date of 2/16/22, Seroquel for schizoaffective with a start date of 5/12/23. On 6/21/23 at 10:00 AM, the Director of Nursing (DON) stated the Social Service Director (SSD) and the Director…

    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 · D2023-06-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 care and services to maintain or prevent decline in Activities of Daily Living (ADL) abilities, for 1 of 3 residents reviewed for Rehabilitation and Restorative services from a total sample of 36 residents, (#98). Findings: Review of the medical record revealed resident #98 was admitted on [DATE] and re-admitted on [DATE] from an acute care hospital and had diagnoses that included stroke, encephalopathy (brain dysfunction), aphasia (difficulty speaking/understanding speech), dysphagia (difficulty swallowing), malnutrition, gastrostomy dependence (feeding tube), lack of coordination, muscle weakness, syncope (fainting) and collapse, heart failure, dependence on supplemental oxygen, type 2 diabetes mellitus, and depression. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 5/22/2023 noted the resident was unable to complete the Brief Interview for Mental Status and was assessed by staff to have…

    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 before2023-06-22 · 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 obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for oxygen of a total sample of 36 residents, (#79). Findings: Resident #79 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and anxiety. On 6/20/23 at 1:36 PM, the resident was seen lying in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:10 AM, the resident was seen sitting up in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:20 AM, a review of resident #79's medical record revealed no order for oxygen therapy. Review of the Medication Administration Record and Treatment Record reflected no documentation of oxygen being administered for resident #79. On 6/21/23 at 9:30 AM, Registered Nurse B stated resident #79 was on oxygen but he could not find an order in the computer for the resident's oxygen liter flow. He stated it may be in the hospice book. On 6/21/23 at 9:40 AM, the South wing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-22 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 behavior monitoring and side effects of antipsychotic medication were documented for 2 of 5 residents reviewed for unnecessary medications out of a total sample of 36 resident, (#55, #67). Findings: 1. Resident #67 was readmitted to the facility on [DATE] with a previous admission on [DATE] with diagnoses of dementia, Alzheimer's disease, malignant neoplasm of prostate, bipolar disorder, and hallucinations. Review of quarterly Minimum Data Set (MDS) with assessment reference date of 4/30/23 revealed short- and long-term memory problems. The resident's care plan initiated 1/23/23 revealed a focus for potential side effects related to psychotropic medications with interventions to observe for potential side effects, notify physician and psych services to follow. Review of the resident's physician orders revealed antipsychotic medication, Risperidone 1 milligram (mg) ordered 1/27/23 to be given by mouth twice a day for dementia,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 psychotropic medications that were ordered as needed (PRN), did not exceed beyond 14 days without documented rationale for 1 of 5 residents sampled for unnecessary medications of a total sample of 36 residents, (#55). Findings: Resident #55 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, depression, psychotic disorder, anxiety disorder, and mood disorder. Review of the physician orders dated 4/26/23, Lorazepam (Ativan) gel 2 milligrams per milliliter (mg/ml), apply to wrist topically every 8 hours as needed (PRN) for anxiety. The order did not have a stop date. Review of the medical record revealed no rationale to continue the Lorazepam order beyond the 14 day period. On 6/21/23 at 4:08 PM, the Director of Nursing stated antianxiety medications that were ordered PRN must be stopped after 14 days and the doctor must see the resident to renew the order. On 6/22/23 at 5:37 PM, Registered Nurse B stated if the PRN…

    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 before2021-08-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the kitchen pantry and the walk-in cooler were clean and in good repair, and failed to ensure the walk-in freezer was maintained to prevent the potential of food contamination. The facility also failed to use non-expired sanitizing strips to ensure proper concentration of the sanitizer in the manual washing sinks. Findings: 1. On 8/02/21 at 10:23 AM, the main kitchen pantry had black biofilm like substance that had leaked on the wall from the pipelines that went into the walk-in freezer. The Kitchen Manager (KM) acknowledged the black biofilm substance on the wall and said that it had been there for weeks. On 8/04/21 at 11:46 AM, the refrigeration service representative said there was air extraction and infiltration from the walk-in freezer around the fire tape seal in the pantry which allowed penetration of moisture into the pantry. On 8/02/21 at 10:23 AM, the walk-in cooler had a sour milk-like odor. On 8/03/21 at 11:08 AM, the walk-in refrigerator still had a sour odor present. The floor tiles in…

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

    Nutrition and Dietary 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

$40,132 in federal fines across 1 penalty.

  • $40,132 — penalty dated 2024-11-22

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 EXCELSIOR CARE GROUP — 33 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 1 of 52.5-1.5 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 3 of 54.2-1.2 vs chain
The other 32 homes this chain runs (chain average 2.5★, per CMS)
1 of 5Ambassador Healthcare At College ParkFort Myers, FL 1 of 5Briarcliff Manor Center For Rehab And Nursing CareBriarcliff Manor, NY 1 of 5Charlotte Bay Rehab And Care CenterPort Charlotte, FL 1 of 5Live Oak Healthcare And Rehabilitation CenterLive Oak, FL 1 of 5River Front Rehabilitation And Healthcare CenterPennsauken, NJ 1 of 5Space Coast Healthcare And Rehabilitation CenterMerritt Island, FL 1 of 5West Delray Nursing & Rehab CenterDelray Beach, FL 2 of 5Alliance Care Rehabilitation And Nursing CenterIrvington, NJ 2 of 5Azure Shores RehabMiami, FL 2 of 5Beach Breeze Rehab And Care CenterWest Palm Beach, FL 2 of 5Boca Circle Rehabilitation CenterBoca Raton, FL 2 of 5Breezy Hills Rehab And Care CenterLakeland, FL 2 of 5Charming Lakes RehabLakeland, FL 2 of 5Lake City Healthcare And Rehabilitation CenterLake City, FL 2 of 5Lake Eustis Healthcare And Rehabilitation CenterEustis, FL 2 of 5Seagate Rehabilitation And Nursing CenterBrooklyn, NY 2 of 5West Volusia Healthcare And Rehabilitation CenterDeltona, FL 2 of 5Yamato Nursing And Rehabilitation CenterBoca Raton, FL 3 of 5Arnold Walter Nursing & Rehabilitation CenterHazlet, NJ 3 of 5Heartland Nursing & Rehab CenterBoynton Beach, FL 3 of 5Nassau Rehabilitation & Nursing CenterHempstead, NY 3 of 5Palm Beach Nursing CenterLake Worth, FL 3 of 5Throgs Neck Rehabilitation & Nursing CenterBronx, NY 4 of 5Acclaim Rehabilitation And Nursing CenterJersey City, NJ 4 of 5Adroit Care Rehabilitation And Nursing CenterRahway, NJ 4 of 5Anchor Care and Rehabilitation CenterHazlet, NJ 4 of 5Atrium Center for Rehabilitation and NursingBrooklyn, NY 4 of 5Isles Of Boynton Nursing And Rehab CenterBoynton Beach, FL 4 of 5Sun Harbor HealthcarePort Charlotte, FL 4 of 5Victoria Crossing Rehabilitation CenterBrandon, FL 5 of 5Cypress Garden Center for Nursing and RehabilitatiFlushing, NY 5 of 5Staten Island Care CenterStaten Island, NY

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
CARNEGIE GARDENS OPERATING INVESTMENTS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/09/2022
BDCC CONSUTKING GROUP LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
FDZ CONSULTING LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
JZ CONSULTING LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
RUBIWEB FLORIDA SERVICES GROUP USA LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
POWERS, BRIANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
RUBENSTEIN, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
WEBER, ARONIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/09/2021
ZAHLER, JACOBIndividualCORPORATE OFFICERsince 12/09/2021
PARISI, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2025
PATEL, GAURANGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2019

CMS files one row per role, so the 13 rows in the source record cover these 11 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.

$10.8M
Net patient revenuemost recent cost report
-9.9%
Operating marginrevenue minus expenses
$1.7M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 7%Other / private 25%

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$338per resident / day
operating cost
$10,284per month
≈ monthly operating cost
$308per 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 105207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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.

What to do next