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

Coral Reef Subacute Care Center LLC

9869 SW 152nd Street, Miami, FL 33157 · For profit - Limited Liability company · 180 certified beds · (305) 255-3220 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Jan 20241 immediate-jeopardy citation$10,039 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,039 in federal fines (most recent 2024-12-06)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 23% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
15155 SW 97th Ave · (305) 689-7272 · Call to confirm hours
Pharmacy
9333 S.W. 152nd Street, Main lobby · (305) 256-2185 · Call to confirm hours
Grocery
14500 SW 95th Ave · (305) 359-3483 · Call to confirm hours
Park
SW 146th St · (305) 235-4503 · 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 improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
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 increased5.6%8.7%15.4%better
Long-stay residents who lose too much weight1.3%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 symptoms3.7%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 injury0.8%2.5%3.3%better
Long-stay residents whose ability to walk worsened4.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.4%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.5%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control2.0%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 table4.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine99.2%94.7%79.4%better
Short-stay residents rehospitalized after admission25.5%26.1%22.6%worse
Short-stay residents with an outpatient ER visit4.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.942.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.181.151.80better

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.

39.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 95 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.7%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
59.0%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 59.0% 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 212 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 0.37 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF39.7%CMS range 31.1–49.751.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.4–14.410.7%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 discharge59.0%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 discharge55.2%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 discharge59.4%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 setting100.0%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 discharge100.0%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 stay0.0%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 worsened1.2%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 hospitalization5.8%CMS range 3.5–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.381.02Oct 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

1.31
RN hours/ resident / day
0.11
LPN hours/ resident / day
2.33
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
1.06
RN hoursweekends
38.4%
Total nursing turnover
38.9%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 155.7 residents a day — about 86% occupied, or roughly 24 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.31 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 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 3.32 hrs/resident/day on weekends vs 3.93 on weekdays — 15% thinner on weekends. RN hours go from 1.42 to 1.06 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% 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

5
deficiencies at the latest standard inspection (2025-06-05)
11
at the previous standard inspection (2024-01-19)

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

Inspection deficiencies

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

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-12-06 · 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 observations record reviews and interviews, the facility's staff failed to supervise and implement adequate measures to prevent the elopement for one (Resident #1) out of three residents sampled. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system were in place enabled Resident #1 who had risk factors that include visual impairment and seizure disorder, exited the facility undetected on 09/01/2024 shortly after lunchtime. Resident #1 who had displayed and voiced his intent to leave the day prior ambulated 3.2 miles from the facility in areas that has high traffic volume, intersections and cross streets; these factors increased the likelihood of an adverse outcomes, serious injury and serious harm or death. The facility's staff were not aware of Resident #1's absence until the resident's sister called the facility and reported a convenience store owner had called and said her brother was at the store. The Registered Nurse (Staff J)…

    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 before2025-12-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility's staff failed to answer incoming calls after 8:00 PM. Six documented calls to the facility were not answered by the staff. This deficient practice had the potential to affect all 159 residents residing in the facility at the time of the survey. The findings include.Observational tour on 01/20/2026 at 3:35 PM, revealed the East Wing nursing station had three desk phones and one portable phone. The [NAME] Wing nursing station had three desk phones and one portable phone. The North Wing nursing station also had three desk phones and one portable phone on the counter. There were three nurses at each nursing station engaged in various tasks.On 12/29/2025 the surveyors made multiple attempts to contact the facility by phone at different times as follows:9:34 PM - The phone rang 10 times, but no one answered 9:42 PM - The phone rang 15 times, but no one answered.9:48 PM - The phone rang 15 times, but no one answered.10:01 PM - The phone rang 15 times, but no one answered.10:16 PM - The phone rang 17 times, but no one…

    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 · E2025-06-05 · 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 necessary housekeeping and maintenance services to maintain a sanitary, clean homelike environment with a comfortable interior free of disrepair for 11 out of 32 resident rooms on the East Unit. (Photographic evidence available). There were 156 residents residing at the facility at the time of the survey. The findings included: On 06/02/25 starting at 06:30 AM during the initial tour and resident screenings on the facility's East Unit observation revealed: The chest of drawers in room numbers 4, 6, 9 ,11, 15,17, 18, 19, 20, 21, 25 and 26 noted with chipped paint, grime (dirt ingrained on the surface) and black marks covering the top. The floor in room# 25 bed A was littered with paper all around the bed. Observation in room [ROOM NUMBER]'s bathroom revealed the toilet tissue/paper dispenser was broken. Interview on 06/04/25 at 10:30 AM, Staff A, Registered Nurse (RN) East Unit Manager when showed the photos of the surveyor findings…

    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 before2025-06-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure one (Resident #131) out of eight residents sampled was treated with respect and dignity during dining, as evidenced by Staff B, Certified Nursing Assistant observed standing while feeding Resident #131. This deficient practice has the potential to affect any residents residing in the facility requiring assistance from staff. The findings included: Observation on 06/02/25 at 12:42 PM, revealed Staff B, Certified Nursing Assistant (CNA) in Resident #131's room standing while feeding Resident #131. On 06/02/25 at 12:44 PM, the surveyor asked Staff B why he was standing while feeding Resident #131. Staff B revealed he prefers to stand and because he takes his time feeding the resident and makes sure the resident is safe. On 06/02/25 at 01:40 PM the Staff Educator (Staff C) acknowledged the identified concern related to dignity during dining and proper feeding practices. Review of the facility policy and procedure titled Dignity dated 11/14/24 states: Each resident shall be cared for in a manner 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · 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 a safe environment that is free from potential hazards for one (Resident #54) out of eight vulnerable residents sampled. As evidenced by the electrical cord for an Intravenous (IV) infusion pump attached to a pole at the right side of the resident's bed observed extended across bed connected to an electrical outlet on the left side of the resident's bed. There were 156 residents residing in the facility at the time of the survey. The findings included: Observation on 06/03/25 at 08:40 AM, Resident #54 was asleep in bed, IV site present on the resident's left arm dated 05/29/25. There was an IV pole with infusion pump attached at the right side of the resident's bed; it was revealed that the IV pump's electrical cord hung from the IV pole on the right side of the resident's bed was positioned under the resident, extending across the bed to the left side of the bed was connected to an electrical socket on the wall behind the bed's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medications and treatment ointments were stored in accordance with facility policy. As evidenced by ointments and medication were found in the residents' rooms unsecured. There were 156 residents residing in the facility at the time of the survey. The findings included: On 06/02/25 starting at 06:30 AM during the initial facility tour and resident screenings on the East Unit of the facility, the following were observed: rooms [ROOM NUMBERS] revealed Zinc Oxide ointment on the dresser in both rooms. room [ROOM NUMBER] had a half full 0.9% Sodium Chloride syringe on top of the dresser in the room. (Photographic evidence available) Interview on 06/04/25 at 10:48 AM, Staff A, Registered Nurse (RN) East Unit Manager when showed the photos of the findings in the residents' rooms, stated: The ointments and creams should be stored in the residents' personal drawers and the Sodium Chloride solutions must be stored on the medication cart 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F641- Accuracy of assessment and F761- Label/Store drugs and biologicals. Facility's failure to accurately code the Minimum Data Set (MDS). Facility's failure to store medications appropriately. There were 156 residents residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 01/19/ 2024, F641- Accuracy of assessment was cited for inaccurate coding of MDS section B for Corrective lenses. F761- Label/Store drugs and biologicals was cited due to facility's failure to ensure medications were securely stored. F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations record review and interviews, the facility's staff failed to ensure accuracy of controlled medication and failed to ensure drugs and biologicals used in the facility are stored and disposed in accordance with professional standards; as evidenced by three out of eight medication carts were observed unattended and unlocked, inaccurate narcotic accounting, medications observed in drawers at the north wing nurses' station and medications incorrectly disposed. On 12/02/2024 at 4:55 AM during the initial tour, the west wing's medication cart # 3 assigned to Staff N, RN was observed unlocked and unattended. On 12/02/2024 at 5:04 AM, Staff A, Registered Nurse (RN) observed tossing medications in the trash can attached to the medication cart. Staff A revealed the resident refused the medications, so she had to toss them. Staff A was asked if that was the process to discard medications. Staff A denied tossing the medications in the trash. The medications were retrieved from the trash and Staff A placed them in the sharps container. Staff A did not respond when was asked…

    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 · E2024-12-06 · 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 observations, record review and interview, the facility's staff failed to implement infection prevention control policies and procedures as evidenced by failure to handle soiled linen and garbage to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all residents residing in the facility. Observation on 12/02/2024 at 4:55 AM, several clear plastic bags containing trash and soiled linen were observed on the floor in the facility's hallways and resident's doorways. On 12/02/2024 at 4:57 AM during an observation on the east wing Certified Nursing Staff (CNA) Staff H was observed placing soiled linen in a bin and then returned few minutes later to remove clean linen from the clean linen cart that was noted beside two bins (a gray bin and a white bin). On 12/02/2024 at 7:11 AM, Staff H, CNA explained; the soiled linens and garbage should be placed in plastic bags and then in bins in the biohazard room. One bin is for the soiled linen and one for garbage. Staff…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-19 · 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 store food under sanitary condition as evidence by: 1) failure to ensure reach-in freezer and the reach-in refrigerators in the kitchen contained thermometers on the inside and 2) failure to ensure the resident's foods were labeled and dated. 3)The refrigerators were not working properly, and the refrigerator contained opened milk cartons in the snack/nourishment refrigerators on the resident's units. This has the potential to affect 163 out of 171 residents who eat orally residing in the facility at the time of the survey and potential to affect 55 out of 56 residents who eat orally residing on the East Wing. The findings included: 1) Observation of the initial kitchen tour on 1/16/24 at 8:34 AM with the Registered Dietitian (RD) and the Kitchen Supervisor revealed the following: 1) Reach-in freezer temperature outside was -4 degrees F and for the inside temperature, there was no thermometer noted. The reach-in freezer contained ice cream and desserts; 2) Reach-in Refrigerator #1 temperature outside was 40…

    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 · E2024-01-19 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review the facility failed to ensure the refrigerator in the East Wing Nourishment Pantry used to store resident's food was working properly. This has the potential to affect 55 out of 56 residents who eat orally residing in the East Wing at the time of the survey. The findings included: Observation of the East Wing Nourishment Pantry on 1/17/24 at 10:40 AM revealed the refrigerator was 60 degrees F (Fahrenheit) and the freezer was 54 degrees F. Photographic evidence submitted. Observation and interview with Staff M, Registered Nurse (RN) North and East Unit Manager on 1/17/24 at 10:42 AM of the East Wing Nourishment Pantry Refrigerator. She stated, The refrigerator temperature should be 41 degrees and the freezer should be 0 degrees F. Record review of the East Wing Nourishment Refrigerator and Freezer Temperature Log for January 2024 documented the following: 1/17/24 7:00 AM Refrigerator temperature was 39 degrees F and the Freezer temperature was -2 degrees F. Interview with the Registered Dietitian (RD) on 1/17/24 at 11:00 AM. She…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-01-19 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to treat residents with respect and dignity by the right to be free from any physical restraints for one (Resident number 27) out of two residents who triggered for physical restraints. The findings included: Initial observation of Resident number 27 on 1/16/24 at 10:10 AM revealed the resident lying in bed with the television on and her left hand contracted with a long sock covering up to the elbow. Second observation of Resident number 27 on 1/17/24 at 7:58 AM revealed the resident lying in bed with the television on and her left hand contracted with a long sock covering up to the elbow. Third observation of Resident number 27 on 1/17/24 at 8:22 AM with Staff A, Registered Nurse (RN) revealed the resident lying in bed with the television on and her left hand contracted long sock covering all the way up to the elbow. Staff A, RN removed the elbow long sock, and the left hand was contracted. Staff A stated, I don't know why the sock is on the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a Significant Change Minimum Data Set (MDS) for hospice for one Resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: On 01/17/24 at 02:49 PM, review of Resident #307's MDS revealed no Significant Change MDS was completed for the resident's status change to hospice effective 12/11/23. Review of the Physician's Orders Sheet for January 2024 revealed Resident #307 had orders that included but not limited to: admitted to Hospice effective (12/11/23) for diagnoses late effect Cerebral Vascular accident (CVA). Prognosis is for a life expectancy of 6 months or less if terminal illness runs its normal course, and Start continuous care 1/15/24 due to uncontrollable vomiting/ Intravenous hydration. Further review of the medical records for Resident #307 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) for one Resident (#100) out of 34 sampled residents. As evidenced by inaccurate coding of MDS section B for Corrective lenses. There were 171 residents residing in the facility at the time of the survey. The Findings included: During observation on 01/16/24 at 09:21 AM Resident #100 was in bed eating breakfast with dark glasses on. On 01/17/24 at 09:07 AM Resident #100 was observed in bed asleep with dark glasses on, call light on the bed and no distress noted. On 01/18/24 at 09:15 AM Resident #100 had a room change and was observed in bed in new room with dark glasses on. Record review of Resident #100's Quarterly Minimum Data Set (MDS) dated [DATE], Section B for Vision and Hearing in subsection B 1200 documented the resident has no corrective lenses. Review of the Physician's Orders Sheet for January 2024 revealed Resident #100 had orders that included but not limited to: May use treat 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · 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 a level 1 Preadmission Screening and Resident Review (PASRR) was revised following admission for one resident (#107) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The findings Included: During observation on 01/16/24 at 09:57 AM, Resident #107 was in bed well-groomed and had a cell phone in her hand. On 01/19/24 at 08:45 AM, Resident #107 was observed on a medical stretcher and leaving the facility, accompanied by two attendants. Record review of Resident #107's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: MI or suspected MI (check all that apply) - no mental Disorders checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related Neurocognitive disorder - no. Section III…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a hospice care plan in a timely manner for one resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: Review of the care plans with reference date 9/29/23 for Resident #307 revealed the hospice care plans created, were completed on 1/16/24, the first day of initial observation of the resident by the surveyor. The care Plans documented: Resident is at end of life, diagnosis of terminal illness and have chosen Hospice care. Date Initiated: 01/16/2024, Revision on: 01/16/2024. Interventions include-Administer medications per physician orders, Assess and treat Pain, assess emotional and spiritual needs of resident/family/caregiver, and meet same when possible and provide comfort measures and honor preferences when possible. Review of the Physician's Orders Sheet for January 2024 revealed Resident #307 had orders that included but not limited to:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · 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 observations, interviews, and record review the facility failed to ensure oxygen therapy was administered accurately as ordered for one out of two sampled residents (Resident #105) who were investigated for oxygen administration. This deficient practice has the potential to affect all residents who are on oxygen therapy. The findings included: Observation on 01/16/2024 at 08:22 AM showed Resident #105 was lying down on her bed while receiving oxygen (O2) via nasal cannula. Further observation showed the oxygen was running at 1 liter per minute (LPM). (Photographic evidence obtained) Observation on 01/18/2024 at 08:19 AM showed Resident #105 was lying on her bed while receiving oxygen (O2) via nasal Cannula. Observed a third-party staff from a hospice care service was at Resident #105's bedside. Further observation showed the oxygen was running at 1 liter per minute (Photographic evidence obtained). Review of Resident #105's face sheet revealed an initial admission date of 04/20/2021 and a re-entry date…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews. The facility failed to ensure medications were securely stored as evidenced by four broken and three loose pills found on two out of four carts checked. There were 71 residents residing in the facility at the time of the survey. The findings included: On 01/17/24 at 02:18 PM, in an observation and interview with Registered Nurse (RN) Staff A on the North Wing's medication cart one, showed inside the cart two (2) broken pieces and three (3) white pills (stamped:C-128, F/91, T/07) were found. When asked about the facility's policy regarding loose pills found on medication carts and the cleaning of medication carts. Staff A, RN stated, Every day I clean my cart. When I receive my cart, I check the resident's insulins, check for expired medications, and refill medications. I check my cart in the morning and in the middle of the day to clean it. Every shift is to clean medication carts. I'm going to place the loose pills in the drug buster. On 01/17/24 at 03:16 PM; in an observation and interview with Staff L, RN on North Wing's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-19 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview and record review, the facility failed to ensure that menus are developed and prepared to meet residents' choices including their cultural and ethnic needs for one (Resident number 207) out of three residents who triggered for food. The findings included: Initial observation and interview with Resident number 207 on 1/16/24 at 9:47 AM revealed the resident sitting up in bed, watching television and eating breakfast which her daughter brought in. The resident stated, They have been giving me Cuban food and I don't eat that. I have told them that I don't like it. My daughter has to bring me food every day to eat. Record review of the Demographic Face Sheet for Resident number 207 documented the resident was initially admitted on [DATE] with a diagnosis that include but not limited to anemia, diabetes mellitus, neuropathy, gastro esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease, osteoarthritis, depression, insomnia, anxiety disorder, major…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F645 PASRR (Preadmission Screening and Resident Review) for Individuals with a serious mental illness (SMI), intellectual disability(ID), F695 Respiratory/Tracheotomy Care and Suctioning, and F812 Food Procurement, Store/Prepare/Serve-Sanitary. This deficiency has the potential to affect 171 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 11/17/2022, F645 PASRR (Preadmission Screening and Resident Review) for Individuals with a serious mental illness, intellectual disability, F695 Respiratory/Tracheotomy Care and Suctioning, and F812 Food Procurement, Store/Prepare/Serve-Sanitary were cited. Interview with Administrator and the Director of Nursing on 01/19/2024 at 12:15 PM. The Administrator stated that the QAPI…

    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 · Fcited before2022-11-17 · 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, prepare, distribute and serve food in a sanitary manner and in accordance with professional standards The findings included: During the initial kitchen tour, on 11/14/22 at 8:19 AM, accompanied by the Registered Dietitian, the Administrator and the Dietary Director, the following were noted: -There was an accumulation of food debris on the floor in the dry storage area. -There was residue on the wall of the dry storage area indicative of something being splashed. -The walk in cooler floor had numerous broken tiles. -There was an accumulation of debris on the floor of the walk in cooler. -There was an accumulation of residue on the vents of the exhaust fans over the cooking equipment. -In the walk in freezer, there were two opened packages of meat that were not dated. -In the dry storage area, there were 3 containers of bulk ingredients that were not dated. During a follow up tour of the kitchen, on 11/16/22 at 11:10 AM, accompanied by the Dietary Director, the following were noted: -Staff F, Dietary Aid, was observed…

    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 · D2022-11-17 · 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 observations, interviews and record review, the facility failed to honor residents' rights to reasonable accommodation of needs as evidenced by failure to ensure call lights can be used by one (Resident #447) out of three residents investigated out of 32 sampled residents. Facility had a census of 160 residents at the time of this survey. The findings included: Observation of Resident #447 on 11/15/22 at 11:30 AM revealed resident was alert and oriented to person, place, and time. Call light was within reach but Resident #447 was not able to use his hands as he stated his medical condition does not let him to use his hands to press the call light. Resident #447 stated that when he came in, he was given a different call light system (one he was able to use as it was meant to be pushed by his elbow not by his fingers). Resident #447 stated after they transferred him to this room, he asked maintenance to get a call light like that the one he had and he said yes but it has been 3 weeks, and he does not 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 before2022-11-17 · 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 observations, interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASSAR) Level I for Serious Mental Illness (SMI) or intellectual disability (ID) was completed at the time of admission for one (Resident # 19) out of two residents investigated. This deficiency had the potential to affect 160 residents residing in the facility at the time of the survey. The findings included: Observations of the resident on 11/16/22 11:39 AM Resident was lying on her bed, sleeping. Observations of the resident on 11/17/22 10:40 AM Resident was observed seated in her wheelchair by her room door. Resident was talking but couldn't understand. Record review of admission Record revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Medical diagnoses included, but were not limited to, Metabolic Encephalopathy; Parkinson's Disease; Schizophrenia, Unspecified; Unspecified Psychosis not due to a Substance or known Physiological Condition; Other…

    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 before2022-11-17 · 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 oxygen per physician's orders for two (Resident #104, Resident #447) of two residents reviewed for respiratory treatment out of 17 residents receiving oxygen. The findings included: The facility's policy titled Oxygen Administration, dated 10/25/22, documented the following: In the section titled, preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. under the heading of 'Steps in the Procedure': 8. turn on the oxygen Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Resident #104 was admitted to the facility on [DATE] and admitted to Hospice on 04/01/22. Resident's orders included: oxygen at 2 liters per minute continuously via nasal cannula dated 03/11/22 Resident #104's care plan, initiated on 05/26/22,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · tag F0732 — isolated
    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 have nurse staffing information posted prior to the beginning of shifts on 2 of 3 nurse's stations. The findings included: During an observation at the East unit Nurse's station, on 11/16/22 at 8:02 AM, it was noted that the staffing information that was posted was dated Monday, 11/14/22. During an observation at the [NAME] Unit Nurse's station, on 11/16/22 at 8:06 AM, it was noted that the staffing information that was posted was dated Monday, 11/14/22. During an observation at the East Unit Nurse's station, on 11/17/22 at 7:31 AM, it was noted that the staffing information that was posted was dated Monday, 11/14/22. During an observation at the [NAME] Unit Nurse's station, on 11/17/22 at 7:58 AM, it was noted that the staffing information that was posted was dated Monday, 11/14/22. On 11/17/22 08:05 AM, Staff E, RN/UM posted updated nurse staffing information to reflect staffing hours on this day. On 11/17/22 at approximately 8:30 AM, the Assistant Director of Nursing (ADON) was made aware 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-17 · 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 observations, interview, and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration for two ( Resident #342, Resident # 446) out of six residents sampled, as evidenced by License Practical Nurse and Registered Nurse observed crushing extended release and enteric coating medications for administration to residents. This had the potential to affect the 160 residents residing in the facility at the time of the survey. The findings included: During medication administration observation on 11/17/22 at 8:12AM on North Cart #2, Registered Nurse (Staff A) placed all of Resident #342's medications in individual cups, crushed all medications individually, mixed the medications with apple sauce individually, entered Resident #342's room, identified resident, proceeded to wash hands to begin medication administration to Resident #342. The surveyor requested Staff A meet with her outside of the resident's room in the hallway before medication…

    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 · D2022-11-17 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, it was determined that the facility failed to ensure a medication error rate below five percent as evidence by licensed nurses observed crushing extended release and enteric coating medications during medication observation for Resident # 342 and Resident # 446 resulting in a 9.09 percent error rate out of 33 opportunities. There were 160 residents residing in the facility at the time of this survey. The findings included: 1. During medication administration observation on 11/17/22 at 8:12AM on North Cart #2, Registered Nurse (Staff A) placed all of Resident #342's medications in individual cups, crushed all medications individually, mixed the medications with apple sauce individually, entered resident #342's room, identified resident, proceeded to wash hands to begin medication administration to Resident #342. Surveyor requested Staff A meet with her outside of the resident's room in the hallway before medication administration. Review of the medical records…

    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 · D2022-11-17 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain communication with Hospice to ensure continuity of care for 1 of 2 residents reviewed for Hospice, Resident #104. The findings included: The contract between Vitas Healthcare Corporation of Florida and the facility documented the following. In section 2.1.3 Coordination, Supervision and Evaluation of Services. Vitas will coordinate, supervise, and evaluate the delivery of services provided to a Hospice Patient hereunder in the following Manner: 2.1.3.1 Vitas will promote open and frequent communication, in person, by phone or FAX, or in writing between Vitas and Facility staff concerning the Hospice Plan of Care and the Hospice Patient's needs. Vitas In Section III of the agreement, the contract documented the following: 3.2 Clinical Records. The parties will each maintain and, subject to applicable laws, rules and regulations governing the confidentiality of medical records, make available to each other for inspection 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-17 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns as evidenced by not implementing an effective plan of action for correcting repeated deficiencies related to reasonable accommodation of needs, respiratory treatment, pharmacy services, medication errors, food services, quality assurance and performance improvement activities resulting in repeated deficient practice. Cross reference of F 558 for Accommodation of Needs, F 695 for Oxygen Treatment, F 755 for Pharmacy Services, F 759 for Medication Error 5% of more, F 812 for Sanitary Food Handling, and F867 for QAPI/QAA Improvement activities. The facility had deficiency practice during the last recertification survey conducted in 2020. The facility had a census of 160 residents at the time of the survey. The findings included: Review of the facility's plan of correction for the last annual survey with an exit date 11/21/2020 related to F 558 Accommodation of Needs indicated as part of the correction measures that DON/designee will make rounds daily to…

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

    Administration 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

$10,039 in federal fines across 1 penalty.

  • $10,039 — penalty dated 2024-12-06

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 CARERITE CENTERS — 34 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 3 of 53.6-0.6 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.2+1.8 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 33 homes this chain runs (chain average 3.6★, per CMS)
1 of 5Bethany Center For Rehabilitation And Healing LLCNashville, TN 1 of 5Quality Center For Rehabilitation And Healing LLCLebanon, TN 2 of 5Nashville Center For Rehabilitation And Healing LlNashville, TN 2 of 5Sans Souci Rehabilitation And Nursing CenterYonkers, NY 2 of 5The Grove At Valhalla Rehab And Nursing CenterValhalla, NY 2 of 5The Paramount At Somers Rehab And Nursing CenterSomers, NY 2 of 5Waters Edge at Port Jefferson for Rehabilitation aPort Jefferson, NY 3 of 5Encore At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 3 of 5Glengariff Health Care CenterGlen Cove, NY 3 of 5Green Hills Center For Rehabilitation And HealingNashville, TN 3 of 5Pearl At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5Savoy At Fort Lauderdale Rehabilitation And NursinFort Lauderdale, FL 3 of 5The Emerald Peek Rehabilitation And Nursing CenterPeekskill, NY 3 of 5The Grand Pavilion For Rehab & Nursing at RockvillRockville Centre, NY 3 of 5The Willows At Ramapo Rehab And Nursing CenterSuffern, NY 3 of 5Trevecca Center For Rehabilitation And Healing LLCNashville, TN 4 of 5Chatham Hills Subacute Care CenterChatham, NJ 4 of 5Creekside Center For Rehabilitation And HealingMadison, TN 4 of 5Gallatin Center For Rehabilitation And HealingGallatin, TN 4 of 5Legacy At Boca Raton Rehabilitation And Nursing CeBoca Raton, FL 4 of 5Manchester Center For Rehabilitation And Healing LManchester, TN 4 of 5St James Rehabilitation & Healthcare CenterSt James, NY 5 of 5Cortlandt HealthcareCortlandt Manor, NY 5 of 5Lebanon Center For Rehabilitation And Healing, LLCLebanon, TN 5 of 5Luxor Nursing & Rehabilitation at Mills PondSt James, NY 5 of 5Palmetto Subacute Care CenterMiami, FL 5 of 5Sayville Nursing And Rehabilitation CenterSayville, NY 5 of 5The Chateau At Brooklyn Rehabilitation and NursingBrooklyn, NY 5 of 5The Enclave At Rye Rehab And Nursing CtrPort Chester, NY 5 of 5The Hamlet Rehabilitation and Healthcare Center atNesconset, NY 5 of 5The Monarch at Brooklyn Rehabilitation and NursingBrooklyn, NY 5 of 5The Phoenix Rehabilitation and Nursing CenterBrooklyn, NY 5 of 5The RiversideNew York, 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 / managerTypeRoleSince
CORAL REEF CENTER HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 03/02/2021
MZM 2017 TRUSTOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/20/2025
MD FRIEDMAN FAMILY 2017 TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/20/2025
NEAL EINHORN FAMILY 2017 TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/20/2025
ZUCKER, YOSSIEIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 07/01/2021
EINHORN, NEALIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 02/20/2025
FRIEDMAN, MARKIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 02/20/2025
GONZALEZ, JESUSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/15/2023
HORNA, JOYCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/15/2009
OLIVA, TANIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/15/2016

CMS files one row per role, so the 19 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$21.4M
Net patient revenuemost recent cost report
+2.6%
Operating marginrevenue minus expenses
$4.7M
Related-party expense23% of expenses
Who pays — share of resident-days
Medicaid 51%Medicare 22%Other / private 27%

This home reported $4.7M paid to related parties — landlords or management companies under common ownership — equal to about 23% 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

$358per resident / day
operating cost
$10,893per month
≈ monthly operating cost
$368per 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 105910. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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