Miami Shores Nursing And Rehab Center
9380 NW 7th Avenue, Miami, FL 33150 · For profit - Limited Liability company · 99 certified beds · (305) 759-8711 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- 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
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.0% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.0% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 8.8% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.9% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 0.3% | 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 table | 7.9% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.4% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 39.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.4% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.80 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.34 | 1.15 | 1.80 | better |
‡ 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.
33.7% 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 104 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.3% 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 97 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 33.7%CMS range 25.5–45.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 8.4–15.3 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 75.3% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 80.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 74.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.9%CMS range 5.2–12.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.50 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 99 beds and averages 89.1 residents a day — about 90% occupied, or roughly 10 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 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above 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 3.82 hrs/resident/day on weekends vs 4.38 on weekdays — 13% thinner on weekends. RN hours go from 1.36 to 1.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below 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
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.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Ecited before2025-06-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interviews, the facility failed to meet infection control standards of practice for Resident #5 during hygiene care. This is evidenced by Staff A not performing hand hygiene, changing gloves or changing washcloths during hygiene care for Resident #5. There were 91 residents residing at the facility at the time of the survey. The findings included: On 06/24/25 at 01:13 PM, Staff A was observed not performing hand hygiene prior to the procedure. Upon the surveyor's entry into the room, the Certified Nursing Assistant (CNA) was already wearing a gown, mask, and gloves. The resident is on enhanced barrier precautions and has a Percutaneous Endoscopic Gastrostomy (PEG) tube; the PEG tube machine was noted to be turned off. The CNA removed the resident's soiled clothing, leaving the resident uncovered while filling the basin with water. Soap was added directly to the water. The CNA did not remove gloves or perform hand hygiene at any point during the procedure. The resident'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.
- Potential for harm · Dcited before2025-06-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interviews, and record reviews, the facility failed to properly store controlled substances on three out of four sampled medication carts as evidenced by unreconciled medication monitoring/control record sheets. The facility had four medication carts. The findings included: On 6/24/2025 at 1:32 PM a medication administration observation was completed with Staff A, Registered Nurse (RN) on the west wing medication cart #1; Staff A, RN verified the physician's order, removed the controlled substance from a bingo card placed it in a medication cup; after administering the controlled substance, Staff A, RN returned to the medication cart and signed in the medication monitoring/ control record sheet to indicate the controlled substance was given. Interview on 6/24/2025 at 1:37 PM, the surveyor asked Staff A, RN about the protocol for documenting removal of a controlled substance. Staff A, RN replied, I sign the narcotic log after the resident takes the medication because if the resident refuses, I can't sign that I have given it. The surveyor asked Staff A, RN, 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.
- Potential for harm · Dcited before2025-06-24 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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, record review and interviews the facility's Quality Assessment and Assurance (QAA)/QAPI) committee failed at demonstrating an effective plan of action to correct identified quality deficiency in problem areas as evidence by repeated deficient practice for F 880-Infection Prevention and Control and F 761- Label/Store Drugs and Biologicals. There were 91 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification conducted on March 23, 2025 through March 26, 2025, F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to trash and food observations on the floor inside The Resident's pantry room on the East side nursing station, indwelling catheter tube touching floor, staff not wearing proper personal protective equipment (PPE) and improper hand hygiene during wound care. F761- Label/Store Drugs and Biologicals was cited related to an unattended unlocked medication cart on the west side…
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.
- Potential for harm · Ecited before2025-03-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to follow their infection control protocol in the East side soiled utility room and with Resident's #2 and #57. This is evidenced by trash and food observations on the floor inside the resident's pantry room on the East side nursing station, Resident #2 indwelling catheter tube touching floor, staff not wearing proper personal protective equipment (PPE) when entering droplet precaution rooms during meal tray distribution and Improper hand hygiene during wound care. There were 96 residents residing at the facility at the time of the survey. The findings included: 1) On 03/23/25 at 07:51 AM, Staff were observed not wearing PPE while entering a contact/droplet resident room while distributing breakfast trays. 2) On 03/25/25 at 11:02 AM, observation of Wound Care. The Wound Care Nurse gathered supplies that consist of kerlix, normal saline, collagen, tape, 4 x 4 gauze, scissors, red bag and chuck pads. The Wound Care Nurse locked the computer…
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.
- Potential for harm · D2025-03-26 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to provide privacy for residents' information on two out of four computer screens on the East side nursing station as evidenced by an observation of an unlocked, unattended computer screen with resident information easily accessible/visible on the east side medication cart #1 and at the East side nursing station. There were 96 residents residing in the facility at the time of the survey. The findings included: 1.On 03/23/25 at 7:39 AM, an observation was made of an unlocked, unattended computer screen on the East side medication cart #1 (photo obtained ). On 03/23/25 at 7:41 AM Staff H, Registered Nurse (RN) returned to the medication cart and was asked by the surveyor the protocol for keeping residents' information private on computer screens and replied, I am supposed to lock the screen before I walk away. I was worried about getting the supervisor for you, so I forgot to lock the screen. 2. On 03/23/25 at 8:08, an observation was made of an unlocked, unattended computer screen at the East side nursing…
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.
- Potential for harm · D2025-03-26 · tag F0645 — isolatedPASARR 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, record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately prior to admission for three Residents (#50, #83, #60) out of three residents reviewed for PASARR. There were 96 residents residing in the facility at the time of the survey. The findings Included: Record review of the Pre-admission Screening and Resident Review (PASARR) Policy and Procedure dated 2016 documented: Policy Intent-It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review; Procedure-1) A facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program as stated under Federal Regulations. 1) Observation of Resident #50 on 3/25/25 at 11:07 AM revealed the resident sitting up in bed with the television on. Record review of the Demographic Face Sheet for Resident #50 documented the resident was admitted on [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.
- Potential for harm · D2025-03-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to develop and implement comprehensive care plans for Residents #43, #74 and #291 as evidenced by no comprehensive care plan with interventions for floor mats for one resident (#291), no implementation of a fall care plan for one resident (#74) out of 6 residents who use floor mats and no care plan for a neck brace for one (#43) out of two residents who require neck braces. There were 96 residents residing in the facility at the time of the survey. The findings included: 1. On 3/23/25 at 7:54 AM Resident#291 was observed in bed with one floor mat on the resident's right side, a call light was in reach. Another observation on 03/25/25 08:53 AM revealed bilateral floor mats were in place for Resident #291. Record review of a demographic sheet for Resident #291 revealed an admission date of 3/1/25 with diagnoses that included: Syncope and Collapse, Muscle Wasting and Atrophy. Record review of an admission Minimum data set (MDS) reference dated…
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.
- Potential for harm · D2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, interviews and record review, the facility failed to provide supervision to prevent safety hazards for one resident (#2) out of 32 sampled residents as evidenced by an observation of an electrical cord plugged into an outlet suspended in the air in such a way that caused a tripping hazard in the room of Resident#2. There were 96 residents residing in the facility at the time of the survey. The findings included: On 03/23/25 at 9:44 AM an observation was made of an electrical cord for the air mattress wrapped around the side table, extending and suspended in the air, which caused a tripping hazard in the room of Resident #2. Staff H, Registered Nurse (RN) was present in the room at the time of the observation and was notified by the surveyor of the potential tripping hazard. Staff H, RN readjusted the plug behind the bed. On 03/25/25 at 12:18 PM the Nursing Home Administrator (NHA) was made aware by the surveyor about the tripping hazard observation and stated, Electrical cords should be…
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.
- Potential for harm · D2025-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services for catheter care for one (Resident #2) out of one resident who has a suprapubic catheter as evidenced by observations of the urinary catheter tubing being kinked, and touching the floor. There were 96 residents residing in the facility at the time of the survey. The findings included: On 03/23/25 at 9:35 AM Resident #2 was observed in bed with oxygen in progress at 2Liters per minute via a nasal cannula and no apparent distress was noted. A urinary catheter tubing was observed kinking in a circle and the urine was not properly draining (photo obtained). Staff H, Registered Nurse (RN) was present in the room and was notified by the surveyor about the kinking of the tubing. Staff H, RN then straightened out the tubing to allow free flow of urine. Staff H, RN was asked by the surveyor the correct way to position the tubing and Staff H stated, I round every morning and check the catheter tubing. This morning, I found the night nurse was working with the indwelling…
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.
- Potential for harm · Dcited before2025-03-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interviews and record reviews, the facility failed to properly store medications as evidenced by an observation of a box of expired Rapid Antigen (Covid-19) test kits in one medication storage room and an unlocked cart (cart #1) on the west wing unit, and an unattended medication at the bedside for resident #2. The Findings included: 1) Accompanied by Staff S, an observation of the [NAME] Wing medication storage room was conducted on 03/23/2025 at 09:50 AM. The observation revealed a box with multiple expired Covid-19 test kits inside the bottom cabinet. Each Covid-19 test kit was observed with an expiration date of 01/30/2024. Staff S, Registered Nurse (RN) supervisor confirmed the expiration date and removed a box of multiple expired Covid-19 test kits. On 03/26/2025 at 02:58 PM, Staff S stated: The nursing supervisors are the ones in charge of monitoring and checking the medication storage room each shift. The supervisor from each shift is responsible of checking the crash cart, med room, and the pantry. When we find something or medication expired, we…
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.
Show the remaining 13 citations
- Potential for harm · D2025-03-26 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the facility failed to assure cardboard boxes were properly disposed and contained on the facility grounds. Cardboard boxes were scattered on the ground outside the kitchen back door. The findings included: Record review of the Food-Related Garbage and Rubbish Disposal Policy and Procedure revised 4/2024 documented: Policy Statement-Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters; Policy Interpretation and Implementation-4) Food storage boxes/containers will be disposed of by the end of each shift into the outside dumpsters. Observation of the outside of the facility at the kitchen back door with the Dietary Aide A on 3/23/25 at 7:01 AM. There were multiple cardboard boxes on the ground and not contained in the garbage bin. Photographic evidence submitted. On 3/23/25 at 7:03 AM, interview with Staff A, Dietary Aide. She stated, Someone is supposed to break down the cardboard boxes and take them to the garbage container. They should not be on the ground. On 3/23/25…
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.
- Potential for harm · D2025-03-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure residents' medical records are accurate in accordance with accepted professional standards and practices for one (Resident #33) out of one resident sampled, as evidenced by a Nurses' Progress Note for Resident#33 documented the resident was COVID 19 positive and the resident was COVID 19 negative. These practices has the potential to affect any of the residents residing in the facility. The findings included: Record review of the Charting and Documentation Policy and Procedure revised 03/2024 documented: Policy Statement-All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record; Policy Interpretation and Implementation-1) All observations, medications administered, services performed must be documented in the resident's clinical record; 2) Entries may only be recorded in the resident's clinical record by licensed personnel (Registered…
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.
- Potential for harm · Dcited before2025-03-26 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 failed to demonstrate effective plans of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention & Control, as evidenced by the infection control protocol was not followed on the east side soiled utility room and failed to follow infection control protocol for one Resident # 57, as evidenced by a failure to implement hand hygiene. There were 96 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated October 19, 2023, F880 Infection Prevention & Control was cited related to the fact that the facility failed to implement infection control procedures for three (Residents 89, 347, 348) out of 28 sampled residents. Interview with the Director of Nursing (DON) on 03/26/25 at 03:44 PM. She stated that the Quality Assurance and Performance Improvement (QAPI) meetings are held each month. She stated that 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.
- Potential for harm · Dcited before2023-10-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for resident rooms. The findings included: Room# 37-D - On 10/16/23 at 10:10 AM, the night table was in bad shape, and had sharp edges. Room#31-D - On 10/16/23 at 09:17 AM, the sink was cracked and in disrepair. Room#32-D - On 10/16/23 at 09:30 AM, the sink was cracked and in disrepair. Room#34-D - On 10/16/23 at 09:39 AM, the night table was in bad shape, and had sharp edges. Room# 35D - On 10/16/23 at 09:55 AM, the night table in bad shape, sharp edges. On 10/19/23 at 10:01 AM the Maintenance Director was interviewed and stated, every day we do the tour in the rooms, and make sure that everything is working in perfect condition. He reported, they worked in the [NAME] area of the facility two years ago and finished like two years ago. The facility does not have inventory or stock because there is no…
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.
- Potential for harm · D2023-10-19 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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, interview and records review, the facility failed to ensure one resident (Resident # 59) was free from the use of physical restraints, as evidenced by the facility's staff inhibiting the resident's ability to get out of his bed by placing four wheelchairs on each side of his bed, out of one resident investigated for restraints. This facility practice had the potential to have a negative impact on the health and safety of all 90 residents residing in the facility at the time of the survey. The findings included: During an observation of resident # 59 on 10/16/2023 at 09:25 AM, the resident was observed to be sleeping and four wheelchairs were observed around the bed. There were two wheelchairs by the right side and two wheelchairs by the left side of the bed. (Photographic evidence). On 10/16/2023 at 09:45 AM, Resident 59 was lying on his bed, awake. It was observed that the resident was dressed. Resident #59 was observed with four wheelchairs around the bed, there were two wheelchairs by…
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.
- Potential for harm · D2023-10-19 · tag F0732 — isolatedPost 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 the daily nurse staffing schedule posted prior to the beginning of shifts on two out of two nurses' stations. This practice had the potential to affect all 90 residents residing in those units and the public who visited the facility at the time of the survey. The findings included: During observation on the East nursing station on 10/16/2023 at 08:17 AM, it was noted that the staffing information posting board had no assignment written down on the board. On 10/16/2023 at 08:17 AM, Staff F, Licensed Practical Nurse (LPN), stated We don't have a schedule here. We keep the schedule at the other nursing station. During observation on the [NAME] nursing station on 10/16/2023 at 08:18 AM, it was noted that the staffing information posting board had no assignments written down on the board. On 10/16/23 at 08:19 AM, Staff E, Registered Nurse(RN), stated, The secretary called off today. I'm going to write the assignment down right now. On 10/16/23 at 08:21 AM, Staff F stated, Oh, I didn't know we had the schedule…
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.
- Potential for harm · Dcited before2023-10-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement infection control procedures for three (Residents #89, #347, #348) out of 28 sampled residents. As evidenced by Transmission Based Precaution (TBP) signage was not posted on Resident #347's door and oxygen therapy equipment not stored sanitarily for Resident's #89 and #348. This had the potential to affect 90 residents residing in the facility at the time of the survey. The Findings Included: 1. On 10/16/23 at 08:22 AM, observed Resident #89 in bed asleep, bed was in the lowest position, bilateral floor mats present, high back wheelchair in room, Continuous Positive Airway Pressure (CPAP) machine tubing and mask on the floor besides the resident's bed (Photo available). On 10/17/23 at 10:26 AM, Resident #89 observed in bed asleep, bed in lowest position, bilateral floor mats present, Continuous Positive Airway Pressure (CPAP) machine with tubing and mask exposed on bedside table (Photo available). On 10/18/23 at 08:50 AM,…
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.
- Potential for harm · Dcited before2022-11-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 observations, interviews, and record review the facility failed to provide a safe, clean, homelike environment for 4 out of 26 sampled residents (Residents #75, #54, #74, #288 and #11). The findings included: On 11/01/22 at 10:20 AM an observation was made of the light on the wall above the head of Resident #288's bed that had a pull cord of approximately 4 inches long (Photographic Evidence Obtained). On 11/01/22 at 10:30 AM an observation was made of the light on the wall behind the head of Resident #75's bed only had a pull cord that was approximately 3 inches long (Photographic Evidence Obtained). On 11/01/22 at 10:35 AM an observation was made of Resident #74's over bed table with the laminate peeling (Photographic Evidence Obtained). On 11/01/22 at 11:15 AM an observation was made in Resident #54's room of the wall mounted telephone next to her bed had no receiver (Photographic Evidence Obtained), On 11/01/22 at 10:55 AM an observation was made in Resident #11's room of a light bulb burnt out over…
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.
- Potential for harm · D2022-11-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist during dining for 1 of 1 resident reviewed for Activities of Daily Living (ADLs), Resident #22. The findings included: In an observation conducted on 11/01/22 at 1:00 PM, the lunch tray was brought into Resident #22's room. Closer observation showed a tray with NAS (No Added Salt) diet mechanical soft consistency. The lunch plate was noted with meat lasagna, collard greens, and tropical fruits. Staff brought the tray into the room and walked out. Continued observation at 1:25 PM showed that Resident #22 only ate 10% of her lunch tray. In an observation conducted on 11/01/22 at 5:15 PM, the dinner tray was brought into Resident #22's room by Staff A, Certified Nursing Assistance (CNA). She set up the tray by the bedside and walked out of the room. Continued observation showed a dinner plate with an egg salad sandwich, potato salad, vegetable soup, and milk. At 5:32 PM, Resident #22 ate only 10% of her dinner meal. In an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-04 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews the facility failed to follow tube feeding orders for 2 out of 5 sampled residents reviewed for tube feeding (Resident #72 and Resident #288). The findings included: Review of the facility's policy titled Tube (Enteral) Fed Residents with a revision date of 2019 included the following: The Dietitian/Diet Technician assesses the adequacy of the tube feeding and recommends changes as indicated. Nursing Services is responsible for the administration of the tube feeding. 1)Record review of Resident #72's clinical records revealed the resident was admitted to the facility on [DATE] with the most recent readmission date of 05/07/21. The diagnoses included Type 2 Diabetes and Encounter for Attention to Gastrostomy. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #72 had a Brief Interview for Mental Status of 0, which indicated that she had severe cognitive impact. Review of Section G of the MDS dated [DATE] documented 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.
- Potential for harm · D2022-11-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 record reviews, observations and interviews, the facility failed to change the oxygen tubing weekly and document changing the oxygen tubing weekly as per facility's policy for 2 out of 3 sampled residents (Resident #288 and Resident #67). The findings included: Review of the facility's policy titled Oxygen Concentrator with an issued date of 03/2020 and no revised date. The policy included the following: Care of the Concentrator - Document in the resident's clinical record. Change tubing weekly. 1)Record review of clinical records for Resident #67 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 09/28/22. Diagnoses included Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Pneumonia. The Minimum Data Set (MDS) for Resident #67, dated 10/03/22 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. In Section O revealed that Resident #67 was receiving oxygen…
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.
- Potential for harm · D2022-11-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to monitor post-dialysis treatments. As evidenced by failure to administer medication for dialysis per the physician ' s orders for 1 of 1 resident reviewed for dialysis (Resident #84). The findings included: A chart review showed that Resident #84 was admitted on [DATE] with diagnoses of Anxiety, Anemia and is dependent on dialysis. A review of orders showed an order for dialysis three times a week on Mondays, Wednesdays, and Fridays dated 10/03/22. It further showed an order for Sevelamer (medication used to treat too much phosphate in the blood), 800 milligrams (mg), take 2 tablets 1600 mg by mouth with a meal for End Stage Renal Disease dated 10/03/22. Resident #84 was hospitalized due to Colitis and syncope/ dehydration. In an observation conducted on 11/01/22 at 1:00 PM, the meal cart arrived at the Unit and was brought into Resident #84's room at 1:10 PM. The continued observation did not show that Sevelamer was given to Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 record review, observations and interviews, the facility failed to secure medications for 1 out of 4 medication carts, and the facility failed to secure medications located in 1 of 2 nursing stations. The findings included: Review of the facility's policy titled Medication Storage in the Facility with a revision date of 03/2021 included the following: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 11/01/22 at 11:15 AM an observation was made of an unlocked and unattended mediation cart located at the East Nursing Station (Photographic Evidence Obtained). Five staff members passed by 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HERNANDO, GLADYS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 10% | since 01/01/2025 |
| ANTONACCI, NICK | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; LIMITED PARTNERSHIP INTEREST | — | since 01/01/2021 |
| HERNANDO, JORGE | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; GENERAL PARTNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST | — | since 01/01/2021 |
| CARRASCO, MARCO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| MOGHADDAM, HAMIDREZA | Individual | ADP OF THE SNF | — | since 02/13/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 2024. 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
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 105449. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, 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.