University Health And Rehabilitation Center
724 NW 19th St, Miami, FL 33136 · For profit - Limited Liability company · 148 certified beds · (305) 917-0400 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 (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 | 4.9% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 5.6% | 4.6% | 6.5% | better |
| 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 | 2.3% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.3% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.5% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 3.4% | 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 | 2.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 99.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.4% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.0% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.64 | 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.
44.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 95 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.6% 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 130 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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
| 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 | 44.3%CMS range 31.6–54.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.1–13.7 | 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 | 54.6% | 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 | 56.9% | 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 | 53.9% | 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 | 99.1% | 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 | 96.5% | 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 | 0.9% | 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 | 0.0% | 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 | 7.6%CMS range 4.6–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 148 beds and averages 144.4 residents a day — about 98% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.36 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.23 hrs/resident/day on weekends vs 3.61 on weekdays — 11% thinner on weekends. RN hours go from 1.45 to 1.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% 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 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.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-01 · 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
Based on observations, records reviewed and interviews it was determined that the facility did not adequately maintain a safe environment to prevent potential hazards that could have resulted in accidents or injuries in two of five soiled utility rooms. Staff failed to secure two soiled utility room doors on the facility's second floor because paper towels had been placed in the locks, which prevented proper locking. At the time of the survey 140 residents resided in the facility. The findings include:On 04/01/2026 at 1:40 PM, the Wound Care Registered Nurse (RN) completed wound care disposed of a biohazard bag in the soiled utility room, and exited, leaving the soiled utility room door unlocked.On 04/01/2026 at 1:45 PM Staff A, Certified Nursing Assistant (CNA) exited the soiled utility room and the door remained unlocked.On 04/01/2026 at 1:46 PM Staff B, [NAME] exited the soiled utility room and the door remained unlocked.Observation on 04/01/2026 at 1:47 PM revealed someone placed a piece of paper towel in the lock of the soiled utility room door, which stopped the door from…
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 · Fcited before2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 conditions as evidenced by the walk-in refrigerator contained flower bouquets on the shelves among the fruits and vegetables. This has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Food Storage Policy and Procedure (review date November 2024); Policy-Food storage areas are maintained in a clean, safe and sanitary manner and maximize nutrient retention and food quality; Procedure-1) Perishable foods are stored immediately after delivery. Observation of the initial kitchen tour on 5/19/25 at 6:47 AM with the Dietary Supervisor and Corporate CDM (Certified Dietary Manager) revealed the walk-in refrigerator with four bouquets of flowers lying on the shelf with vegetables and fruits. Photographic evidence submitted. Interview with the Corporate CDM on 5/19/25 at 6:48 AM. He revealed that the bouquets of flowers were for Nurses' week. He confirmed that the bouquets of flowers…
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 · D2025-05-22 · 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 observation, interview and record review, the facility failed to secure confidential information for the residents on the fourth floor as evidenced by an observation of an unattended paperwork with residents' pictures, names and rooms left visible on top of the fourth floor's south medication cart. There were 24 residents residing on the fourth floor. The findings included: Observation on 5/19/25 at 6:40 AM revealed confidential paperwork with residents' names, corresponding pictures and room numbers were observed on top of the unattended fourth floor's south medication cart. During an interview on 5/19/25 at 6:55 AM, Staff A, Registered Nurse (RN) stated: Sorry, I left the paperwork on top of the medication cart; I know all information should be kept private. Interview on 5/21/25 at 1:17 PM, the Director of Nursing (DON) stated: All resident information should be kept confidential. Record review of a policy titled Protected Health Information (PHI), Safeguarding Electronic revised January 2024, Reviewed January 2025 revealed Policy: Electronic protected health information…
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 · D2025-05-22 · 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
Based on observations, record reviews and interviews, the facility failed to update a respiratory care plan for one (Resident #79) out of one sampled resident as evidenced by a respiratory care plan with interventions for a Bilevel Positive Airway Pressure (BiPAP) machine, despite physician orders for the discontinuation of the BiPAP machine since 10/15/24. There were three residents with BiPAP machines in the facility at the time of survey. The findings included: On 5/19/25 at 6:52 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer (photographic evidence). On 5/20/25 at 9:26 Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. On 5/22/25 at 7:26 AM Resident # 79 was observed in bed with eyes closed; a BiPAP machine was observed on the nightstand next to the resident with the tubing extending into drawer. Record review of Resident #79's demographic sheet revealed an…
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 before2025-05-22 · 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 secure medications for residents residing on the fourth floor, as evidenced by a plastic bag with medications observed on top of the unattended fourth floor's south medication cart. There were 24 residents residing on the fourth floor at the time of survey. The findings included: Observation on 05/20/25 at 9:15 AM, revealed a plastic bag filled with medications left unattended on top of the south medication cart (photographic evidence). On 05/20/25 at 9:15 AM, Staff A, Registered Nurse (RN) who was seated at the nursing station was asked if medications were inside the plastic bag on top of the south medication cart. Staff A, RN walked with the surveyor to the medication cart, opened the plastic bag and revealed the contents which included loose pills and pills in containers. Staff A, RN stated:I found these medications in a resident's room, removed it and was going to notify the supervisor when I was called to help another nurse with an emergency situation. On 05/20/25 at 9:25 AM, Staff A, RN…
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 before2025-05-22 · 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, interviews and record review, the facility failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F812- Food Procurement, Store/Prepare/Serve - Sanitary and F867- Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA). These repeated deficient practices have the potential to affect all residents residing in the facility. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated 01/11/ 2024, F812 Food Procurement, Store/Prepare/Serve/ Sanitary was cited related the facility's failure to store food under sanitary conditions related to a buildup of ice in the ice cream freezer with the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of that survey. During this survey with an exit dated 05/22/2025, repeated deficient practice was identified for F812-Food Procurement, Store/Prepare/Serve/Sanitary, related…
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 · D2025-02-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews the facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury which required medical attention for one resident (Resident #1) out of four sampled residents, as evidenced by during assisted transfer Resident#1 hit her head on the wheelchair and the incident went unreported after bruising was identified and reported the family member to staff. There were 143 residents residing in the facility at the time of the survey. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall. Record review of an Annual Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-17 · 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 interviews and record reviews, the facility failed to ensure one resident (Resident #1) out of four sampled residents received adequate supervision to prevent accidents as evidenced by during transfer, Resident #1 sustained injuries that were not reported immediately by staff and were discovered by a family member. The findings included: On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a small scratch on the left leg. Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall. Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and had no falls since admission/entry or reentry or 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.
- Potential for harm · Dcited before2024-01-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 promote dignity and respect for two residents (#41 and #93) out of 28 sampled residents. As evidenced by a Certified Nursing Assistant (CNA) was observed standing while feeding Resident #41 and Resident #93 not having any food while his roommate was being fed and eating food. There were 143 residents residing in the facility at the time of the survey. The findings included: On 01/08/24 at 12:15 PM Certified Nursing Assistant (CNA), (Staff B) was observed standing over the bed of Resident #41 and feeding him lunch from the lunch tray. On 01/08/24 at 12:15 PM Resident #93's roommate was eating lunch being fed by Staff B meanwhile, Resident # 93 was observed with no food. The surveyor asked Staff B where Resident #93's food was. Staff B reported it will be coming soon. During an interview on 01/08/24 at 12:17 PM Staff B was asked about standing while feeding the resident. Staff B stated, I am sorry but there is only one chair in the room, and it has stuff on it. Staff B acknowledged that she should not 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 · D2024-01-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 provide reasonable accommodations for Resident #343 as evidenced by Resident #343 call light was out of reach and had difficulty using other devices. There were 143 residents residing in the facility at the time of the survey. Findings include: On 01/08/24 at 10:31 AM. In an interview with Resident #343. Resident #343 stated, I'm not able to use the call light to ask for help. I'm not able to move my fingers to touch the device. On 01/10/24 at 02:50 PM, during an observation and interview with Resident #343. It was observed that the thumb call light was tucked underneath Resident #343's pillow to the right side of the resident's head. The resident was holding the bed control keypad on his chest. The resident was asked: Are you able to use your call light, if not, how are you able to call staff for assistance? Resident #343 stated, I'm hard of hearing. The call light is too hard to push. It's very difficult. The bed control is hard 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.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-01-11 · 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 and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, homelike environment and comfortable interior for 1 out of 3 residential floors (Resident rooms on 300 floor North Unit). The Findings Included: During the initial observations on 01/08/2024 beginning at 08:41AM of residents and residents' rooms revealed: room [ROOM NUMBER]B was noted with water stains on the wall and roof by the window (B Bed), (Photo Available). Rooms 307A, 308, 311B, 314B-Garbage on the floors-Straw wrapping, empty condiment packets, tissues, alcohol pad packets, and paper of different kinds (photo available). room [ROOM NUMBER] B-Privacy curtain observed with dark red stains (Photo available) During an interview on 01/08/24 at 09:22 Resident #92 reported that when it rains, water leaks through the wall in her room (Photo available). The resident stated she has respiratory issues, every time it rains the situation gets worse, you can see more water spots on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-11 · tag F0641 — isolatedEnsure 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 Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 139) out of one resident whose MDS assessments reviewed at the time of survey. This deficiency has the potential to affect 143 residents residing in the facility at the time of survey. The findings included: Record Review of admission Record revealed Resident # 139 was admitted to the facility on [DATE] and discharged on 10/13/2023. Record review of the clinical records revealed the resident's diagnosis included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified focal traumatic brain injury without loss of consciousness, subsequent encounter, other lack of coordination, difficulty in walking, not elsewhere classified, dysphagia, oropharyngeal phase, muscle weakness (generalized), generalized anxiety disorder, gastro-esophageal reflux disease with esophagitis, without bleeding, anemia, unspecified, unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-11 · 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 observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for two Residents (#69 #46,) out of 28 sampled residents. As evidenced by several observations of Resident #46 revealed the oxygen was running at the incorrect rate. Resident #69's tracheostomy (trach) collar that provided oxygenation to the resident was dislodged from the trach opening and hanging to the right side of the resident's neck. There were 14 residents that required respiratory services out of the 148 residents residing in the facility at the time of the survey. The Findings Included: During observation on 01/08/24 at 09:43 AM Resident #69 was in bed Oxygen (02) running at 10 liters per Minute (LPM) via trach collar, the resident was not receiving oxygenation via trach collar because the trach collar for oxygenation was off of the resident and laying on the right side of resident's neck. On 01/08/24 09:49 AM Registered Nurse (Staff C) and the surveyor went 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 before2024-01-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 by ensuring the ice cream freezer was properly defrosted and did not contain a buildup of ice. This has the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Refrigerators and Freezers Policy and Procedure (revision date May 2023); Policy Statement-This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation; Policy Interpretation and Implementation-7) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance and or cleaning schedules will be monitored for compliance. Observation of the initial kitchen tour on 1/08/24 at 8:31 AM with the Certified Dietary Manager revealed the ice cream freezer noted with a thick buildup of ice within the inside parameter of the unit.…
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 before2024-01-11 · 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 record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to resident rights, safe, clean, comfortable and homelike environment and food procurement, store, prepare and serve-sanitary resulting in repeated deficient practice. The facility was cited for Resident rights in 2022; Safe, clean, comfortable and homelike environment in 2022 and Food procurement, store, prepare and serve-Sanitary in 2022. These repeated deficiencies practice has the potential to affect any of the 143 residents residing in the facility. The findings included: Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure (implemented November 2017, reviewed March 2023) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) 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.
- Potential for harm · Fcited before2022-11-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety that include; maintenance of refrigeration units, holding of foods at regulatory temperatures, proper thawing of foods, and preparation of foods within clean areas. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 11/07/22 at 9 AM with the Certified Dietary Manager (CDM) , the following were noted: (a) Prior to entering the kitchen it was noted that 3 large uncovered carts full of used resident trays were located outside the kitchen. Specifically the trays were from the resident's breakfast meal of 11/7/22 and the garbage and trash was exposed to the area areas. The surveyor requested to the CDM that all garbage/trash inside of the facility must be covered as per regulation (b) The ice cream freezer was noted to have a thick build up of ice within the inside parameter of the unit. The surveyor requested that the unit was not being maintained properly and 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 · Ecited before2022-11-15 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review,observation and interview, it was determined that the the facility failed to treat residents with respect and dignity as evidenced by; 5 out of 18 residents sampled residents (Resident #2, Resident #12, Resident #54, Resident #76, and Resident #158) who drank thickened liquids from condiment cups, 119 resident were not provide with proper drinking cup/glass to pour milk into of which 2 out of 19 were sampled residents who were required to drink milk from the carton, 2 (Resident's #57 and Resident #69) 2 sampled residents were fed by standing staff, and 1 (Resident #48) of 1 sampled resident who was referred to as a feeder. The findings include: Review of facility's policies and procedures for Resident Rights noted Policy Statement: * Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to be: (a) a dignified existence; (b) be treated…
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 before2022-11-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary , orderly, and comfortable interior for 3 of 3 resident floors (second, third, and fourth floors). The findings included: During the environment tour conducted on 11/8/22 at 1 PM accompanied with the Administrator and Director of Maintenance, the following were noted: room [ROOM NUMBER] - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. room [ROOM NUMBER] - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), and numerous large black scuff room marks walls. room [ROOM NUMBER] - Exterior of over-bed table in disrepair (worn with sharp edges), exterior of dresser in disrepair (heavily worn), numerous large black scuff room marks walls, toilet seat not secure, and Geri chair exterior…
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 · E2022-11-15 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to comply with the state minimum staffing requirements for 48 consecutive hours and failed to comply with the stated minimum weekly average of 3.6 hours of care by direct care staff per resident per day. There were 140 residents residing in the facility at the time of the survey. The findings included: On 11/07/22 at 12:12 PM, an interview was conducted with Staff R, Certified Nursing Assistant ( CNA) stated she had worked for the facility for 12 years. Staff R stated having 13 residents assigned to her today and sometimes she had more than that. Staff R added she normally she had 10 residents assigned. Staff R stated that they usually had six (6) CNAs working, but they had five (5) today. On 11/07/22 at 12:25 PM, an interview was conducted with Staff S, an agency CNA. Staff S stated having 14 residents assigned to her today, but usually had 8-10 residents assigned to her. Staff S was asked why of the residents caseload bigger that normally…
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 before2022-11-15 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, observation and interview, the facility failed to ensure that 1 of 3 (third floor unit) medication storage room was kept free of expired medications. The findings included: Review of the facility's policy titled Storage of Medications with no revision date, provided by the Director of Nursing, documented discontinued, outdated .drugs .are returned to the dispensing pharmacy or destroyed. On 11/08/22 at 8:51 AM, a side by side review of the facility's third floor medication storage room was conducted with the Unit Supervisor. Observations revealed a bright yellow (tackle box like) locked with a green plastic tie. The Unit Supervisor was asked to open the box and the box contained the following expired medications: -1 box of 30 vials of Asthmanephrin (used to treat asthma)- Inhalation solution with an expiration date on 07/2020. -1 box of 25 vials of Albuterol Sulfate 1.25 mg (milligrams) (used to treat wheezing and shortness of breath) Inhalation solution with an expiration date on 08/2020. -1 box 25 vials of Albuterol Sulfate 1.25 mg (milligrams) Inhalation…
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 · E2022-11-15 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to prepare and serve food in a form (mechanical soft) to meet the individual needs of 53 facility residents that included 2 sampled residents (Resident #74 and Resident #103) The findings included: Review of the facility's approved Diet and Nutritional Care Manual for Level 2: Dysphagia Mechanically Altered (Easy to Chew) noted the following: Foods to Include: Fork mashable fruits and vegetables On 11/14/22 a review of the approved lunch meal was conducted and noted 1/2 cup Diced Pineapple to be served to Mechanical Soft /Easy to Chew Diets. During the observation of the lunch meal of 11/14/22 at 11:30 AM, it was noted that large chunks greater than approximately 1 inch in diameter were being served to residents with physician ordered Mechanical Soft/Easy to Chew Diets. The facility's Registered Dietitian and Certified Dietary Manager were requested to observe the pineapple portion and confirmed that the chunks were too large not prepared correctly for residents with swallowing 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.
- Potential for harm · E2022-11-15 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview it was determined that the facility failed to prepare and serve Carbohydrate Controlled therapeutic diet for 50 facility resident's that included 3 sampled residents (Resident #22, Resident #74, and Resident #88). The findings included: During the review of the facility's Diet and Nutritional Care Manual for Consistent Carbohydrate Diet, the following was noted * Foods Allowed ; Milk (fat free or low fat - skim, 1%, 2%) * Food to Avoid: Whole Milk * Foods Allowed: Sugar Free Food * Foods to Avoid: Any with additional sugars On 11/08/22 a review of the facility's approved cycle menu for the breakfast meal on conducted. The review noted that 8 ounces of 2% milk was to be served to residents with a physician ordered Consistent Carbohydrate Diet. Observation of the breakfast meal in the main kitchen on 11/08/22 at 7:00 AM noted that residents with a Consistent Carbohydrate Diet were not being served an 8 ounce carton (serving) of 2% milk on their breakfast trays. Further investigation and interview with the breakfast cook (Staff L)…
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 · D2022-11-15 · 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, interviews and record review, the facility failed to provide grooming of the fingernails for 2 of 3 sampled residents (Residents #12, Resident # 22) and failed to provide toenails care for 1 of 1 sampled resident (Resident #74). The findings included: Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting with no revision date provided by the facility's Director of Nursing documented .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene .Appropriate care and services will be provided .including appropriate support and assistance with hygiene ( .grooming .) 1) Review of Resident #12's, clinical record documented an initial admission to the facility on [DATE] with no readmissions reported on file. The resident diagnoses included: Alzheimer's Disease, Flaccid Hemiplegia Affecting Right Dominant Side, Absence Of Right Leg Below Knee, Macular…
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 · D2022-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure proper care of wounds for 1 of 1 resident reviewed for wound care, Resident #341. The findings included: During the initial tour of the facility conducted on 11/07/22 at 10:00 AM, the surveyor noted that Resident #341 had bandages wrapped from her hands to her mid forearms, both dated 11/03/22. Resident #341 was admitted to the facility on [DATE]. Resident #341 had a medical history significant for a stroke, atrial fibrillation, depression, muscle weakness, and a deep tissue injury to her right heel. Review of clinical records revealed the admission Minimum Data Set (MDS) dated [DATE], documented Resident #341 had a Brief Interview of Mental Status (BIMS) score of 6, which indicates Resident #341 had moderate cognitive impairment. There was a Care Plan in place regarding Resident #341 having impaired skin integrity of the right heel and a skin tear to the left leg, but no documentation of the wounds on her bilateral forearms.…
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 · D2022-11-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 3 sampled residents (Resident #12, Resident # 47 and Resident # #54) for range of motion. The findings included: Review of the facility's policy provided by the Therapy Director titled Screening Process last revised on 02/01/19 documented .a screen is completed in order to assist with OBRA compliance and care planning and identify areas of functional loss/decline that would suggest the need for an evaluation Data will be gathered for the screen within 72 business hours of admission and readmission notification of a significant change in a patient/resident's functional ability of referral .screens at the time of a significant change .the screen will be filed in the patient's/resident's medical record. 1) Review of Resident #12's, clinical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to perform hand hygiene between gloves changes during urinary catheter care for 1 of 1 resident sampled for catheter care (Resident #11). The findings included: Review of the facility's policy titled Handwashing/Hand Hygiene revised on January 2022 provided by the facility's Director of Nursing documented use an alcohol-based hand rub .or alternatively, soap and water for the following situations: before and after direct contact with residents .before moving from a contaminated body site to a clean body site during resident care .after removing gloves .perform hand hygiene before applying non-sterile gloves . Review of Resident #11's, clinical record documented an admission on [DATE], no readmissions. The resident diagnoses included Sepsis, UTI on admission, Dementia, Neuromuscular Dysfunction of Bladder, Dysphagia, Retention of Urine. Review of Resident #11's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief…
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.
Part of a chain
This home belongs to ONYX HEALTH — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.5 | -0.5 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 5 of 5 | 4.6 | +0.4 vs chain |
The other 10 homes this chain runs (chain average 4.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ALLAPATTAH OPCO HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2021 |
| SCHUSTER, RACHEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| ACOSTA, YALMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/26/2022 |
| CAMACHO, ALEJANDRO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/08/2023 |
| GONZALEZ, MARGINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/23/2017 |
| OJEDA, MANUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2021 |
| ONYX HEALTHCARE CONSULTING LLC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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
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
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 106100. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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 →
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