Bentley Care Center
875 Retreat Drive, Naples, FL 34110 · For profit - Corporation · 84 certified beds · (239) 431-2100 Medicare only — no Medicaid
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (17) — 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
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 held steady at 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 | 14.5% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.3% | 5.5% | 5.4% | worse |
| 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 | 2.5% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.3% | 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 | 4.2% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.2% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.1% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.6% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.6% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.2% | 9.1% | 12.0% | typical |
| 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 | 1.21 | 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.
58.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 162 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.3% 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 179 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 0.64 therapist hours per resident per day in 2026Q1 — more than 90% 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 | 58.8%CMS range 51.1–64.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.1%CMS range 5.6–11.1 | 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 | 55.3% | 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 | 42.5% | 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 | 49.2% | 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 | 99.6% | 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 | 98.5% | 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 | 97.9% | 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 | 1.2% | 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 | 4.1% | 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 | 7.8%CMS range 4.8–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 84 beds and averages 75.3 residents a day — about 90% occupied, or roughly 9 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 6.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.85 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 5.84 hrs/resident/day on weekends vs 6.70 on weekdays — 13% thinner on weekends. RN hours go from 2.12 to 1.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · F2024-11-21 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that clinical nutritional assessments were completed within the scope of practice and failed to ensure appropriate competencies in accordance with standards of practice for 5 of 6 residents reviewed for nutrition (Residents #55, #6, #14, #43, and #26). This had the potential to affect 67 residents on the facility's current census. The findings included: A review of the Certified Dietary Manager (CDM) scope of practice dated March 2022 showed the following: Gather Nutrition Data. Interview and identify client-specific nutritional needs/problems. Review nutrition screening data and calculate nutrient intake. Document in the medical record. Identify food customs and nutrition preferences based on race, culture, religion, and food intolerances. Utilize standard nutrition care procedures following ethical and confidentiality principles and practices. Participate in care conferences and review the effectiveness of nutrition care. Provide nutrition…
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 · F2024-11-21 · 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 it was determined that the facility failed to store prepare, distribute, and serve food in accordance with professional standards for food service safety in the skilled nursing home kitchen, satellite serving kitchen, and the main campus kitchen, which potentially effected all of the 66 facility residents. The findings included: 1. During the initial kitchen/food service observation tour conducted on 11/18/24 at 9 AM and accompanied with the facility's Certified Dietary Manager (CDM). The following were noted: Observation of the walk-in refrigerator noted that the exterior fan covers (3) of the unit were soiled and dust ladened, and the surrounding ceiling area was also dust ladened. Observation of the walk-in refrigerator noted 4- 20 thawed whole turkeys. The CDM stated that the turkeys were defrosted last week and would be cooked next week for the holiday meal. The surveyor discussed with the CDM that the regulatory requirement was thawing of frozen meats for a prior to not exceed 72 hours and be prepared after that time. It was…
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 · F2024-11-21 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 dispose of garbage and refuse properly. The findings included: During the review of the facility's Policy Protocol - Waste, Recycling and Biohazard Management, the following were noted: Purpose - This policy establishes guidelines for disposal of regular trash, recycling material, hazardous and biohazard waste materials within the communities. Process - Comply with applicable laws and regulations and help protect employees, residents, and visitors from harm. #2: Hazardous and biohazard wastes are separated from common trash recycling to avoid creation of mixed wastes. #3: Trash, recycling hazardous and biohazard waste are discarded are discarded in the designated container(s). #4: The compactor , recycling storage containers and hazardous waste storage areas are kept clean and free of spilled waste and liquids to avoid rodents, insects, and odors. #8: Employees are trained on an annual basis by their immediate supervisor in the appropriate and safe handling and disposal of trash 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 · F2024-11-21 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the Administrator failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The facility's Administrator failed to ensure that the Consultant Clinical Dietitian provided dietary services, supervision, and oversight in accordance with State and Federal Guidelines. The facility's Administrator failed to ensure that the current Certified Dietary Manager (CDM) was providing dietary services within her scope of practice for 6 of 6 residents reviewed for nutrition (Residents #17, #43, #14, #55, #6, and #26). This had the potential to affect 67 residents who were on the census at the facility. The findings included: A review of the Job Description of the facility's Administrator, revised on February 1, 2018, showed the following: The Care Center Administrator has full legal authority and responsibility for the operation of the Care Center, ensuring that it operates in compliance with all…
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 · E2024-11-21 · tag F0583 — failed to protect personal privacy — patternKeep 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 and interview, the facility failed to maintain resident privacy by posting signs with private medical information on the entrance doors to their rooms. This affected 12 residents in the final sample (Residents #4, #9, #14, #16, #17, #22, #26, #38, #43, #53, #55, and #211) with the potential to affect 27 additional residents in the facility with signs on their doors. The findings included: During the initial tour of the facility on 11/18/24 at 9:15 AM, the surveyor observed signs on resident rooms on the second and third floor of the facility. 39 rooms had signs posted that indicated fall risk, general caution, caution oxygen, swallow caution, sight impaired, hearing impaired, and/or no additional liquids. Resident #4's posted sign on the entrance to her room stated Fall risk, Hearing impaired, Swallow caution and General caution. Resident #9's posted sign stated Fall risk. Resident #14's posted sign stated Fall risk, General caution. Resident #16's posted sign stated Fall risk, Caution oxygen. Resident #17's posted sign stated Fall risk. Resident #22's posted…
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 · D2024-11-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to treat each resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her life, recognizing each resident's individuality for 2 of 21 sampled residents (Residents #26 and #18) The findings included: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Pneumonia Unspecified Organism and Unspecified Severe Protein-Calorie Malnutrition. Review of the Minimum Data Set for Resident #26 dated 10/30/24 documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. On 11/18/24 from 11:50 AM until 12:20 PM an observation was made of Resident #26 sitting up in her bed. Staff D Registered Nurse (RN) came into the resident's room to take her vital signs (Temperature, pulse, blood pressure, respiration). She called the resident honey twice upon entering the room and addressing 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 · D2024-11-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure services provided (Administration of Intravenous [IV] medication) meet professional standard of quality for 1 of 12 Licensed Practical Nurses (LPNs) employed by the facility for 1 of 1 resident with Peripherally Inserted Central Catheter affecting Resident #264. The findings included: Review of the Florida Board of Nursing located at the web address: https://floridasnursing.gov/administration-of-intravenous-therapy-by-licensed-practical-nurses/ Included in part the following: CHAPTER 64B9-12 ADMINISTRATION OF INTRAVENOUS THERAPY BY LICENSED PRACTICAL NURSES 64B9-12.005 Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy. (1) The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduation level course teaching aspects of IV therapy. The didactic intravenous therapy education must contain…
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 · D2024-11-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to assess and provide adaptive eating utensils and drinking cups to maintain independence in eating ability for 1 (Resident #43) of six residents reviewed for nutrition. The findings included: Observation of the lunch meal on 11/18/24 at 12:30 PM noted Resident #43 eating in the second floor Main Dining Room and was served a served a Regular diet. Continuous observation noted the resident to have shaking and tremors when attempting to eat independently. Specifically the resident would spill food from use of regular silverware, and would press the glass cup against his nose and face to decrease hand shaking/tremors. A review of the clinical record of Resident #43 on 11/18/20/24 noted an admission date of 12/20/23 with diagnoses that included Parkinson's Disease with Dyskinesia (involuntary movements), and Dementia. Further review noted a physician order dated 12/20/23 for a Regular diet and Ensure Lactose Reduced 8…
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 · D2024-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to ensure nutritional assessments were completed accurately with appropriate interventions in place for 3 of 6 residents reviewed for nutrition (Residents #55, #6 and #26). The findings included: A review of the policy titled, Weight Management Protocol, revised in March 2021, showed that Resident intake of ordered snacks and ordered supplements is monitored. If intake is less than 50% in a 24-hour period for 3 days, the healthcare provider, with prescriptive authority and Dietitian, will be notified. It further showed educated diet and the importance of intake. A review of the Revised 2024 Scope and Standards of Practice for the Registered Dietitian Nutritionist by the Academy of Nutrition and Dietetics showed the following: Roles of Registered Dietitian Nutritionists (RDNs), whose practice involves nutrition care, Medical Nutrition Therapy, and nutrition-related services use knowledge, skills,…
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 · D2024-11-21 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to transcribe the physician's order agreeing to pharmacy recommendation for psychotropic medication for 1 of 5 sampled residents for unnecessary medication affecting Resident #22. The findings included: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Dementia, Anxiety and Depression. Review of the Minimum Data Set for Resident #22 dated 06/12/24 documented in Section C a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment. Review of the Consultant Pharmacist Recommendations to Physician for Resident #22 dated 09/29/24 included the following: Recommend discontinue PRN (as needed) use of Chlordiazepoxide HCl. Physician Response: Evaluation for the appropriateness of use of Chlordiazepoxide PRN has been completed. Non-pharmacological interventions have failed multiple times. Continuing PRN use of Chlordiazepoxide prescribed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2024-11-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that PRN (as needed) orders for psychotropic drugs are limited to 14 days for 2 of 5 sampled residents for unnecessary medication (Residents #22 and #53). The findings included: The facility's policy titled Psychotropic Medication Use revised July 2022, revealed For psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included Cerebral atherosclerosis exacerbation and Vascular dementia. A chart review revealed a Physician order for Ativan (lorazepam) 0.5 milligrams (mg) give 1 tablet as needed every 6 hours with no stop date. Special Instructions: Monitor for side effects such as Nausea, unable to sleep, dry mouth, constipation.…
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 · D2024-11-21 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to ensure that the correct fluid restriction was provided as per physician's order for 1 of 1 resident reviewed for Dialysis (Resident #55). The findings included: A review of the facility ' s policy titled Encouraging and Restricting Fluids, revised in October 2010, showed the following: the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Follow specific instructions concerning fluid intake or restrictions. When a resident is placed on fluid restriction, remove the water pitcher and cup from the room. If the resident refuses to have the water pitcher removed, notify the supervisor and, in turn, the Physician. Record review revealed Resident #55 was admitted on [DATE] with diagnoses of acute kidney failure and anemia and was on hemodialysis. A review of the Physician's orders showed the following: An order for dialysis 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 · D2024-11-21 · 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 observations, interviews and record review, the facility failed to maintain medical records for each resident that are complete and accurately documented for 1 of 1 resident sampled for transmission based precautions with peripherally inserted central catheter (PICC) affecting Resident #264. The findings included: Review of the facility's policy titled, Charting and Documentation with a revised date of July 2017 included in part the following: The following information is to be documented in the resident medical record: a) Objective observations, b) Medications Administered, c) Treatments or services performed, d) changes in the resident's condition. Record review for Resident #264 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Acute and Subacute Infective Endocarditis, Bacteremia, Sepsis due to Methicillin Susceptible Staphylococcus Aureus, Nonrheumatic Aortic (Valve) Stenosis, Bacterial Infection Unspecified. Review of the Minimum Data…
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 · D2024-11-21 · 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, interview, and record review the facility failed to implement appropriate infection prevention and control practices during medication administration for 1 of 5 residents observed for medication administration affecting Resident #265. The findings included: Review of the facility policy titled, Standard precautions - Infection Control with a revision date of September 2017 included in part the following: Process: 1. Gloves are worn whenever exposure to the following items is planned or anticipated, or an item is contaminated with the following, including but not limited to: Blood/blood products/body fluids Mucous Membranes Performing venipuncture or invasive procedure(s) Saliva Review of the facility best practice guidelines and principles titled, Medication Administration Documentation and Storage: with no date included in part the following: Appendix B Recommended Procedures for Administration Insulin Administration Procedures Injection Technique 1. Wash hands and wear gloves. 7. Remove…
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 · D2024-11-21 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview it was determined that 6 of 13 resident room bathrooms located on the East Wing of the second floor were disabled, inoperable, and out of reach in a resident emergency. The six identified rooms were noted to effect Resident's #2, #7, #17, #24, #31, and #41. The findings included: During the initial screenings conducted by the surveyor on 11/18/24 of resident rooms #225 through # 240, it was noted that 6 of the rooms had bathrooms of which the nurse emergency call bell was wrapped around the wall mounted hand rails resulting in the in the bell coming inoperable when pulled. It was also noted that due to the wrapping around the handrails that the end of the cord exceeded the 4 inch minimum requirement from the floor. It was also noted that the bathroom trash containers were placed in front of the pull cords blocking reaching of the cord during a potential emergency. The resident's potentially effected included the following: Resident #41 - Minimum assistance by staff with toileting. Resident #17 - Maximum assistance by staff with toileting. 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 · D2023-03-02 · 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
Based on observation, record review, staff and resident interview, the facility failed to provide the necessary services to maintain personal grooming and hygiene for 1 (Resident #13) of 2 sampled residents requiring assistance with activities of daily living. The findings included: Review of the clinical record for Resident #13 revealed an admission date of 2/2/2022. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 11/14/22 noted Resident #13's cognition was intact. The diagnoses included heart failure. Resident #13 required limited physical assistance of two persons for dressing, and limited assistance of one person for personal hygiene. The MDS noted the resident was totally dependent of one person physical assistance for bathing. The plan of care initiated on 2/3/2022 and revised on 2/15/23 noted Resident #13 required extensive to total assistance with daily care tasks related to weakness related to Atherosclerotic heart disease (ASHD). Resident #13 was receiving hospice services. The intervention was to encourage her to do as much as possible…
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 · D2023-03-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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, review of the facility's protocol, Resident and staff interviews, the facility failed to implement preventive measures to prevent the development of pressure ulcers for 1 (Resident #13) of 1 resident at risk for pressure ulcer. The findings included: The facility's Pressure Ulcer Treatment and Prevention Protocol, revised in November 2022, noted the protocol provides guidelines for the assessment of skin integrity; interventions for the prevention and treatment of impaired skin integrity; and the evaluation and modification of the plan of care related to the resident's skin integrity. Prevention and intervention measures are placed in the resident plan of care. The protocol listed the following risk factors that increase the resident's susceptibility to develop or have impaired-healing pressure injuries: Impaired/decreased mobility; co-morbid conditions; drugs that affect wound healing; impaired diffuse or localized blood flow; resident refusal of some aspects of care 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.
- 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 VI LIVING — 9 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 | 3 of 5 | 4.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 4.0 | -2.0 vs chain |
| Staffing | 5 of 5 | 5.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 4.7 | -1.7 vs chain |
The other 8 homes this chain runs (chain average 4.4★, 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 |
|---|---|---|---|---|
| MARGOT AND TOM PRITZKER FOUNDATION | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 05/22/2025 |
| P. G. - DANIEL TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| P. G. - DON #3 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| P. G. - JIM TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| P. G. - JOHNNY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| P. G. - KAREN TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 01/01/2012 |
| P. G. - LINDA TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| P. G. - NICHOLAS TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 6% | since 01/01/2012 |
| P. G. - TONY TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 5% | since 01/01/2012 |
| PRITZKER PUCKER FAMILY FOUNDATION NO. 2 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 9% | since 05/22/2025 |
| MUSZYNSKI, THOMAS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNF | — | since 06/01/2022 |
| POORMAN, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/29/2004 |
| SMITH, GARY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2012 |
| COPE, TARA | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 06/01/2018 |
| CLASSIC RESIDENCE MANAGEMENT LIMITED PARTNERSHIP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/18/2025 |
| ALLISON, PAMELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/21/2025 |
| CONZELMAN, TINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/09/2025 |
| ELTERMAN, FRANK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| EVRAETS, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/31/2020 |
| KOSZYLKO, TOMEK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/15/2018 |
| MASLOW, CARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2019 |
| SMITH, PENNY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2016 |
| WILLIAMS, BRIDGET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2022 |
CMS files one row per role, so the 37 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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 $179K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Florida Medicaid page for homes that do.
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 106062. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-21, 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.