Naples Health And Rehabilitation Center
2900 12th Street N, Naples, FL 34103 · For profit - Limited Liability company · 120 certified beds · (239) 261-2554 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jul 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 7 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (47) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $172,682 in federal fines (most recent 2025-04-10)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 10.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.7% | 5.5% | 5.4% | worse |
| 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 | 1.2% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.0% | 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 | 3.8% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.8% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 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 | 5.6% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.4% | 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 | 6.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.9% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.0% | 9.1% | 12.0% | 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.
34.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.6% 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 66 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 34.2%CMS range 24.2–47.5 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 8.3–15.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.6% | 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 | 48.5% | 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 | 51.5% | 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 | 81.8% | 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 | 97.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 2.3% | 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 | 7.2%CMS range 3.6–13.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 120 beds and averages 109.2 residents a day — about 91% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.27 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 3.38 hrs/resident/day on weekends vs 3.76 on weekdays — 10% thinner on weekends. RN hours go from 0.59 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as 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 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.
47 citations, most serious first. The 18 most serious are shown; the remaining 29 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-06 · 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 observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for four (Residents #37, #67, #118 and #119) of 17 smokers observed with lighters in their rooms. The unsafe practice of allowing four of 17 residents who smoke to store unsecure ignition sources such as lighters in their rooms created a significant fire hazard from accidental ignition. A possible accidental ignition and fire risk created a likelihood of serious injury, impairment or death and resulted in the determination of Immediate Jeopardy.The findings included:Cross reference F835, F926Review of the facility's policy and procedure titled, Resident Smoking supervised and Unsupervised - Use of Electronic Smoking/Vaping Devices issued 2/1/26 revealed, Residents who have independent smoking privileges are NOT permitted to keep cigarettes, e-cigarettes (electronic cigarettes), pipes, tobacco, nicotine, and other smoking/vaping…
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.
- Immediate jeopardy · Jcited before2026-03-06 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and failed to take appropriate actions to protect residents' safety from foreseeable and avoidable incidents from unsafe smoking practices and unsafe storage of ignition devices. This failure created an environment that placed four (Residents #37, #67, #118 and #119) of 17 resident smokers at a likelihood of serious injury, impairment or death from an accidental fire and resulted in the determination of Immediate Jeopardy. The findings included:Refer to F689, F926Review of the Director of Nursing's job description revealed that the essential duties and responsibilities included: Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facilities. Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards 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.
- Immediate jeopardy · J2026-03-06 · tag F0926 — failed to keep the home smoke-free / fire-safe — isolatedHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's Resident Smoking Supervised and Unsupervised policy to ensure safe smoking practices for 4 (Residents #37, #67, #118 and #119) of 4 sampled residents reviewed for safe smoking out of 17 total smokers in the facility.The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing four of 17 resident smokers at a likelihood for serious harm, injury or death. These concerns resulted in the determination of immediate jeopardy. The findings included:Cross reference F689, F835Review of the facility's policy and procedure titled Resident Smoking Supervised and Unsupervised - Use of Electronic Smoking/Vaping Devices from the Nursing/Clinical Quality of Care Manual revealed, Prior to, and upon admission, residents shall be informed of the facility…
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.
- Immediate jeopardy · K2023-08-25 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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, review of facility's policies and procedures, and staff interviews, review the facility failed to have processes in place to ensure nursing staff were trained and competent to safely use mechanical lifts for resident transfers. On 8/12/23 Resident #1 sustained a fall during transfer with a mechanical lift resulting in a transfer to the hospital. Resident #1 suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training and competency in the use of the mechanical lift. The failure to ensure the nursing staff have the necessary training, skills set and competency to safely transfer residents using a mechanical lift created an unsafe environment of avoidable accidents and falls which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ)…
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.
- Immediate jeopardy · Jcited before2023-08-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect, in that the facility failed to ensure staff who use mechanical lifts to transfer residents were trained, and competent to safely use the lifts. Resident #1 was dependent on staff for transfer and required the use of a mechanical lift. On 8/12/23 Resident #1 fell from the full body mechanical lift during transfer. Resident #1 was hospitalized and suffered spinal and pelvic fractures. There was no documentation the staff who transferred Resident #1 were trained and competent to safely use the mechanical lift. The facility's failure to provide the necessary structure and processes to prevent neglect placed other residents who require the use of mechanical lifts at a likelihood of avoidable accidents and falls which could result in serious injury, impairment, or death, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was notified of the determination of Immediate…
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.
- Immediate jeopardy · Jcited before2023-08-25 · 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 observation, record review, review of facility's policies and procedures, family and staff interviews, the facility failed to implement ongoing training, competencies, and supervision of staff to ensure the safe use of mechanical lifts and prevent avoidable accidents. On 8/12/23 Resident #1 fell from a mechanical lift during transfer, was hospitalized and suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training, or competency for the proper use of the lift. The failure to ensure staff use safe transfer techniques during mechanical lift transfers created an unsafe environment of avoidable accidents or falls which could result in serious injury, impairment, or death of residents from improper use of the lift and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. 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.
- Immediate jeopardy · Jcited before2023-08-25 · tag F0835 — failed to run the facility competently — isolatedAdminister 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure staff who use mechanical lifts were trained and competent in the safe use of the lift to transfer residents. On 8/12/23 Resident #1 sustained a fall during a transfer with a mechanical lift resulting in multiple fractures and transfer to the hospital. The CNAs using the lift were not trained and competent to use the mechanical lift. The facility's Administration failure to ensure the nursing staff had the appropriate skills and competency to safely transfer residents with a mechanical lift created a likelihood of avoidable falls and accidents which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ…
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.
- Actual harm · G2024-03-28 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and family interview, the facility failed to establish a communication process between the nursing facility, the hospice provider, and the responsible party to ensure the resident needs are met for 1 resident (#1) of 3 residents reviewed who are currently receiving hospice services. Hospice is a specialized form of medical care that provides comfort and quality of life while facing a life limiting or terminal condition. Coordination of care between facility services and Hospice services is vital to ensure the highest level of comfort and care during the end of life. The Findings Included: Coordination of Hospice Services Policy implemented 11/4/2020, Reviewed 11/29/2022, said, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the residents highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines included: 1. The facility maintains written agreements with hospice…
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 before2026-07-01 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, resident interview and observation, the facility failed to protect the resident's right to be free from neglect by failing to provide antibiotics in a timely manner to 1 (Resident #1) of 4 residents reviewed. The failure to provide the necessary care, antibiotics for a positive wound culture, to avoid physical harm placed the resident at risk for sepsis, a life-threatening response to an infection. The findings included: Review of facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin, revised 8/2024 which stated, Neglect 1. Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.Review of Resident #1's clinical records documented she is a [AGE] year-old female admitted to the facility on 4/9/ 2026. The primary admitting diagnosis was surgical aftercare following surgery of the digestive system. Secondary diagnosis include diverticulitis of intestine, sepsis, and 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 · D2026-07-01 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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, facility policy review, and staff interviews the facility failed to ensure staff notified providers of abnormal lab results in a timely manner for 1 (Resident #1) of 4 residents reviewed.The findings included: Review of facility policy titled Condition Change and Physician Notification Policy and Procedure reviewed January 2024 which stated, Doctor (Designee)/ Family Notification of a resident condition change will occur when a resident experiences a change of condition including but not limited to acute change in condition fever, nausea vomiting diarrhea, behavioral changes, lab work, falls, etc. If unable to reach family all attempts will be documented. If a resident attending physician does not return call timely, the DON and Medical Director must be notified.Review of facility policy titled Episodic and Narrative Documentation and Physician Notification, reviewed 1/2026 which stated, Documentation will occur in the Nurses Progress notes to reflect a change in status, event, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-06 · 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 observations, interviews and record review, the facility failed to have sufficient staff to provide nursing care and services to maintain safety and the highest level of resident care needed to meet the needs of the residents, # 2, #12, #24 #50, #51, #52, #22, #25,#30, #133, and #140, by failing to ensure enough staff were available to respond to call lights and address resident concerns.The findings included: Review of the Facility Assessment's Staff Assignments plan noted we conduct a comprehensive assessment of each resident's medical, physical, and emotional needs upon admission. The Facility Assessment further states the facility will ensure an equitable distribution of workload among staff to prevent burnout and maintain high-quality care.Resident #50On 3/2/26 at 10:19 a.m., Resident #50 was observed sitting up in bed, removing her blanket, moving to the edge of the bed and pointing at the bathroom. Resident #50's roommate (Resident #22) said she is not able to get up on her own because she will…
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 before2026-03-06 · 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 observation and interview, the facility failed to ensure medications were secured, locked and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff for 4 (Residents # 67, #16, #118, and #132) of 4 residents observed with medications left at bedside.The findings included: Facility policy titled Medication Administration, revision date 10/2023 indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compliance guideline #15 indicated: Observe resident consumption of medication. On 3/2/2026 at 9:27 a.m., a red tablet was observed on Resident #67's bedside table. Resident #67 walked to the bedside table, picked up the red circular tablet and set it back on the table. He said it was his iron pill and said sometimes he didn't take it. On 3/2/2026 at 9:45 a.m., an inhaler was observed on the bedside table. Resident #16 said…
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 · D2026-03-06 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility failed to respond and follow up with grievances and concerns brought forward by the resident council for 2 of 4 Resident Council meetings minutes reviewed (November and December 2025).The findings included: Review of the facility Resident Right- Grievances policy (last revised 2/1/26) states the resident has right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have. The policy further states ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions the regarding resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.During a resident council meeting conducted on 3/3/26 at 2:55 p.m., the residents at the meeting said they have to wait too…
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 before2026-03-06 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy and procedure, residents and staff interviews, the facility failed to ensure prompt resolution and follow-up for grievances for 3 (Resident #12 Resident #2 and Resident #24) of 3 residents reviewed for grievances.The findings included: Review of the facility Resident Right- Grievances policy (last revised 2/1/26) states the resident has right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have. The policy further states ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions the regarding resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.Review of the Resident Grievance Log showed Resident #12 had filed a grievance for call light…
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 · D2026-03-06 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Level 1 PASRR (Preadmission Screening and Resident Review Process- a federal requirement for nursing facilities to screen individuals for mental illness (MI), intellectual / developmental disabilities (ID/DD) to ensure appropriate placement and access to specialized services preventing unnecessary institutionalization and supporting community living) assessments were completed accurately and Level 2 pre-admission screening and resident review (PASRR) screenings were completed as required for 2 (Residents #8 and #50) of 3 residents reviewed.The findings included: Facility policy Coordination-PreFacility policy Coordination - Pre-admission Screening and Resident Review (PASRR) Program. Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 1. The facility will coordinate assessments with 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 before2026-03-06 · 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, record review, staff and resident review, the facility failed to provide the necessary services to maintain personal grooming and hygiene for 1 (Resident #132) of 3 residents requiring assistance with activities of daily living. This had the potential to cause psychological harm to the resident.The findings included: On 3/2/26 at 11:02 a.m., Resident #132 was observed laying in his bed wearing a hospital gown, his fingernails on both hands were observed to be uneven and extending approximately 3/4 of an inch long with dark brown substance noted under each nail. Resident #132's hair and beard were uncombed and long. Resident #132 said his fingernails had not been trimmed in a long time and he had asked the staff to trim his fingernails several times over the past few months.Review of Resident #132's medical record revealed he was admitted to the facility on [DATE]. Review of Resident #132's Minimum Data Set (MDS) quarterly assessment on 2/19/26 noted a Brief Interview for Mental Status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-30 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 clinical record review, residents and staff interviews, the facility failed to ensure 3 (Residents #7, #8, and #3) of 3 dependent residents reviewed received their scheduled showers. The findings included: 1. On 5/29/25 at 9:30 a.m., in an interview Resident #7 said she asks staff regularly for a shower but has only received one shower since her admission to the facility. She said once she refused a shower as she was already in bed for the night. Review of the clinical record revealed Resident #7 was admitted on [DATE]. The 5-Day Minimum Data Set (MDS) assessment with a target date of 5/21/25 revealed Resident #7 scored 12 on the Brief Interview for mental status (BIMS), indicative of moderate cognitive impairment. Diagnoses included weakness and history of falling. The MDS assessment revealed Resident #7 required partial assistance with bathing and showers and did not reject care. Review of the shower schedule revealed Resident #7 was scheduled for a shower on the evening shift on Monday and Thursday.…
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 before2025-05-30 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to demonstrate prompt efforts to address grievances, including steps taken to investigate the grievance and failed to maintain evidence of the result of the grievance voiced by the family member of 1 (Resident #1) of 3 residents reviewed for grievances. The findings included: Review of the facility policy titled Resident Right - Grievances, issued 11/7/2024 revealed, It is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights . The resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have . All residents, staff, and visitors will have access to the professional designated to manage the Grievance Program, Grievance Officer. The grievance policy must include . Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 29 citations
- Potential for harm · D2025-05-30 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and records review, the facility failed to identify, investigate and prevent misappropriation of physician prescribed medication for 1 (Resident #4) of 3 residents reviewed. The findings included: Review of the facility policy titled, Abuse, Neglect, and Exploitation with a date reviewed/revised of 11/16/23 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit . exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Review of the facility policy titled, Pharmacy Services with a date reviewed/revised of 4/17/23 revealed, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs . to meet 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 · D2025-04-10 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to protect residents' right to be free from physical restraint for 1 (Resident #1) of 1 resident reviewed for restraints. The findings included: Review of the clinical record revealed Resident #1 was re-admitted to the facility on [DATE]. Diagnoses included Traumatic Subdural Hemorrhage (bleeding in the brain), Aphasia (language disorder affecting ability to speak) following Cerebral Infarction, and muscle weakness. The admission Minimum Data Set (MDS) assessment with a target date of 11/12/24 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 05. Review of the facility's incident investigations revealed on 11/25/24 at 7:45 a.m., the Director of Rehab reported to the Administrator when the Certified Occupational Therapist Assistant (COTA) went to get Resident #1 for therapy, she found the resident in his room, in his wheelchair with a sitter. The resident had a gait belt around his abdomen 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 · Ecited before2024-08-08 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, review of facility policy and procedure, review of the clinical record and resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Resident # 899, #800 and #7) of 3 residents reviewed for ADL's (activities of daily living). The findings included: The facility policy Activities of Daily Living (ADL's) implemented 11/2020 (revised 11/22/21) documented Residents who are unable to carry out activities of daily living independently will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #899 had a readmission date of 5/5/24 with diagnoses including cerebral palsy, contracture of hands and left leg, and muscle wasting. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated of 5/10/24 documented the resident was dependent on staff assistance for personal hygiene, dressing and bathing. The MDS noted Resident #899's cognitive…
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 · E2023-11-30 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably 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 records review, review of facility's policy and procedure, residents, and staff interviews, the facility failed to honor the bathing preferences for 4 (Residents #11, #15, #45 and #85) of 4 residents reviewed for bathing preferences. The findings included: Review of facility policy titled Resident Showers implemented 11/2020 showed, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedule as per facility policy . Review of facility policy titled Activities of Daily Living (ADLs) reviewed / revised 11/29/22 stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless…
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 before2023-11-30 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to file and maintain an accurate record of grievances for 3 (Residents #74, #83, and #3) of 3 residents reviewed. The findings Included: The facility Resident and Family Grievances policy Implemented 11/2020 and revised 3/8/2022 stated, It is the policy of this facility to support each resident's and family member's right to voice grievances . The policy noted the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form; Forward the grievance form to; the Grievance Official as soon as practicable; The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. On 11/27/23 at 11:30 a.m., in an interview, Resident #74 said he had been a resident at the facility for three months. He said the laundry had lost all his clothes. He said he spoke with 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 · E2023-11-30 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of the facility's policies and procedures and staff interviews, the facility failed to ensure the appropriate Pre-admission Screening and Resident Review (PASARR) for 2 (Residents #87, and #77) of 2 residents admitted to the facility with a diagnosis of Serious Mental Illness or Intellectual Disability. The findings included: Review of the facility policy for Resident Assessment - Coordination with PASARR Program revised 9/19/22 indicated the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), ID (intellectual disability), or a related condition receives care and services in the most integrated setting appropriate to their needs. PASARR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to provide appropriate urinary catheter care and monitoring for 2 (Residents #64 and #85) of 2 sampled residents with urinary catheter to prevent urinary tract infections. The findings included: Review of facility policy titled, Catheter Care revised 1/6/23 states, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Catheter care will be performed every shift and as needed by nursing personnel . 3. Privacy bags will be changed out when soiled, with a catheter change or as needed. 4. Leg bags may be used for ambulatory residents or per resident request . 1. Review of the clinical record for Resident #64 revealed an initial admission date of 3/8/22 with a most recent readmission date of 11/22/23. Diagnoses included bladder-neck obstruction. Resident #64 had an indwelling urinary catheter (catheter inserted into 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 · E2023-11-30 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 review of the clinical record, review of facility policy and procedure and resident and staff interview, the facility failed to ensure freedom from significant medication error for 2(Resident #9 and #56) of 6 residents reviewed for medication administration. Failure to administer medications accurately puts residents at risk for adverse health consequences. The findings included: The facility policy Medication Administration (revised 10/23) documented Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. The policy specified to sign the MAR (Medication Administration Record) after the medication was administered. On 11/27/23 at 11:09 a.m., in an interview, Resident #9 said he was supposed to receive eye drops for his dry eyes but rarely gets it. He said, the nurses tell me they don't have it. He said his eyes…
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 before2023-11-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy, staff and residents interviews, the facility failed to ensure safe storage of medications for 3 (Residents #3, #74, and #56) of 3 residents observed with unsecured medications at the bedside and 1 unlocked, unattended medication cart (South Unit) of 2 units observed. The findings included: Review of facility policy titled Medication Storage reviewed/ revised 5/4/2022 which stated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanations and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .c. During a medication pass,…
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 · D2023-11-30 · 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, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to privacy during medical treatment for 1(Resident #249) of 2 residents observed. The findings included: The facility policy Blood Glucose Monitoring (revised 1/2022) documented, It is the policy of this facility to perform glucose monitoring to diabetic residents as per physician's orders. The policy procedure instructed to provide privacy. On 11/28/23 at 8:57 a.m., Licensed Practical Nurse (LPN) Staff G was observed in the hallway on the South Nursing Unit obtaining a blood sample via fingerstick for blood glucose monitoring for Resident #249. The procedure was clearly visible to a hospice nurse, facility staff and other residents observed in the hallway. Resident #249 had his head down and appeared uncomfortable during the observation. On 11/28/23 at 9:00 a.m., in an interview, LPN Staff G said she was from a staffing agency and did not know she was supposed to provide privacy to the resident for blood glucose monitoring. She said, ok,…
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 · D2023-11-30 · 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 staff interview the facility failed to provide maintenance and housekeeping services to maintain a clean and homelike environment in 4 (Rooms 136, 138, 148, and 149) of 12 rooms observed on the South Unit. The findings included: On 11/27/23 at 10:00 a.m., during an initial tour of the South Unit, the following was observed: room [ROOM NUMBER] A: The top drawer of the nightstand was broken. The floor next to the nightstand was littered with multiple personal items, soda bottles and plastic bags. The privacy curtain was stained and soiled with black and brown grime. Photographic evidence obtained. room [ROOM NUMBER] A: The paint on the wall behind the bed was peeling, exposing the dry wall. Photographic evidence obtained. room [ROOM NUMBER] A: The bed was made with a torn blanket. Photographic evidence obtained. room [ROOM NUMBER] B: The privacy curtain had multiple large brown stains. Photographic evidence obtained. On 11/29/23 at 8:43 a.m., during a joint observation, the Maintenance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · 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, review of the clinical record, review of facility policies and procedures, and resident and staff interviews the facility failed to provide the necessary care and services to maintain personal hygiene and bathing for 3 (Residents #1, #9 and #249) of 10 residents reviewed for activities of daily living. The findings included: The facility policy Activities of Daily Living ADL's) revised (11/29/22) documented The facility will, based on the resident's comprehensive assessment and consistent with the residents needs and choices, ensure a residence abilities and ADL's do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility policy Resident Showers documented It is the practice of this facility to assist residents with bathing to maintain proper hygiene stimulate circulation and help prevent skin issues as per current standards of practice as resident request allows tolerates or agrees.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · 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 record review, and staff interview, the facility failed to ensure monitoring and care of cardiac pacemaker for 1 (Resident #90) of 1 resident reviewed for pacemakers. The findings included: Review of the facility policy for Use of Pacemaker revised on 3/7/23 indicated residents with a pacemaker will be monitored according to protocol and plan of care. Documentation about the pacemaker will be placed in the resident's chart and part of their permanent record. Pacemaker checks will be performed as ordered by the physician. Review of the clinical record for Resident #90 revealed an admission date to the facility of 8/10/23. The hospital documentation dated 8/2/23 noted Resident #90 had a history of cardiac pacemaker. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/10/23 noted Resident #90 had a cardiac pacemaker. Review of Resident #90's admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident had a Cardiac Pacemaker. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · 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
Based on observation, record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to provide an ordered therapeutic carbohydrate control diet for a diabetic for 1 (Resident #11) of 1 diabetic resident reviewed. The findings included: Review of facility clinical services policy titled, Therapeutic Diet Orders implemented 11/3/2020 stated, Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment / plan of care, in accordance with his/her goals and preferences . Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietician, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease, or increase specific nutrients in a diet. Examples include low salt, diabetic, or low cholesterol diets . 2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · 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, review of facility's policies and procedures, staff and resident interviews, the facility failed to ensure that 1 (Resident #15) of 17 residents receiving respiratory treatment received physician ordered oxygen consistent with professional standards of practice, and the comprehensive person-centered care plan. The findings included: Review of facility policy titled Oxygen Therapy reviewed/revised 5/4/2022 stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is administered under orders of a physician, except in the case of an emergency . Review of the clinical record for Resident #15 document initial admission to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-25 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to complete a yearly performance review for 5 (Staff I, Staff L, Staff S, Staff T, and Staff U) of 5 Certified Nursing Assistants (CNAs) employed at the facility for more than 12 months. The findings included: Cross reference to F726. Review of facility policy titled Job Descriptions and Performance Evaluations revised September 2020 which states, The objectives of our job descriptions and performance evaluations are to: a. clarify who is responsible for particular duties; b. assist employees in understanding essential functions, responsibilities, working conditions, qualifications, and specific physical requirements of the positions; c. Prevent misunderstandings about job responsibilities and how each job is evaluated; d. Aid management in analyzing and improving the facility's services and structure of its organization; e. Provide a basis for job evaluation, wage and salary increases, promotions, demotions, transfers, and to improve quality of work performances. 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 · E2023-08-25 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and administrative staff interview, the facility failed to ensure the facility-wide assessment was complete in that the facility assessment failed to include resident care equipment, including mechanical lifts, staff education and competency necessary to safely provide the level and type of care needed for residents using mechanical lifts. The findings included: Cross reference to F689, F726, and F835. The facility assessment with a date reviewed with the QAA (Quality Assessment and Assurance) Committee of 2/28/23 noted, The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations and emergencies. The Facility Assessment showed the Administrator signed and approved the assessment on 2/28/23. The facility assessment noted the resident acuity affecting Nurse Aides included, Assistance Provided with Transfers: 92. The sections addressing residents preferences, services and care offered based on residents needs were left blank. The section addressing competencies noted, Our…
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 before2022-01-06 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff and resident interviews, the facility failed to ensure process to support resident's rights to voice grievances for 5 (Residents #83, #31, #3, #12, and 41) of 5 residents reviewed. The findings included: The facility policy for Resident and Family Grievances, 2021 read, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility . On 1/4/22 at 9:45 a.m., in an interview Resident #41, Resident Council President, said she has been a resident at the facility since 9/11/2021. She said they usually have a resident council meeting once a month and there are about 7-8 residents who attend. She said Activities Director Staff B who has been here for a couple of months takes notes and keeps records for resident council. She said she thinks laundry was 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 · E2022-01-06 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to the resident and the Office of State Long Term Care Ombudsman (LTCO) office with written notice of hospital transfer and facility discharge for 3 (Resident #136, #137, and #139) of 4 sampled residents transferred to the hospital and discharged from the facility. The findings included: Review of the facility's policy titled Transfer and Discharge (Including AMA) dated November 2021, under sub-heading (7) Emergency Transfer/Discharge, the facility would, Complete and send with the resident (or provide as soon as practicable) a Transfer Form. The policy also noted the facility Social Services Director, or designee, shall provide notice of transfer to a representative of the Long-Term Care Ombudsman (LTCO) via monthly list. 1. Review of Resident #136's medical record revealed she was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, encephalopathy,…
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 · E2022-01-06 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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, staff and resident interview, the facility failed to provide the resident and their representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 9 (Residents #9, #24, #25, #30, #38, #66, #81, #82 and #285) of 10 residents reviewed for baseline care plans. This had the potential to cause confusion as to the care expected to be provided by the facility. The findings included: Review of the facility's policy Baseline Care Plan, implemented and revised on 2/12/21 read, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy explanation and compliance guideline: 1. The baseline care plan will be: a. developed within 48 hours of a resident's admission . 3. A supervising nurse shall verify within 48 hours…
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 · D2022-01-06 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident and staff interview the facility failed to have documentation of an assessment to determine the ability to self-administer medications for 1 (Resident #43) of 1 resident observed with unsecured medication at the bedside. The findings included: Facility policy Resident Self-Administration of Medications, 2021 noted, . A resident may only self-administer medications after the facility's interdisciplinary team determined which medications may be administered safely . On 1/3/22 at 9:46 a.m., observed an unsecured Ventolin inhaler stored at Resident #43's bedside. Resident #43 reported he used it, some days more often than others. Resident #43 said when he runs out of the medication he requests a new inhaler. Photographic evidence obtained On 1/4/22 at 8:45 a.m., Licensed Practical Nurse (LPN) Staff I verified the observation and said medication should not be left at bedside. Staff I confirmed Resident #43 did not have an assessment completed authorizing self-administration of the inhaler. She said Resident #43 would often ask to keep 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 · D2022-01-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff and resident interviews and review of facility policies and procedures for Advance Directives, the facility failed to ensure proof of advance directives review and advanced care planning was in place for 2 (Resident # 285 and # 81) of 9 residents reviewed for Advanced Directives. This failure may impact quality of care at the end of life for the residents. The findings included: Review of facility policy: Advance Directives. Reviewed/revised December 2021 revealed, .Procedure . 2. Prior to or upon admission, the admission Director/ designee will provide written information to the resident and or legal representative concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives . Each resident, family member or legal representative will be asked to sign an acknowledgement indicating they have been given the required Advance Directive information. 1. On 1/3/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-01-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, resident and staff interview, the facility failed to provide evidence a care plan conference was conducted with the resident and/or resident representative after completion of the comprehensive admission Minimum Data Set (MDS) assessment for 2 (Resident #82 and #25) of 2 residents reviewed. This did not allow the resident and/ or representative to participate in decision making related to the plan of care. The findings included: 1. On 1/3/22 at 12:08 p.m., in an interview Resident #25 said he was not invited to his care plan meeting and was never given a copy of his baseline care plan. He said he was unaware of the plan of care the Interdisciplinary Team (IDT) had determined for him as of this time. On 1/5/21 a review of Resident #25's medical record confirmed he was admitted to the facility on [DATE] with diagnoses of Chronic Hepatic Failure, Bipolar Disorder, and Alcohol-Induced disorder. Further review of the medical record revealed no documentation Resident #25 attended his IDT care…
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 · D2022-01-06 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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, staff and resident interview, the facility failed to ensure 2 (Residents #18 and #50) of 17 residents surveyed received activities according to the activities assessment, care plan, and the abilities of the resident. This has a potential to cause loneliness and mental anguish for residents. The findings included: 1. On 1/3/22 from 11:00 a.m., to 12:00 p.m., on 1/4/22 from 10:00 a.m., to 12:00 p.m., and on 1/4/22 from 1:00 p.m. to 3:00 p.m., Resident #18 was observed in her bedroom not involved in an activity. Further observation noted the television was not on nor was there a radio playing music for Resident #18. On 1/4/22 at 1:30 p.m., interview with Resident #18 confirmed she only spoke Spanish. She said there was not much to do at the facility. On 1/5/22 review of Resident #18's medical record revealed she was admitted to the facility on [DATE]. An activity plan of care and the Activities Quarterly Participation Review dated 10/20/21 stated Resident #18 enjoyed listening…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-06 · 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 observation, record review, staff, and resident interviews the facility failed to assess, document, monitor, and provide care in a manner to promote healing for 1 (Residents #50) of 1 resident reviewed for edema (swelling caused by excess fluid). There was no evidence of a nursing assessment of the resident's edema to his lower legs to determine the extent of the swelling, blood flow to each leg, pain level, interventions which could be put in place to reduce the edema, and/or signs of infection. Ongoing monitoring and documentation of Resident #50's lower extremities allow clinical staff to detect complications and implement new interventions to prevent worsening of the lower extremity edema. The findings included: On 1/3/21 at 11:40 a.m., Resident #50 was observed sitting in his wheelchair in the hallway. Resident #50 pointed to his right leg and said that it was swollen, and it hurt. Observation of Resident #50's lower extremities noted the right leg was larger than the left leg. On 1/3/21 at 11:44…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-06 · 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 observation, staff and resident interview, and review of facility policy and procedures, the facility failed to ensure the resident environment remains free of hazards and provide adequate supervision when smoking for 1 (Resident #17) of 2 resident reviewed for smoking. The findings included: The facility policy: Resident Smoking Implemented November 2020, Revised October 2021, read, This facility provides a safe environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. Policy explanation and compliance guidelines: . 6. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process . 8. All residents will be supervised while smoking . 10. All safe smoking measures shall be documented on each resident's care plan and communicated as applicable . 12. Smoking materials of residents shall be maintained by nursing staff. An admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-06 · 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 observation, policy review and staff interview the facility failed to ensure proper storage and labeling of medications for 2 (Residents #43, and #385) of 7 sampled residents. The facility also failed to properly label and store medications in 2 (Medication Cart A and B ) of 2 medication carts observed on the North Unit. The findings included: Facility policy Resident Self-Administration of Medications, 2021 noted, . A resident may only self-administer medications after the facility's interdisciplinary team determined which medications may be administered safely . 1. On 1/3/22 at 9:46 a.m., observed an unsecured Ventolin inhaler stored at Resident #43's bedside. Resident #43 reported he used it, some days more often than others. On 1/4/22 at 8:45 a.m., Licensed Practical Nurse (LPN) Staff I said medication should not be left at bedside. Staff I confirmed Resident #43 did not have an assessment completed authorizing self-administration of the inhaler and leaving the inhaler at bedside would be an error. 2. On 1/4/22 at 9:15 a.m., observation of medication cart A of North…
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 · D2022-01-06 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff and resident interviews, the facility failed to maintain a safe, sanitary, and comfortable homelike living environment for 3 (Residents #48, #37, and #22) of 3 residents reviewed. The findings included: On 1/3/22 10:05 a.m., in an interview Resident #48, said last Wednesday he was short of breath and was given a nebulizer (a small machine that turns liquid medicine into a mist) treatment. The nebulizer tubing and mouth piece were observed uncovered at the Resident's bedside. Resident #48 said it had been there since last Wednesday. On 1/5/2022 at 9:15 a.m., the nebulizer tubing and mouth piece remained stored uncovered on the Resident's dresser. Resident #48 reiterated the nebulizer tubing and mouth piece had been on the dresser since last Wednesday. On 1/6/22 at 12:15 p.m., the nebulizer tubing and mouth piece remained uncovered on the Resident's dresser. 2. On 1/3/22 at 10:08 a.m., Resident #37 was observed in bed watching television. She said the light above her bed was not working and made it difficult to see things when there 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 · D2022-01-06 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
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 provide 12 hours of annual in-service education for 2 (Staff L and Staff M) of 2 Certified Nursing Assistants reviewed. The findings included: On 1/5/22, record review revealed no evidence of 12 hours of annual training for Certified Nursing Assistants (CNA) Staff L and Staff M with a date of hire of 4/1/20. On 1/5/22 at 8:15 a.m., the Business Office Manager (BOM) said the Assistant Director of Nursing (ADON) was in charge of staff development and training, but the ADON resigned. She said there was no one responsible for staff development and training. On 1/5/22 at 8:22 a.m., the Administrator said the ADON's last day at the facility was 12/24/21. The Administrator said the Director of Nursing (DON) and Unit Manager Staff D, Registered Nurse (RN) were responsible for staff development and training. She said they use [Name] University and the training records would be in the computer. On 1/5/22 at approximately 11:00 a.m., RN Unit Manager Staff D…
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
$172,682 in federal fines across 3 penalties.
- $19,256 — penalty dated 2025-04-10
- $35,426 — penalty dated 2024-03-28
- $118,000 — penalty dated 2023-08-25
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 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 | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.7 | -1.7 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; lowest-rated first.
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 | Since |
|---|---|---|---|
| SPENCER, EVERTON | Individual | W-2 MANAGING EMPLOYEE | since 04/20/2020 |
| GORELICK, BATYA | Individual | CORPORATE OFFICER | since 04/20/2020 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 105439. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.