Heather Hill Healthcare Center
6630 Kentucky Ave, New Port Richey, FL 34653 · Non profit - Other · 105 certified beds · (727) 849-6939 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 2 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 | 25.6% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.9% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.3% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.0% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.6% | 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 | 1.5% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.4% | 10.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.7% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.1% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.4% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.3% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 3.0% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.19 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
37.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.5% 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 47 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 0.45 therapist hours per resident per day in 2026Q1 — more than 76% 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 | 37.8%CMS range 26.2–49.2 | 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 | 10.8%CMS range 6.8–15.6 | 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 | 42.5% | 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 | 23.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 27.7% | 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 | 97.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.7% | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 4.8–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 105 beds and averages 90.8 residents a day — about 86% occupied, or roughly 14 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 3.53 on weekdays — 8% thinner on weekends. RN hours go from 0.71 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2026-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure monitoring and supervision for the safety of one resident (#1) out of three sampled residents. Resident #1 suffered a fall with major injury requiring transfer to a higher level of care for treatment. Findings included: Review of the report titled incidents by incident type for 1/1/2026 to 5/20/2026 showed Resident #1 as having an unwitnessed fall on 1/11/2026, 2/10/2026, 3/9/2026, and 4/12/2026. Review of Resident #1's progress notes revealed:4/12/2026 at 11:40 p.m. Resident returned back to facility from the hospital with a comminuted left humeral head fracture with surgical neck involvement and displacement of the greater tuberosity (meaning: a severe, multi-part break near the shoulder joint. It signifies the bone is shattered into multiple pieces, the main ball of the shoulder joint is damaged, and the rotator cuff attachment is pulled out of place).2/10/2026 at 3:31 p.m. Resident was pushing another resident in wheelchair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-22 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents were served food in a manner that was appealing in appearance and that was palatable for consumption for six (#1, #2, #3, #4, #5, and #6) of six sampled residents. Findings included: 1. On 10/22/2024 a review of photographic evidence provided by Resident #1's family member revealed Resident #1 had received a blue plate on her over the bed table with what appeared to be two diagonal cut sections of black toast. Further observation revealed the resident had received two grilled cheese sandwiches, both of which were totally black in color, burned, charred and not consumable. Four photographs of the burned and charred grilled cheese sandwiches were kept as evidence. It was determined the photos taken were taken in a manner showing Resident #1's personal belongings on the bed in the background, and it was evident she had received these burned and charred grilled cheese sandwiches. On 10/22/2024 at 1:45 p.m. Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-06 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon having a qualifying mental health diagnosis for 7 of 20 residents sampled (Residents #80, #54, #19, #62, #22, #52, and #33). Findings included: 1. Review of the admission Record showed Resident #54 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Dementia, psychosis, anxiety, pseudobulbar affect, and other comorbidities. Review of Resident #54's PASRR Level I Assessment, dated 4/30/2021 did not reveal a qualifying mental health diagnosis marked in section I A. Section 6 was marked yes for dementia with a suspected mental illness although a level II PASRR was not completed. Due to the diagnosis' Resident #54 should have a Level II PASRR requested. Review of the admission Record showed Resident #38 was admitted on [DATE] with diagnoses of Dementia, Parkinson's, Schizoaffective Disorder of the bipolar type; Mood Disorder, and other comorbidities. Review 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.
- Potential for harm · E2024-06-06 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 2. An observation on 06/03/24 at 9:13 a.m. revealed Resident #5 laid in bed with a bloody forehead. Further observation showed Resident #5 had a bloody area on the left side of her chest area. Resident #5 was non-verbal and did not response to Surveyor. During an interview on 06/03/24 at 9:13 a.m., Staff N Certified Nursing Assistant (CNA) stated Resident # 5 was known to pick her skin and she must have been picking this weekend as she had new picking spots especially on her chest. Review of the admission Record showed Resident #5 was initially admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's Disease, Dementia in other diseases classified elsewhere unspecified severity with behavioral disturbances, disorganized Schizophrenia and generalized anxiety disorder. Review of the Order Summary Report showed Resident #5 had the following orders: -Geodon Oral Capsule 40 [milligrams] mg (Ziprasidone HCl)- Give 1 capsule by mouth one time a day for schizoaffective disorder. Give…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-06 · 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
Based on observations and interview, the facility failed to ensure sufficient staff to meet the needs of 30 residents on one (400 - secure) of four units during mealtime and for 30 residents on one (400 - secure) of four units for activities over three (06/03/2024, 06/04/2024 and 06/06/2024) out of four days observed. Findings included: An observation was conducted on 6/3/24 at 10:50 a.m. of Resident #17 sitting in the dining room on the 400 unit. No staff were interacting with the resident, she had nothing at the table to do, and there were no activities going on. The resident remained in the same spot at 1:48 p.m. No staff interacted with the resident or provided any stimulation. No activities were observed throughout the day on 6/3/24. An observation was conducted on 6/3/24 at 11:59 a.m. during lunch service in the 400-unit dining room. Lunch trays were being set up for residents. There were only two staff members in the dining area to pass trays, set up food, and assist residents. Twenty-three residents were present in the dining area. One resident was wandering around 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 · E2024-06-06 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#342, #22 and #87) of three residents sampled. Findings included: 1. During an observation and interview conducted on 06/05/24 at 03:03 p.m., Resident #342 stated she had signed the arbitration agreement during orientation. She stated a young man came to the room the other day with a stack of papers and had her sign all kinds of paperwork. She said, To be honest I don't know what that is. Everything was mumbo jumbo (meaning confusing or meaningless). I told my husband to listen to him. The resident and surveyor reviewed the Arbitration Agreement with her signature dated 06/03/24. She said, Yes that is my signature. I don't remember him saying anything about waiving my rights. The resident stated the staff member may have explained those things. I just was not in my right mind. The resident stated I still do not understand it. The resident asked, why…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and policy review, the facility failed to ensure proper infection control practices during medication pass for three out of three observations, for one of one CPR backboard, and during dining on one (100) out of four hallways. Findings included: An observation was conducted on 6/4/24 at 9:09 a.m. of Staff H, Licensed Practical Nurse (LPN) during medication pass. Staff H was observed preparing medication for a resident, she then administered the medication, took two bottles of body cleanser another resident handed her, then returned to the medication cart and documented on the computer. During this process Staff H did not perform any hand hygiene. At 9:19 a.m. Staff H began pulling medication for a second resident. She left to get medication from the medication room and performed hand hygiene upon returning to the cart. Staff H continued preparing medication for the second resident, put on gloves and crushed/opened medication and placed in pudding, removed gloves, then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility did not ensure dignity was maintained for residents in one (400) out of two dining rooms and on one (200) out of four units related to staff standing while assisting residents with eating, not serving residents at a single table their meals at the same time, and having residents eat in the hallway. Findings included: An observation was conducted on 6/4/24 at 5:16 p.m. in the 400-unit dining room of a table with four residents seated. Three of the residents had their meals and were eating while the fourth resident (#79) did not have any food. At 5:21 p.m. Resident #79 was observed walking to the tray cart and asked why everyone had food but her. She said, I am having to wait. Staff A, Licensed Practical Nurse (LPN) walked up to the resident and the resident told Staff A she wanted her food. Staff A told Resident #79 someone would bring it to her in a minute. Staff A proceeded to leave the unit and stand in the hall talking with other staff members.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · 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 observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievance for one (Resident #30) out of three (3) residents sampled. Findings included: During an interview and observation on 6/4/2024 at 5:48 PM the Responsible Party (RP) of Resident #30 stated visiting the resident daily and assists with dinner and gets the resident ready for bed. The RP showed the brief that had just been taken off of Resident #30. The incontinent product appeared saturated with yellow liquid. The RP stated approximately 4 days out of the week when arriving Resident #30 has not been changed and the incontinent product is saturated. The RP stated, they [the facility] do not have enough staff to help with the population of residents on the 400 [memory care] unit. The RP states reporting these events to the nurse on multiple occasions. The RP states telling Staff A, Licensed Practical Nurse (LPN) multiple times including tonight. The RP continued to state staffing is probably the problem, as the unit (memory care unit) usually only has 1 Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-06 · 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 record review, interview, and policy review facility did not ensure Preadmission Screening and Resident Review (PASRR) Level 1 Screen was updated when new diagnoses were added for three residents (#9, #11, and #17) out of twenty-six reviewed for PASRR screening. Findings included: Review of admission Records for Resident #17 showed she was admitted on [DATE] and re-admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, symptoms and signs involving cognitive functions. Review of Resident #17's PASRR Level 1 Screen, dated 12/23/22, showed no diagnoses or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR not required. No mental illness or suspected mental illness were checked in Section I and dementia was indicated as No in Section II. Review of admission Records for Resident #17 showed during her stay a diagnosis of dementia was added on 10/1/22, anxiety disorder was added on 4/11/24, and persistent mood disorders 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 · Dcited before2024-06-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility's policies Care Plans, Comprehensive Person-Centered and Pain Assessment and Management, the facility failed to develop a care plan for pain management for one Resident (Resident #22) and diabetic management with insulin use for one Resident (Resident #80) out of twenty sampled residents reviewed for development of care plans. Findings included: During an interview on 06/03/24 at 9:48 a.m., Resident #22 stated, I had fallen prior to coming to the facility and broke my leg. Resident #22 stated her leg began to heal but was set wrong, so the hospital had to go in and rebreak it and set it correctly. Resident #22 stated after the procedure she came to the facility but stated she was in pain. Resident #22 stated the facility gave her something for pain but felt as though that pain medication did not help much. Resident #22 stated the facility offered her morphine, but she declined as she felt that was too strong and would prefer something stronger than…
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 14 citations
- Potential for harm · E2022-03-16 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure the Quality Assurance Committee was actively involved in the effective creation, implementation, and monitoring of the plan of correction (POC) for deficient practice identified during the annual recertification survey, conducted on 3/13/22 to 3/16/22. The facility developed a plan of correction with a completion date of 4/16/22. During a revisit survey conducted on 5/11/22 deficient practice was again identified at F758, F761, and F656 with an additional deficiency identified at F757. Findings include: The Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership policy, revised March 2020, identified that The quality assurance and performance improvement program was overseen and implemented by the QAPI committee, which reports its findings, actions, and results to the administrator and governing body. The interpretation and implementation of the policy indicated the following: - 1. 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 before2022-03-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure dependent diners were treated with dignity during a meal service for two (Residents #3, and #68) of two residents as evidence by staff assisting residents while standing next to the resident and above eye level. Findings included: 1. An observation on 3/13/22 at 12:15 p.m., identified that a meal cart was delivered to the 200-hall. On 3/13/22 at 12:47 p.m., Staff N, agency Certified Nursing Assistant (CNA), raised the bed of Resident #3 and offered the resident a cup of pink-colored liquid. Staff N stood against the bed and cut up the resident's food. Staff N was observed standing in between an over-the-bed table and bed and place an eating utensil into the mouth of the resident. Staff N pulled the privacy curtain toward the end of the resident bed and continued to assist the resident while standing up. Resident #3 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Alzheimer's Disease 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 · D2022-03-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure medication self-administration orders were in place for one (Resident #27) of 30 sampled residents. Findings included: During a facility tour on 03/13/22 at 9:55 a.m. to 10:48 a.m., medications were observed unattended on Resident #27's bedside table. The observed two tablets were in two separate plastic medicine dispensing cups. One of the tablets was a small round white pill. The second one was a large pink pill. (Photographic evidence was obtained) Resident #27 and her roommate were not in the room during the observation. The door was wide open. Review of the electronic medical record (EMR) for Resident #27 showed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia with behavioral disturbance, non-[NAME] Lymphoma, unspecified, and Gastro-esophageal Reflux disease. A review of the Minimum Data Set (MDS) for Resident #27 dated 01/07/22 showed a brief interview for mental status (BIMS) of 14…
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 before2022-03-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure care plan interventions and physician orders were followed for one (Resident #52) of five sampled residents related to catheter care. Findings included: During a facility tour on 03/13/22 at 9:24 a.m., Resident #52 was observed in her room. Resident #52's catheter was covered, urine discoloration was noted in the tubing. The urine was observed with a dark, tea color. On 03/15/22 at 9:35 a.m., Resident #52 was observed in bed. Her catheter was noted with dark brown and hues of red color. She stated that she did not feel very well. Photographic evidence of the catheter was obtained. An interview was conducted on 03/15/22 at 9:37 a.m. with Staff B, Licensed Practical Nurse (LPN). He stated he did not know there were concerns with the output and was not aware the resident was not feeling well. Staff B stated sometimes the resident preferred to lay in bed. He said, I gave her meds this morning. I did not notice anything unusual. Staff B…
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 · D2022-03-16 · 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 observations, record review, and interviews, the facility failed to ensure one (Resident #49) of thirty sampled residents , was set up and assisted with Eating Activities of Daily Living (ADL) during three meals. Findings included: On 3/13/2022 at 12:15 p.m., a staff member was observed to deliver a lunch tray to Resident #49. The staff member left after setting up the meal. Resident #49 was observed in her room alone and with no Eating supervision or Eating assistance. An interview with Staff H, Personal Care Assistant (PCA) revealed she was not sure if Resident #49 required Eating supervision or Eating assistance. At 12:24 p.m. the Director of Nursing entered Resident #49's room to assist her with eating. The Director of Nursing did not stay in the room the entire meal service, and left the room at 12:45 p.m. There were periods of time, at least fifteen minutes, when Resident #49 was left in her room with her lunch tray in front of her and with no staff present. When the meal tray was removed, it was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to apply splints and braces to one (Resident #57) of seven residents requiring the use of supportive devices. Findings included: Resident #57 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Alzheimer's disease, left knee contracture, swan-neck deformity of right fingers, unspecified polyosteoarthritis, and other specified joint contracture. The Quarterly Minimum Data Set, dated [DATE], identified that the resident had bilateral upper and lower extremity functional limitation in range of motion. An observation of Resident #57, on 3/14/22 at 10:24 a.m., revealed the resident was lying in bed. The residents' bilateral hands appeared to be contracted and a soft blue cylindrical device with an elastic band was observed lying on the blanket in front of the resident's left hand, no other upper extremity orthotic device was observed. On 3/15/22 at 11:14 a.m., Resident #57 was observed lying in bed with…
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 · D2022-03-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 record reviews, interviews, and observations, the facility failed to ensure two (#28 and #64) of three sampled residents for unnecessary medications received insulin within the accepted parameter of before meals as ordered by the physician. Findings include: 1. According to the admission Record, Resident #28 was admitted on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with diabetic cataract, and aphasia following cerebral infarction. A review of Physician Orders for Resident #28 on 5/11/22 revealed: - Novolin R Solution 100 unit/milliliter (mL) (Insulin Regular Human): Inject 5 unit subcutaneously with meals for Diabetes Mellitus (DM). - Novolin R Solution 100 unit/mL (Insulin Regular Human): Inject as per sliding scale: if 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 315-400 = 10 units. If greater than 400 give 10 units and call MD [medical doctor], subcutaneously before meals and at bedtime for DM. A review of Resident #28's May 2022 Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure psychotropic medications were monitored for patient-specific behaviors and staff documented observed behaviors for two (Residents #28 and #64) of five residents sampled for unnecessary medications. Findings included: 1. Resident #28 was admitted on [DATE]. The admission Record included diagnoses not limited to narcolepsy without cataplexy, unspecified convulsions, vascular dementia without behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, moderate recurrent major depressive disorder, and generalized anxiety disorder. The Order Summary Report, active as of 3/15/22, identified the following orders: - Antidepressant Medication - Bupropion. Monitor for weight gain, agitation, anxiety, insomnia, dry mouth, restlessness, fatigue, constipation, diarrhea, and headaches. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code…
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 · D2022-03-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for two (Resident s #44 and #16) of seven residents observed. These errors constituted a 7.69% medication error rate. Findings included: 1. On 3/14/22 at 4:26 p.m., an observation of medication administration with Staff S, Licensed Practical Nurse (LPN), was conducted with Resident #44. Staff S was observed obtaining a blood glucose level of 307 from the resident. Staff S placed an Insulin pen needle onto a Novolin R insulin pen, dialed the dosage selector to 2 units, held the pen with the needle pointing downwards, and expressed the 2 units. Staff S dialed the dosage selector to 8 units, re-entered the resident room, washed hands, and without gloves the staff member injected the insulin into the residents right arm. Staff S stated, on 3/14/21 at 5:49 p.m., she primed the Insulin pens to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to (1) ensure medications were inaccessible to unauthorized personnel, residents, and visitors as evidence by leaving ten Insulin pens on top of one (200-hall) of four medication carts and (2) ensure medications were not left at bedside for one (Resident #27) of 30 sampled residents Findings included: 1. On 3/14/22 at 4:16 p.m., a random observation of the 200-hall revealed the floor nurse was in room [ROOM NUMBER] and the medication cart was parked further down the hallway. The observation identified the following Insulin pens on top of a locked unattended medication cart: - three Levemir pens - one Lantus Solostar pen - two Novolog pens - two Novolin R pens - one Lantus pen - one Humalog pen Staff U, Registered Nurse (RN), returned to the cart, approximately a minute later, and confirmed the findings. Staff U confirmed the pens should not have been left on top of the cart. On 3/16/22 at 12:19 p.m., the Consultant Pharmacist stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-16 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure all essential members of the Quality Assurance Committee attended the meeting and were involved with the discussion and implementation of the plan of correction regarding the deficiencies identified during the annual recertification survey conducted on 3/13/22 to 3/16/22. Findings include: The roster of attendance for the Risk Management/Quality Assurance Committee meeting, dated 3/23/22, did not identify the Medical Director attended or was involved via other means. Also, the Medical Director did not attend or was involved in the Licensed Independent Practitioners (LIP) Credentialing Committee also held on 3/23/22. During an interview, on 5/11/22 at 4:02 p.m., the Nursing Home Administrator (NHA) reviewed the roster of attendees of the QAPI meeting on 3/23/22. She confirmed the roster did not identify the Medical Director had attended. She stated she had a hard time believing he was not there, and he must have forgotten to sign in. She stated after the exit conference for the annual survey on 3/16/22 she had a…
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 before2021-01-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not ensure that the residents on one (200 hall) of four wings sampled were treated with dignity during meal tray distribution in regards to not knocking and asking permission to enter residents' rooms. Findings included: On 1/12/2021 at 12:25 p.m. during the lunch meal service staff members (B, C, D and E) CNA's were observed to enter the following rooms without knocking and asking permission to enter: 201,204,205,206,207, 212, 214 and 215. Staff member (B) was asked if he was to knock before entering and ask permission, he acknowledge he was and had just forgotten. Staff member (E) was asked if she had received training on what to do before entering a resident's room, she reported that she was aware of knocking and asking permission but had forgotten to do so. An interview was conducted with the Director of Nursing (DON) on 1/14/2021 at 2:45 p.m. she was informed of the observations. She reported that she expected staff to follow policy and knock before entering and to ask for permission. The DON provided a policy…
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 · D2021-01-15 · 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 interview and record review the facility failed to ensure that the comprehensive care plan was revised to reflect residents' currents needs related to falls and Activities of Daily Living (ADL's) for 2 of 21 (#46, #65) sampled residents. Findings included: 1. Review of Resident #46's record revealed that this resident was admitted to the facility on [DATE] and had a fall risk assessment dated [DATE] with a score of 13.0 (High Risk); and a fall risk assessment dated [DATE] with a score of 12 (High Risk) Review of the residents progress notes revealed the following: -12/21/20-Informed by staff resident sitting on floor in room upon entering room noted resident sitting on floor next to bed on buttocks states he did not hit his head did not hurt himself request to get up assessed patient no injury noted able to move all extremities without difficulty notified family notified MD. -12/28/20-APRN progress note refers to a fall on 12/21/20 with no injury. -12/23/20-Psych note found on floor, med eval per staff.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-01-15 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer Intravenous medications (IV) consistent with physician orders for two (#59 and #48) of two residents receiving IV fluids. Findings Included: 1. An observation was conducted on 1/12/21 at 9:30 a.m. of Resident #59 lying in bed with an IV pole positioned by the bed near the door, IV fluids were not running. An observation was conducted of Resident #59 on 1/12/21 at 12:00 p.m. sitting up in bed drinking fluids during lunch. The IV was observed not running or attached to Resident #59. An observation conducted of Resident #59 on 1/12/21 at 2:45 p.m. revealed the IV pole without an IV bag; a replacement IV bag was on the bedside table with IV tubing. Staff member O, LPN was present and stated that the resident pulled out the IV last night some time and the IV team will be coming to put the IV back in. Staff member O, LPN stated she is not certified to insert the IV but Staff member N, LPN Supervisor can start the IV when the IV team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HEALTH SERVICES MANAGEMENT — 16 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 | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 2.6 | +1.4 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 15 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HEALTH SERVICES MANAGEMENT, INC. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 10/01/2000 |
| NATIONAL HEALTH INVESTORS, INC. | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 02/20/2008 |
| NHI-REIT OF FLORIDA, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 02/20/2008 |
| BAXTER, KEVIN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/20/2008 |
| FISHER, SCOTT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/20/2008 |
| JACKSON, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/20/2008 |
| SHATZ, JIM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/20/2008 |
| WHITE, JOSHUA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/20/2008 |
| DILELLA, VINCENT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2022 |
| FLORES-DEJESUS, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/18/2023 |
CMS files one row per role, so the 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% 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 $422K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
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 105343. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-06, 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 →
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