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Life Care Center Of New Port Richey

7400 Trouble Creek Road, New Port Richey, FL 34653 · For profit - Corporation · 113 certified beds · (727) 375-2999 Medicare & Medicaid certified

Call the home — (727) 375-2999 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 21% 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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4740 Rowan Rd · (727) 800-4393 · Call to confirm hours
Pharmacy
4140 Rowan Rd · (727) 372-1070 · Call to confirm hours
Grocery
6445 State Road 54 · (727) 834-9774 · Call to confirm hours
Park
7425 Trouble Creek Rd · (727) 599-4958 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.5%8.7%15.4%better
Long-stay residents who lose too much weight8.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.7%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.1%2.5%3.3%typical
Long-stay residents whose ability to walk worsened7.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.1%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.7%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control7.7%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table1.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.3%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.6%94.7%79.4%better
Short-stay residents rehospitalized after admission28.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.3%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.622.131.67typical
Long-stay outpatient ER visits per 1,000 resident days1.341.151.80better

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.

52.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 370 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.3%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
89.3%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.20hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 89.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 205 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.3%CMS range 48.2–59.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 7.2–12.210.7%Oct 2022–Sep 2024no 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 discharge89.3%56.6%Oct 2024–Sep 2025CMS 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 discharge84.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge71.7%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting90.1%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 5.1–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 2022–Sep 2024CMS 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

0.89
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.26
Aide hours/ resident / day
3.98
Total nurse hours/ resident / day
0.75
RN hoursweekends
37.4%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 113 beds and averages 107.9 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.67 hrs/resident/day on weekends vs 4.11 on weekdays — 11% thinner on weekends. RN hours go from 0.95 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

10
deficiencies at the latest standard inspection (2025-03-05)
6
at the previous standard inspection (2023-04-19)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · E2025-03-05 · tag F0565 — failed to support the resident council — pattern
    Honor 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 interview and record review, the facility failed to ensure resident council grievances were fully and promptly acted upon, for ten of ten resident council members who regularly attend the resident council meetings. Findings included. On 3/3/25 at 11:10 a.m., a resident council meeting was held with ten participants. The group confirmed on-going complaints related to the following: - Related to call lights - Sometimes it takes a while for them to answer, depending on who's on duty. Day shift is great, second shift is good, third shift is not so great. We have told the nurses .They don't have enough staff. When one pushes the bubble, no one comes. This has been discussed in council meetings. - They keep saying they are short of help. We have reported to staff. When they are short they pull restorative staff, which means restorative is not offered that day . - Call lights take too long to answer at night. They refuse to wear name tags, so you don't identify them. _ They said they will give us more TV stations. 10 or more they said. We voted which ones we wanted . there are not…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-05 · tag F0645 — pattern
    PASARR 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 record review and interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for six (#12, #57, #66, #30, #73, and #84) of 23 residents reviewed for PASRRs. Findings included: 1. Review of a level I PASRR for Resident #12 dated 8/9/22, showed the resident was screened upon admission for MI (mental illness) or suspected MI. The review showed the resident had diagnoses of Anxiety disorder, Bipolar disorder and depressive disorder. The review showed diagnoses of Bipolar disorder and depressive disorder were not indicated and the level I PASRR was not revised. Review of a level II screening and determination summary report showed during the time of submission, on 06/28/23 the diagnoses of Bipolar, dementia and major depression were not included for consideration. 2. Review of a level I PASRR for Resident #57 dated 9/9/20, showed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-05 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure 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 observation, interview and record review, the facility failed to ensure competent staff were available to provide skilled nursing care and services related to (1.) Failure to monitor resident's access to food allergens for two residents (#163 and #66), 2. Failure to ensure dressings were dated for one resident (#73), 3. Failure to follow up on a physician order with a black box warning for one resident (#264), 4. Failure to provide nutrition services for one resident (#91), and 5. Failure to provide hydration for three residents (#91, #16, and #49) of 58 sampled residents. Findings included: 1. On 03/04/25 at 8:31 a.m., Resident #163 was observed in her room eating breakfast. The resident stated she was served wheat, and she was allergic. She said, this is not the first time. last night I was served milk. I am allergic. The resident stated she had requested an alternate, almond milk and had not received it. Observation of the resident's plate revealed the resident ate approximately 1/3 of pureed bread…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two (#108 and #110) of fifty - six sampled residents. Findings included: 1. Resident #108 was admitted to the facility on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus without Complications, Acute and Chronic Respiratory Failure with hypoxia, Major Depressive Disorder, Recurrent, Moderate Review of Resident #108's Minimum Data Set (MDS) dated [DATE], Section A- Identification Information revealed section A2105- Discharge Status was coded number 01 which indicated the resident discharged to home/ community. Review of a change in condition dated 12/17/2024 revealed Resident # 108 was transferred to the hospital for further evaluation and treatment for altered mental status, increased lethargy, no urinary output. Record review revealed Resident #108 Minimum Date Set (MDS) dated [DATE] was coded inaccurately revealing the resident was coded…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation interview and record review, the facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident (#162) of three residents reviewed for comprehensive assessments. Findings included: Review of a facility document titled Nutrition At Risk dated 2/27/25 showed Resident #162 had the following weights recorded: -On 2/18/25 the resident weighed 114.6 lbs. (pounds). - On 2/25/25 the resident weighed 108.6 lbs. - On 2/26/25 the resident weighed 102.8 lbs. The review showed a 10.53% weight loss. Review of a care plan last updated on 2/24/25 showed resident #162 - has nutritional problem related to Advanced age, Right Femur fracture with hemi-arthroplasty, Weakness, Dysphagia on altered diet consistency, Chronic Constipation, Dementia, and variable intake with refusals at times. The goal section showed - The resident will maintain adequate nutritional status as evidenced by maintaining weight at 115# with no significant change through 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-05 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure activities of daily living (ADLs) were completed and maintained for one (#91) of three residents sampled related to meals/snacks and three (#91, #16 and #49) of 23 residents sampled for hydration. Findings included: 1. During an interview on 03/02/2025 at 10:53 a.m., Resident #91 was observed lying in bed dressed for the day. Resident #91 stated she had had some weight loss, but had lost more because she had not felt like eating. During an observation on 03/03/2025 from 10:45 a.m. to 12:45 p.m., Resident #91 was observed sitting in a wheelchair in the activities room of the 100 unit. Resident #91 was observed to have no hydration. Her lips were noted to be dry and cracked. During an observation on 03/03/2025 at 12:48 p.m., Resident #91 was observed sitting in a wheelchair in the hallway. Staff was observed telling Resident #91 that she had a doctors appointment and they needed to get her ready to leave the facility. During an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, and interview, the facility failed to follow-up on a physician order with a black box warning for one resident (#264) of fifty-one residents sampled. Findings included: On 03/4/2025 at 9:00 am., an observation was made revealing Staff P, License Practical Nurse (LPN) on the phone with the pharmacy ordering medication for Resident #264. On 03/04/2025 at 9:21 am, an interview was conducted with Staff P. She stated Resident #264 was out of his Dronedarone Hydrochloride (HCI) 400 Milligram (MG), a medication he took for Arrhythmia. Staff P stated she believed Resident # 264 was only out of the medication today, that was why she called in a STAT (immediate) order for the medication. She stated she would fax the request over to pharmacy as soon as possible. Review of Resident #264's admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include but not limited to Paroxysmal Atrial Fibrillation, Presence of Cardiac Pacemaker. Review of the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-05 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Twenty-nine medication opportunities and 3 errors were identified for two residents (#102 and #361) of four observations, resulting in an error rate of 10.34% Findings included: On 3/3/25 at 8:12 a.m., during medication administration observation Staff J, Licensed Practical Nurse (LPN) was observed administering the following medications to Resident #361, Bupropion ER 100MG, Sertraline HCl 100 mg, Olanzapine 5MG, Calcium Carbonate 600mg, Cholecalciferol 1000 UNIT, Lidocaine 5% patch, Losartan Potassium 50 mg, Metoprolol ER 625mg, Multiple Vitamins with Minerals 1 tablet, Vitamin B Complex with Vitamin C 1 tablet, Vitamin C 250 mg and Aspirin 81 mg low dose EC 1 tablet. A review of the order summary report dated 3/4/25 showed Resident #361 did not receive Aspirin 81 mg Delayed Release and Vitamin B Complex as ordered. On 3/3/25 at 8:49 a.m., during medication administration observation Staff E, Registered Nurse (RN) administered the following medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 observation, interview, and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for five (#265, #63, #12, #164 and #18) of 58 sampled residents. Findings included: 1. On 3/2/25 at 11:32 a.m., an observation in Resident #265's room revealed a medication bottle, labeled Custom medication crafted for (Resident #265). The medication name was CA/MAG/[NAME] 8/2/12/89 %, apply to treatment area one to two times daily. The medication was observed on a table in the resident's room. Review of the admission Record for Resident #265 showed the resident was admitted to the facility on [DATE] with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina protectors. Review of active physician orders for Resident #265 dated 3/5/25 did not show an order to administer the medication. 2. On 3/2/25 at 10:20 a.m. an albuterol inhaler was observed on Resident #63's bedside table. The resident stated it was her rescue…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-05 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 food that accommodates resident allergies, intolerances, and preferences was served for one (#163) of four residents reviewed for nutrition. Findings included: On 03/04/25 at 8:31 a.m., Resident #163 was observed in her room eating breakfast. The resident stated she was served wheat, and she was allergic. She said, this is not the first time. last night I was served milk. I am allergic. The resident stated she had requested an alternate, almond milk, and had not received it. Observation of the resident's plate revealed the resident ate approximately 1/3 of pureed bread and one scoop of cream of wheat. Review of an admission Record for Resident #163 revealed an admission date of 2/27/25 with diagnoses to include Dysphagia. Review of the Resident Information showed under allergies: iodine, Tetracycline, milk and wheat. Review of the Resident #163's care plan revealed prior to the observation and interview, the resident did not have a focus related to food allergies. A focus initiated on 3/5/25 showed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-03-05 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 complete a significant change assessment within 14 days of determining a weight loss for one (#162) of four residents reviewed for nutrition. Findings included: Review of a facility document titled Nutrition At Risk dated 2/27/25, showed Resident #162 had the following weights recorded: -On 2/18/25 the resident weighed 114.6 lbs. (pounds). -On 2/25/25 the resident weighed 108.6 lbs. -On 2/26/25 the resident weighed 102.8 lbs. The review showed a 10.53% weight loss. Review of the Minimum Data Assessments (MDS) section showed there were no documented assessments relate to a change in status for Resident #162. On 03/02/25 at 10:38 a.m., Resident#162 was observed in the dayroom visiting with family members. The family members stated the resident had lost a lot of weight and did not eat very much anymore. Review of the admission record for Resident #162 revealed the resident was admitted to the facility on [DATE] with diagnoses to include…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-21 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with facility staff and family members, the facility failed to notify the Resident Representative (RR) of a significant change in the resident's health status that resulted in acute care for one (Resident #1) of three residents reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, major depressive disorder, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An SBAR (Situation Background Assessment Recommendation) form dated 1/14/24 at 8:50 p.m., showed the resident presented with nausea, vomiting, labored or rapid breathing and shortness of breath which had gotten worse. The form did not indicate that family or RR were notified. A physician note dated 01/14/24 9:04 p.m. showed under description: OBC (outbound call to family. I reported the CIC (change in condition and the orders put in place. She (RR) 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 interviews and record review, the facility failed to ensure timely assistance was provided for ADLs (Activities of Daily Living) for one (Resident #2) of two sampled residents reviewed. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses to include emphysema and unspecified dementia. A review of the care plan for Resident #2 showed a goal revised on 2/16/23, indicating the resident required ADL assistance and therapy services needed to maintain or attain highest level of function. Interventions included: assist with mobility and ADL's as needed, therapy services as ordered. During a facility tour on 02/20/24 at 11:15 a.m., the hall outside Resident #2's room was noted with a strong bowel (BM) movement odor. Resident #2 did not respond to the interview. An attempt to locate the Certified Nursing Assistant (CNA) or the Nurse assigned to this hall was unsuccessful. On 02/20/24 at 11:18 a.m., an interview was conducted with Staff M, Licensed Practical Nurse ( LPN.) She 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 review and interview, the facility failed to ensure an advance directive was accurate in the medical record for one (Resident #257) of thirty-two sampled residents. Findings included: A review of the admission Record showed Resident #257 was admitted into the facility on [DATE] with a principal diagnosis of other fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing. The form also indicated the advance directive was full code. The Social Services Assessment signed [DATE] revealed a code status of full code. The form also showed Resident #257 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. The Medication Review Report with an on and after date of [DATE] revealed the following orders for advance directives: [DATE]- Do Not Resuscitate (DNR) and [DATE]- full code. The My Advance Directive form from a local hospital signed by the resident and dated [DATE] at 4:05 p.m. showed Resident #257 did not want…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form to two (Residents #94 and #49) that were terminated from Medicare Part A Services that included physical therapy, occupational therapy, speech therapy, and nursing services, but would remain living in the facility. Findings included: A review of the admission Record for Resident #94 revealed she was admitted into the facility on [DATE] with a principal diagnosis of atherosclerosis of native arteries of left leg with ulceration of heel and midfoot. A review of the SNF Beneficiary Protection Notification Review form completed by the Administrator showed Resident #94's last covered day of Part A Service was 02/06/23 and the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The form indicated the resident was only issued the Notice of Medicare Non-Coverage (NOMNC) form. A review of the admission Record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident assessments accurately reflected the resident's status for one (Resident #39) of 32 sampled residents related to assessments. Findings included: Observations of Resident #39 on 4/16/23 at 12:50 p.m. revealed the resident seated in the 100 hall common room in her motorized wheelchair. Closer observations at this time revealed the resident had a clip seatbelt attached around her lower trunk which was also noted to be attached to her wheelchair. A family interview on 4/17/23 at 9:25 a.m. revealed she was the resident's daughter and joint Power of Attorney (POA) with her sister. She reported she was not aware of the seat belt being in use, but thought the chair came with the seat belt already attached. She reported the facility was probably using the seatbelt for safety as her mother had falls in the past. Review of Resident #39's record revealed she was originally admitted to the facility on [DATE] and re-admitted on [DATE].…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-19 · tag F0644 — isolated
    Coordinate 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 and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a qualifying mental health diagnosis for five (Residents #257, #25, #24, #82, and #4) of thirty-two residents sampled for PASARR Level II. Findings included: 1. A review of the admission Record showed Resident #257 was admitted into the facility on [DATE] with a diagnosis of major depressive disorder with an onset date of 04/01/23. Review of Resident #257's PASARR Level I Screen dated 03/22/23, completed at a local hospital, revealed no qualifying mental health diagnosis and the Level II PASARR evaluation was not required. 2. A review of the admission Record showed Resident #25 was admitted into the facility on [DATE] with diagnoses of paranoid schizophrenia, brief psychotic disorder, bipolar disorder, current episode depressed, mild or moderate severity, unspecified, and generalized anxiety disorder with on onset date of 03/23/23. Review of Resident #25's PASARR Level I…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, record review, and interview, the facility failed to revise the care plan for one (Resident #24) of thirty-five sampled residents related to code status. Findings included: A review of Resident #24's admission Record indicated the resident had been admitted to the facility on [DATE] with diagnoses that were not limited to Multiple Sclerosis, unspecified heart failure, and unspecified chronic obstructive pulmonary disease. A review of Resident #24's care plan, on [DATE] at 2:28 p.m., included a focus that identified the resident as (resident) has Advance Directives Cardiopulmonary Resuscitation (CPR) - Full code. Certificate of Terminal Illness (CIT) in place. The focus was initiated on [DATE] and revised by Staff G, Minimum Data Set Licensed Practical Nurse (MDS, LPN) on [DATE]. The interventions attached to the residents' advance directives included the following: - Code status will be reviewed on a quarterly basis and as needed (prn), initiated [DATE]. - Resident has decided to remain 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was below 5.00%. A total of twenty-seven medications were observed, and two errors were identified for two (Residents #8, #78) of four residents observed. These errors constituted a medication error rate of 7.41 percent. Findings included: On 04/19/2023 at 08:00 a.m., an observation of medication administration with Staff F, Registered Nurse (RN), was conducted with Resident #8. Staff F was observed administering medication Trelegy Ellipta Inhalation one (1) puff inhaled. The resident inhaled two (2) puffs and then was observed to be given a clear medication cup of 09:00 a.m. medications with water. Resident #8 swallowed the medications with water and did not rinse her mouth during the observation. Review of the pharmacy label for the above medication read Wait one minute between inhalation and rinse mouth after use. A review of the Medication Administration Record (MAR) for Resident #8 showed the medication was scheduled to be administered at 10:00 a.m., and not at 08:00 a.m.…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, interview, and record review the facility failed to ensure new and adequate interventions and supervision measures were in place following repeated falls with injury for one (Resident #14) of three sampled residents. Findings Included: Review of the facility matrix report (resident data report) revealed that Resident #14 had a fall with injury in the past 90 days. The facility's incident log for the date range of 04/12/21-07/12/21 revealed the resident had five unwitnessed falls: 05/01/21; 06/15/21; 06/18/21; 07/03/21; 07/06/21. Observation was conducted in Resident #14's room on 07/13/21 at 12:25 p.m. She was observed lying on her back in bed with the head of bed raised, the bed was not in a lowered position, there were no mats on the floor. The call light was observed in reach. The resident engaged freely with some confusion noted. She confirmed she had fallen in the facility, said she did not get hurt, and said she did not know why she was falling. At 12:23 p.m. on 07/13/21 the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 record review and interviews, the facility failed to prescribe when necessary (PRN) psychotropic medication within the acceptable duration of use for one (Resident # 17) of five sampled residents who were reviewed for unnecessary medications. Findings included: Resident # 11 is a [AGE] year-old female originally admitted to the facility on [DATE] and a readmission date of 9/22/2020. Diagnoses included, multiple sclerosis, functional quadriplegia, chronic pain syndrome, post-traumatic stress disorder, major depressive disorder and generalized anxiety. A review of Resident #11's quarterly minimum data set (MDS) section C dated 7/12/2021 revealed that she was cognitively intact. Section D had no reported concerns related to mood; and section D did not indicate that resident was exhibiting any behavioral symptoms directed to herself or others. A review of Resident #11's physician order date 7/1/2021 revealed an order for Alprazolam 1 milligram(mg) every 6 hours by mouth PRN for anxiety. Order 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 medication error rate was below 5.00%. A total of twenty-five medications were observed administered and three errors were identified for three (Residents #72, #91, and #99) of three residents observed. These errors constituted a medication error rate of 12 percent. Findings included: An observation of the 200 Hall medication administration on 07/13/2021 at 09:11 a.m., resulted in Staff F, Licensed Practical Nurse (LPN), giving Resident #91 Stiolto Respimat (Tiotropium/Olodaterol), 2.5 microgram (mcg) inhaler which had instructions on the label to administer 1 puff inhale orally one time a day. Staff F (LPN) administered to Resident #91 two (2) puffs of the medication instead of one (1) puff. Staff F (LPN) was asked what the directions for the medication were and she turned to the Medication Administration Record (MAR) and showed the surveyor Symbicort Aerosol MCG/ACT (Budesonide-Fomoterol Fumarate), 2 puffs inhale orally two times a day for Shortness of Breath (SOB) and Pneumonia (PNA). 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-07-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to appropriately secure medications in five (100, 200, and 300 Halls) of five medication carts. Findings included: On 07/15/2021 at 10:23 a.m., an observation was conducted of Medication Cart #2 located on the 100 Hall and the findings were as follows. In the second drawer from the top of the medication cart there were two loose ½ white tablets, and one loose ¼ piece of a tablet. The third drawer from the top of the medication cart included four and 1/2 loose tablets. Staff A, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured tablets. On 07/15/2021 at 10:45 a.m., an observation was conducted of the Medication Cart #1 located on 100 Hall, which included in the second draw from the top of the medication cart unsecured tablets. Staff B, (LPN) confirmed the presence of one orange capsule, one white oval tablet, two round yellow tablets, one round tablet and two pieces of ½ a tablet. (Photographic Evidence Obtained.) On 07/15/2021 at 11:00 a.m., an observation was conducted of Medication Cart…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation of medication administration and of medication storage carts, both with facility nurses, review of facility documents and interview with facility staff including the Director of Nursing and the Administrator, it was determined the quality assessment and assurance committee failed to implement appropriate plans of action related to the facility's plan of correction for education and competency not being fully implemented and their auditing tools, even with identification of the continued concern of expired medications, were not changed to ensure compliance. Findings included: 1-During a revisit survey, conducted on 09/09/2021 to ensure compliance with regulations cited on a recertification survey (07/12 - 07/15/2021), the facility's plan of correction was reviewed. The plan of correction for administering medications without error included educating licensed nurses to ensure discontinued medications were removed from the medication cart so they couldn't be administered to residents inappropriately, ensure medications were administered to residents in compliance…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 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 →

RatingThis homeChain avg
Overall 4 of 53.4+0.6 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; 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 / managerTypeRoleSince
DEVELOPERS INVESTMENT COMPANY II, INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 08/27/2002
PRESTON, FORRESTIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 02/26/2019
BLANK, WENDYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 09/26/2023
EDMISTER, LEEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2025
PRESTON, AARONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 11/01/2018
CROSS, CINDYIndividualCORPORATE OFFICERsince 10/29/2002
HENRY, TERRYIndividualCORPORATE OFFICERsince 08/16/1999
LAY, LISAIndividualCORPORATE OFFICERsince 02/09/2018
SWANKER, RICHARDIndividualCORPORATE OFFICERsince 04/01/2011
THURMOND, JOANIndividualCORPORATE OFFICERsince 10/29/2002
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2025
NEW PORT RICHEY MEDICAL INVESTORS, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2003
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
FORTNER, FLORENDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/13/2024

CMS files one row per role, so the 25 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$14.1M
Net patient revenuemost recent cost report
+0.1%
Operating marginrevenue minus expenses
$2.9M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 19%Other / private 22%

This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$364per resident / day
operating cost
$11,053per month
≈ monthly operating cost
$364per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

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.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

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 106049. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-05, 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.

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