Southern Pines Nursing Center
6140 Congress St, New Port Richey, FL 34653 · For profit - Limited Liability company · 120 certified beds · (727) 842-8402 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
- about 17% of its spending goes to commonly-owned related companies
- 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 | 5.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.6% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| 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 | 1.6% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 6.6% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.0% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 13.1% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.9% | 10.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.7% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 78.6% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.2% | 9.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.94 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.87 | 1.15 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
45.2% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 26.8% 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 71 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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 | 45.2%CMS range 31.7–64.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.0–15.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 26.8% | 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 | 15.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 19.7% | 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 | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 90.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 92.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.2–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 93.4 residents a day — about 78% occupied, or roughly 27 beds typically open. It usually has some room. 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 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.20 hrs/resident/day on weekends vs 3.54 on weekdays — 10% thinner on weekends. RN hours go from 0.63 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above 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 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.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-24 · 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 provide supervision to a known wandering resident resulting in an incident of potential sexual abuse for two residents (#8 and #9) out of three residents sampled. On 05/30/2026, facility staff became aware that Resident #9, who was cognitively impaired, had entered Resident #8's bed while both residents were fully unclothed. The facility did not implement immediate protective measures consistent with their policy. Findings included: On 06/24/2026 at 02:36 PM, Resident #9 was observed self propelling through D Hall without staff present. Resident #9 did not answer questions, and continued past her own room, and approached the threshold of another resident's room. At 02:48 PM the same day, Resident #9 was observed self propelling from the dining room toward the area between A Hall and B Hall, without staff supervision. During an interview on 06/24/2026 at 02:12 PM, Resident #8 stated that on 05/30/2026, Resident #9 came into his room,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-11 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide a clean, comfortable, sanitary, and homelike environment in four halls (A, B, C, D) of four hallways and one of one dining room. Findings included: The following observations were made on 6/11/25: - At 9:20 a.m. a treatment cart parked in the dining room beside the exit door to the courtyard. The cart was empty and unlocked, on top of the cart were crumbs of an unknown substance, a piece of black fabric, and the front of the cart was stained with brown and black substances, the cart appeared to be unclean and unsanitary. On the floor next to the cart was a piece of white paper and a plastic domed lid with a brown liquid attached to it. The floor surrounding the cart was unclean and scuffed. The observation revealed a white piece of paper and a clear piece of plastic against the wall opposite of where the cart was parked in the dining room. The floor was unclean. At the time of the observation no residents were eating a meal in the dining room. Staff B, Certified Nursing Assistant (CNA) reported being unsure how…
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 · E2025-06-11 · 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 Based on interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice related to performing weekly skin checks for four residents (#1, #3, #5, #6) out of five sampled residents. Findings included: 1. Review of Resident #3s admission Record showed the resident was admitted on [DATE] and discharged to the community on 3/13/25, residing at the facility for a total of 15 days. The record revealed diagnoses not limited to prediabetes, morbid (severe) obesity due to excess calories, and generalized muscle weakness. Review of Resident #3s nursing assessments showed the resident was evaluated on 2/27/25 for an admission/readmission. The clinical record did not reveal a skin evaluation/check was completed during the fifteen days the resident resided at the facility. The admission/readmission evaluation revealed the resident had redness to buttocks. The progress notes did not reveal licensed nursing had completed a weekly skin evaluation/check for 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 · E2025-06-11 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of Resident #3's admission Record revealed the resident was admitted on [DATE] from an acute care hospital. The record included diagnoses not limited to other idiopathic peripheral autonomic neuropathy, unspecified chronic obstructive pulmonary disease, unspecified cord compression, and generalized muscle weakness. The resident discharged to a private home on 3/13/25. An interview was conducted on 6/11/25 at 1:57 p.m. with the Director of Rehab (DOR). The DOR stated all new admissions are evaluated or screened by therapy. The DOR reported remembering Resident #3 did participate in physical and occupational therapies. A review of the therapy notes for both disciplines revealed the resident did not miss any scheduled visits. Review of Resident #3's assessments did not reveal any Daily Skilled Nursing notes were completed for the resident.Review of Resident #3's progress notes showed no nursing notes had been completed after the residents' admission. The progress notes showed Physician/Practitioner notes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to promptly notify the resident representative of a room change for one resident (#4) of three sampled residents. Findings included: Resident #4 was admitted on [DATE] and discharged on 04/16/2025. Review of the admission Record showed diagnoses included but not limited to fracture of the left femur, history of falling, hypertension, anemia, urine retention, and weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 09 or moderately impaired. Review Resident #4's progress notes lacked any documentation regarding the room change that occurred on 04/09/2025 from room A2A to A5A. Review of a Social Services Director's (SSD) progress note read: On 04/11/2025 at 10:12 a.m. Resident #4 will be moving from A5A to A3A due to family request. Resident was notified of the room change on 04/11/2025. The resident representative was notified, the family member…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow standard infection control practices related to hand hygiene and cleaning of resident care multi-use equipment. Findings included: On 06/11/2025 at 9:55 a.m. Staff A, Licensed Practical Nurse (LPN) was observed entering room A-3 which had Contact Precaution signage on the outside of the door. Staff A placed a blood pressure cuff on Bed A's, Resident #8's lower right arm. While waiting for the blood pressure to be performed Staff A placed her right hand on the footboard of the bed. Staff A removed the blood pressure cuff, exited the room and placed it on the medication cart. Staff A did not hand hygiene nor clean the blood pressure cuff. Staff A documented the blood pressure on her paperwork. Staff A moved the medication cart across the hall to room A-11. Staff A was approached by another staff member, and she went down the hall with the staff member. Staff A opened the wound care cart and removed items and returned to the medication cart without performing hand hygiene. Staff A started performing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances and progress toward a resolution for concerns expressed in Resident Council Meetings by three residents (#63, #52, and #23) of 36 sampled residents. Findings included: A review of the facility's the Resident Council Minutes from 9/12/2023 at 10:00 a.m. revealed the residents were voicing complaints regarding receiving clothing back from the laundry. (Photographic Evidence Obtained) An interview was conducted with Resident #63 on 10/16/23 at 10:10 a.m. During the interview Resident #63 stated, I had a lot of expensive stuff, now it's gone. They told me to write my name on my stuff, I did, and it didn't make a difference. Yes, I told them, and they said I needed to go to the clothing drive. I told them what's that got to do with my missing stuff. I don't trust them. I don't trust them when it comes to my clothes. An interview was conducted with Resident #52 on 10/16/23 at 11:35 a.m. During the interview Resident #52 stated, Oh, it's bad. You can ask anybody . They just keep saying…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-19 · tag F0641 — patternEnsure 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 3. A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in bed, covered with a sheet and arms above the sheet. Resident #33's right and left hands were folded at the metacarpophalangeal joints (MCP aka knuckles). During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure 1) medications on one medication cart (A-wing cart) were secured while unattended, 2) insulin pens and vials were dated in one medication cart (B-wing cart), 3) bottles of ophthalmic solutions were dated and internal/external medications were not stored in the same compartments on one medication cart (C-wing cart) of four medication carts observed. Findings included: An observation was made on 10/18/23 at 8:19 a.m. of medication administration with Staff G, Licensed Practical Nurse (LPN) for Resident #33. The nurse dispensed one Multivitamin over the counter (otc) tablet, one Vitamin C otc tablet, and one Zinc otc tablet from separate bottles. The staff member left the three otc medication bottles sitting on the unlocked and unattended medication cart (A-wing cart) as the medications were administered in the resident's room. The medication cart was parked in the hallway and to the side of the doorway to the resident's room. An observation was conducted with Staff N, Registered Nurse (RN) on 10/18/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · 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 2. During an observation of medication administration on 10/18/23 at 8:21 a.m. with Staff G, LPN the following medications were dispensed for Resident #37: -Buspirone 10 milligram (mg) tablet -Folic Acid 1 mg tablet -Diltiazem 120 mg tablet -Montelukast 10 mg tablet -Spirolactone 50 mg tablet -Xifaxan 550 mg tablet -Potassium 20 milliequivalents (meq) Extended Release (ER) tablet -Omeprazole 20 mg over the counter (otc) tablet -Iron 325 mg otc tablet -Magnesium oxide 400 mg tablet otc. Staff G, LPN placed the tablets in a medication cup while dispensing and when asked to confirm there were 10 tablets, Staff G poured the tablets out of the cup and onto an 8x11 piece of paper lying on the medication cup. Staff G put the tablets back into the cup with bare hands including a couple that had rolled off the paper and onto the top of the medication cart. Staff G confirmed 10 tablets and turned toward the doorway of Resident #37's room. Based on observation, interview, and record review, the facility failed to maintain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2023-10-19 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 honor a resident preference to have medication administered at a later time in the morning for one resident (#75) of five residents sampled. Findings included: An interview was conducted with Resident #75 on 10/16/2023 at 1:18 PM. Resident #75 stated, I didn't sleep well last night as the facility insists on giving me my medication before the sun is up. I keep telling them, I don't want to be woken up until after 7:00 AM. They don't listen, I have told them numerous times and continue to tell them not to wake me up. A review of Resident #75's electronic Medication Administration Record (eMAR) revealed a note, dated 8/22/2023 at 5:00 AM that showed, resident does not want to be woke up for meds this early. A review of Resident #75's progress note, dated 8/24/2023 at 11:14 AM, revealed APRN [APRN] (advanced practice registered nurse) in to see resident, new orders for different time on hydralazine due to resident refusals of the 6:00 AM dose. Resident is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · 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, record reviews, and interviews the facility failed to develop and implement a care plan related to: 1. smoking for one resident (#82), 2. lack of range of motion for one resident (#33), and 3. related to the changes in one resident's (#78) mood, behavior and new medications for depression and anxiety out of thirty-three sampled residents. Findings included: 1. An observation and interview was conducted on 10/16/23 at 10:51 a.m. with Resident #82. The resident confirmed he smoked while at the facility. The resident stated staff members are always with the residents while smoking and the facility keep all cigarettes and lighters. On 10/18/23 at 10:49 a.m. Resident #82 was observed walking the facility's hallway. A review of the admission Record for Resident #82 revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record showed the resident had diagnoses not limited to other encephalopathy, fracture of unspecified part of neck of unspecified femur subsequent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · 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
Based on observations, interviews, and record reviews the facility failed to ensure one resident (#33) of two sampled residents received treatment and services to prevent further decrease in range of motion. Findings included: A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with diagnoses of cerebrovascular disease (stroke), peripheral vascular disease, muscle weakness and other co-morbidities. A review of Resident #33's Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 8/14/2023, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. Resident #33 was observed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure respiratory equipment was changed and maintained in a sanitary manner for one resident (#60) out of one resident sampled for receiving respiratory therapy. Findings included: On 10/16/23 at 10:01 a.m. Resident #60 was observed wearing a nasal cannula which was attached to an oxygen concentrator. The concentrator showed the resident was receiving 3 liters per minute (lpm) of oxygen. An additional observation of the nebulizer machine on the table next to the resident's bed revealed tubing attached to the machine with an aerosol mask. The tubing was dated 10/01/23. The mask was lying directly on the table and not in a storage bag or standing in the slot provided on the machine. On 10/17/23 at 10:39 a.m. Resident #60 was observed sitting in a wheelchair next to the bed wearing a nasal cannula, and the nebulizer mask was sitting on the round table in front of the resident. On 10/19/23 at 8:42 a.m. Resident #60 was observed lying in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide psychological and behavioral health care services to maintain the highest practicable mental and psychosocial well-being for one resident (#60) out of three residents sampled for emotional and mood behaviors. Findings included: An observation and interview was conducted on 10/16/23 at 9:55 a.m., with Resident #60. The resident was very hard of hearing and stated, This is no way to live, and for the last couple of weeks felt if only he had a Couple white pills. The resident stated, Should talk to a mental health specialist. The resident did report he informed others of suicidal thoughts. On 10/16/23 at 10:14 a.m. an interview was conducted with Resident #60's assigned nurse, Staff J, Licensed Practical Nurse (LPN). Staff J stated the resident had not previously voiced the suicidal thoughts. Staff J stated the psychiatric provider was in the facility and would be notified. On 10/16/23 at 10:33 a.m. Staff J, LPN stated the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · 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
Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed and three errors were identified for three residents (#240, #33, #64) of seven residents observed. These errors constituted a 8.82% medication error rate. Findings included: 1. On 10/16/23 at 5:06 p.m. an observation of medication administration with Staff L, Licensed Practical Nurse (LPN) was conducted with Resident #240. The staff member dispensed the following medications: - Symbicort 160/4.5 microgram (mcg) inhaler - Oxycodone/Acetaminophen 5/325 milligram (mg) tablet The staff member confirmed one tablet and one inhaler had been dispensed. A review of Resident #240's October 2023 Medication Administration Record (MAR) revealed the resident was scheduled to receive Oxycodone/Acetaminophen at 4:00 p.m. 2. On 10/17/23 at 8:54 a.m. an observation of medication administration with Staff M, Registered Nurse (RN) was conducted with Resident #64. The staff member dispensed the following…
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 · F2021-09-03 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and facility record review, the facility failed to ensure it had an effective pest control program with regards to flying insects observed in resident spaces to include one of one main dining room, hallways, and one of one kitchen, during four of four days observed, (8/31/2021, 9/1/2021, 9/2/2021, and 9/3/2021). Findings included: On 8/31/20212 at 11:00 a.m., the main dining room was observed for the lunch meal service. The dining room was a very large open area located in between both the 100/200 and 300/400 unit stations. Further, the middle of the dining room was observed with double doors that led to the smoking area/courtyard. The dining room was observed with ten tables with thirty residents seated throughout the area. While interviewing several random residents at least twelve medium sized flying insects (possible house flies) were observed on the table tops and then started buzzing around the tables. There were three residents that were in the immediate area while being interviewed. Two of the residents were observed to swat away the flies…
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 before2021-09-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews the facility failed to ensure one of one outside courtyard area was maintained in a safe, clean, and sanitary manner during four of four days observed (8/31/2021, 9/1/2021, 9/2/2021, and 9/3/2021). Findings included: On 8/31/2021 at 9:30 a.m. and 1:00 p.m., 9/1/2021 at 9:00 a.m. and 12:41 p.m., 9/2/2021 at 8:00 a.m., and 9/3/2021 at 7:45 a.m. and 10:00 a.m., the outside smoking porch/courtyard area was observed. During the observations, four of six chairs were observed with black bio-growth with ripped/torn chair coverings. Residents were observed seated in these chairs during all smoking scheduled times on four of four survey days. In addition, the sidewalk in the courtyard area was covered with black bio-growth. The bio-growth was observed to be slippery from the extensive rain and created a possible accident hazard. Many residents were observed walking and or self propelling in wheelchairs in this area during all four days of the survey. Continued observations revealed the outside double doors for the courtyard area had built up heavy…
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 before2021-09-03 · 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 medical record review, the facility failed to implement interventions for a fall care plan for one (#16) of four residents sampled for accidents out of a total resident sample of 39. Findings included: On 08/31/21 at 8:19 a.m., Resident #16 was observed sitting on the right side of the bed. A floor mat was visible on the floor to the left of the bed. A second floor mat was observed propped against the wall behind the door. On 09/01/21 at 8:22 a.m., Resident #16 was observed sitting in his wheelchair. The floor mat on the left side of the bed was placed on the floor with the front left corner caught on the wheel of bed. The other floor mat was observed propped against the wall. On 09/01/21 at 12:35 p.m., Resident #16 was observed in bed. The floor mat placed on the left of the bed was not placed flat on the floor, and the corner edge of the mat was still caught on the bed. Photographic evidence was obtained. Review of the Resident Face Sheet for Resident #16 revealed…
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 before2021-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, medical record review and policy review, the facility failed to ensure the safety and supervision for one (#36) of four residents sampled for accidents related to Resident #36 self propelling through a busy parking area, positioning himself off of the facility property with no orders for leave of absence, and smoking cigarettes unsupervised in an area with high vehicle traffic. Findings included: On 9/2/2021 at 7:57 a.m., Resident #36 was observed in the front parking lot, as viewed from the conference room window. Resident #36 was observed self propelling while seated in his wheelchair. The resident was using both hands to turn the wheels to propel. His right foot was placed on a foot pedal and his left foot was amputated from below the knee. He was observed to propel on the paved throughway where cars drive to park. The resident continued heading towards the south entrance of the parking lot where vehicles would enter. Resident #36 continued to the entrance of the parking lot and continued out to the sidewalk, near a two lane road. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (#73) of one resident sampled for dialysis out of 3 facility residents receiving dialysis. Findings included: Review of Resident # 73's admissions record revealed that he was admitted to the facility in October of 2020 with diagnoses that included type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. Review of the Minimum Data Set Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates that Resident # 73 was cognitively intact. Review of Resident # 73's medical records revealed no documentation of communication between the facility and the dialysis center related to his status prior to and after hemodialysis treatment. A review of Resident # 73 care plan dated 10/26/2020 and edited on 8/24/21 under the category Dialysis revealed: Resident #73 is at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2020-01-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 resident record review, interviews, observation and review of policy and procedure, it was determined that the facility did not ensure development of a comprehensive person centered care plan with individualized approaches for Resident #39's behaviors, did not develop a care plan for Resident #77's pressure ulcers, #45's indwelling catheter, and the implementation of care plan for #51 and #45 related to application of devices out of a total sample of 43 residents. Findings Included: Review of the record for Resident #39 revealed that he was admitted to the facility on [DATE]. Diagnoses included Unspecified Dementia without behavioral disturbance, Cardiovascular Disease with hemiplegia and hemiparesis affecting left dominant side and unsteadiness on feet. A quarterly Minimum Data Set ( MDS) assessment was completed on 11/13/19. The Brief Interview for Mental Status ( BIMS) score on this MDS was 9 , indicative of moderate cognitive impairment. On 1/9/20, the Social Service Director completed a BIMS…
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 · D2020-01-10 · 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 observation, interview, and record review, the facility failed to revise the comprehensive care plans for one resident of forty-three residents sampled related to Resident #242's safe smoking ability. Findings included: Resident #242 was admitted on [DATE] with multiple diagnoses that included Pulmonary Embolism without acute cor pulmonale, Dysphagia oropharyngeal phase, Conversion disorder with seizures or convulsions and Exocrine pancreatic insufficiency, Nicotine dependence, other tobacco product, with withdrawal. A record review identified the Quarterly Minimum Data Set (MDS) dated [DATE], for Resident # 242 to have a Brief Interview of Mental Status (BIMS) Score of 15 (on a 1-15 score range) indicating the resident to be cognitively intact. Review of the clinical record revealed Resident #242's most recent smoking evaluation (observation detail report) was dated 12/24/19, which indicated the resident was a safe smoker and did not require supervision while smoking. The comprehensive care-plan 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 · Dcited before2020-01-10 · 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
Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and twenty-eight errors were identified for three (#72, #88, and #33) of five residents observed. These errors constituted a 75.68% medication error rate. Findings included: 1. On 1/9/20 at 11:19 a.m., an observation of medication administration with Staff Member F, Registered Nurse (RN), was conducted with Resident #72. Staff Member F, RN was observed administering the following medications: - Hydrocodone-Acetaminophen 7.5-325 milligram (mg) tablet orally - Alprazolam 0.25 mg tablet orally - Acidophilus tablet orally - Iron 325 mg tablet orally - Vitamin D3 5000 international unit (iu) tablet orally - Breo-Ellipta 100 microgram/25 microgram (mcg/mcg) inhaler, one puff inhaled - Fluticasone Propionate 50 mcg nasal spray, one spray bilateral nares - Lisinopril 10 mg orally - Myrbetriq Extended Release (ER) 50 mg tablet orally - Sertraline Hydrochloride (HCl) 100 mg tablet orally -…
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 before2020-01-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and interviews the facility failed to ensure expired medications were removed from two of four medication carts, medication ointment was labeled with a resident name in one of two treatment carts, and one of two treatment carts were locked when left unattended. Findings included: An observation, on 1/8/20 at 3:58 p.m., was conducted with Staff Member E, Licensed Practical Nurse (LPN), of the D-wing medication cart. The D-cart contained a 100 unit/milliliter (u/mL) vial of Humulin R insulin which the label identified as being opened 12/7/20 and expired on 1/7/20, one 100 u/mL vial of Lantus which the label identified as being opened 12/7/19 and expired on 1/7/20. The D-wing medication cart contained six (6) 14 milligram (mg) Nicotine Transdermal System patches which the packaging indicated had expired in August (Aug) 2019. A 4 fluid ounce bottle of Tearless Baby Shampoo was observed to be stored with mulitple bottles of oral over-the-counter medications. Photographic evidence was obtained. The Consulting Pharmacist stated, on 1/8/20 at 4:01 p.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.
- Potential for harm · Dcited before2020-01-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the indwelling catheter tubing and bag were appropriately maintained for Resident #55 for three of four days observed (1/8/20, 1/9/20 and 1/10/20); and failed to perform hand hygiene during the task of medication administration. Findings included: 1. On 1/8/20 at 9:54 a.m., Resident #55 was observed to be seated in a wheelchair located on the smoking patio. The resident's indwelling catheter was inside a privacy bag, that was dragging on the ground along with the catheter tubing when the resident self-propelled in the wheelchair. Resident #55 was immediately interview and he indicated that the Certified Nursing Assistant's (CNA), put his indwelling catheter bag inside the privacy bag. On 1/9/20 at 08:11 a.m. Resident #55 was observed to be sitting in a wheelchair in the main dining room, holding a large Styrofoam cup filled with coffee. The resident's indwelling catheter tubing was on the floor, and the catheter bag was contained…
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 BENJAMIN LANDA — 48 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 | 3.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 3.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 3.5 | -1.5 vs chain |
The other 47 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 47; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SOUTHERN PINES NURSING MEMBER LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/07/2022 |
| FLNHO CAPITAL GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| TAMPA 2 OPCO PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| ZBL-18 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| FISCHEL, MAYER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/08/2022 |
| LANDA, BENJAMIN | Individual | CORPORATE OFFICER | — | since 10/08/2022 |
| THACKER, TRICIA | Individual | CORPORATE OFFICER | — | since 04/04/2022 |
| FORTINO, VICTORIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/24/2023 |
| KWAPIL, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/15/2025 |
| WILSON, HEIDI-LYNN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/25/2025 |
| ASTON HEALTHCARE LLC | Organization | ADP OF THE SNF | — | since 03/15/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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 82% 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 $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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. 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 105275. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-10-19, 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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