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The Lilac At Silver Palms

14601 NE 16th St, North Miami, FL 33161 · For profit - Corporation · 104 certified beds · (305) 701-9699 Medicare & Medicaid certified

Call the home — (305) 701-9699 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20231 actual-harm citation$35,500 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $35,500 in federal fines (most recent 2023-09-14)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 36% 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) 3 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
14205 W Dixie Hwy · (305) 892-2077 · Call to confirm hours
Pharmacy
14025 W Dixie Hwy · (305) 899-0943 · Call to confirm hours
Grocery
14500 W Dixie Hwy · (305) 945-1570 · Call to confirm hours
Park
Jaycee Park · 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
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 increased4.6%8.7%15.4%better
Long-stay residents who lose too much weight4.9%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse 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 symptoms3.7%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 injury0.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened5.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.6%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control4.0%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 table18.8%8.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission10.9%26.1%22.6%better
Short-stay residents with an outpatient ER visit1.2%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.812.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.201.151.80better

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.

39.7% 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 147 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.7%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
41.0%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.27hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 41.0% 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 95 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF39.7%CMS range 31.9–53.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.2–13.810.7%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 discharge41.0%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 discharge49.5%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 discharge32.6%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 identified66.7%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 setting92.9%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%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 worsened1.4%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 hospitalization7.8%CMS range 5.2–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.261.02Oct 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

0.75
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.67
RN hoursweekends
32.6%
Total nursing turnover
38.9%
RN turnover

How full it usually is: this home is certified for 104 beds and averages 97.9 residents a day — about 94% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.11 hrs/resident/day on weekends vs 3.57 on weekdays — 13% thinner on weekends. RN hours go from 0.78 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below 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 (2026-02-20)
4
at the previous standard inspection (2025-01-30)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2023-09-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one (Resident #13) out of 16 sampled residents was not verbally abused by facility staff. The findings included: Record review of the facility's Abuse, Neglect and Exploitation Policy and Procedure dated 10/1/2022 included, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse - means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. III. Prevention of Abuse, Neglect and Exploitation - The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-20 · tag F0761 — failed to label and store drugs safely — pattern
    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 observations, record review, and interviews, the facility failed to ensure medications and biologics were properly stored in two out of two medication rooms (First floor and Second floor medication rooms). As evidenced by: Expired saline and sterile water on the second-floor treatment cart, eye drops observed at Resident # 5's bedside; ointment and medications observed in residents' rooms at bedside (Resident #7, Resident # 15, Resident #31, Resident #60, Resident #76 and Resident #108). Expired Intravenous (IV) start kits and alcohol pads found in the first-floor medication room, expired liquid Lansoprazole for Resident#4 in the second-floor medication room and expired insulin for Resident # 68 found in the first-floor medication cart. There were 94 residents residing in the facility at the time of the survey. The findings include. Resident # 31 Observation on 02/17/2026 at 10:08 AM in Resident # 31's room revealed lanolin-petrolatum ointment (A&D ointment) on top of the resident's dresser. (Photo…

    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 before2026-02-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to honor residents right to a dignified experience for one (Resident #29) out of one sampled resident with an indwelling cholecystostomy drainage device as evidenced by observation of Resident # 29 receiving physical therapy and the cholecystostomy drainage collection bag was not inside a privacy bag and visible. There was one resident with a cholecystostomy drainage device residing in the facility at the time of survey. The findings included: Observation on 02/18/2026 at 10:27 AM, revealed Resident #29 self-propelling in wheelchair on the 2nd floor hallway towards the therapy room. A cholecystostomy drainage bag was visible (photo). On 02/18/2026 at 10:30 AM Resident # 29 was observed being assisted with ambulation using a walker by the Physical Therapist and Staff D, Occupational therapy assistant. Resident # 29's cholecystostomy drainage bag was visible. On 02/18/2026 at 10:35 AM, Staff B, Licensed Practical Nurse (LPN) was made aware…

    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 · D2026-02-20 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 protect residents' personal information on one out of four medication carts as evidenced by: 1) facility's staff left paperwork with residents' personal medical information unattended on top of medication cart. 2) Facility's staff failed to close a computer screen before walking away and resident information visible on the second-floor nursing unit. There were three nursing units in the facility at the time of survey. The findings included:Observation on 02/19/2026 at 10:32 AM on the facility's second-floor south unit revealed an unattended medication cart with paperwork that contained residents' personal information visible (photo). On 02/19/2026 at 10:34 AM Staff J, Registered Nurse (RN) exited a room and approached the medication cart and was made aware of the identified concern. Staff J, RN stated: We keep resident's information private by closing our computer screens and shredding documents. This paperwork shouldn't be on top of cart and should have been shredded.On 02/19/2026 at 2:45 PM the Director…

    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 · D2026-02-20 · 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 observations, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Resident #68) out of one sampled resident receiving insulin injections as evidenced by documentation indicating expired insulin found on the first-floor medication cart was administered to Resident # 68. The findings included: Observation and interview on 02/18/2026 at 12:30 PM during a medication cart inspection conducted on the facility's first floor with Staff E, Licensed Practical Nurse (LPN) revealed an insulin pen (Admelog solo injection) labeled with Resident #68's name with open date 01/15/26 and expiration date 2/13/26 stored in the medication cart (photo). Staff E, LPN stated: According to the date on the pen it is expired. Review of Resident # 68's electronic medication administration record revealed the Admelog solo injection was last administered on 02/17/2026 at 5:36 PM by Staff E, LPN (photo). Staff E, LPN was asked about 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · 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 observations, record review, and interviews, the facility failed to ensure an environment free of accident hazards as evidenced by razor observed in Resident #7's room, 2) Resident #107 observed with heating pad; 3) Overfilled sharps container in Resident #29's room and 4) Unsecured door with interior lock on second floor south hallway. There were 94 residents residing in the facility at the time of the survey.The findings included. 1) On 02/17/2026 at 9:49 AM, observation revealed Resident # 7 in bed alert there was a shaving razor on the shelf. Photo evidence was obtained. On 02/18/2026 at 10:58 AM, observation revealed a razor on the shelf in Resident #7'ss room. On 02/19/2026 at 11:25 AM, Resident # 7 was in therapy and the razor remained on the shelf in the resident's room. Photo evidence was obtained. Record review revealed the resident was admitted on [DATE] with diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure. Review of Resident #7's admission Minimum Data Set, dated…

    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 · D2026-02-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to properly position indwelling urinary catheter's tubing in a manner to promote free flow of urine for two ( Resident #29 and Resident #76) of two sampled residents with an indwelling urinary catheter as evidenced by: 1)Resident # 29's indwelling urinary tubing observed extending down and up through pants with urine in the tubing. 2) Resident # 76's indwelling urinary catheter tubing observed coiled with urine in the tubing. This deficient practice prevented urine from freely flowing, increasing the risk for catheter-associated urinary tract infections and other serious medical issues.The findings included: Resident #76Observation on 02/17/2026 at 10:09 AM revealed Resident # 76 in bed, the indwelling urinary catheter tubing was looped and contained urine; there was less than 5 milliliters (mL) of urine in the drainage bag.On 02/17/2026 at 10:11 AM, the second-floor charge LPN was made aware and repositioned catheter tubing to allow 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review the facility failed to store food under sanitary condition and to ensure resident's food items were dated and labeled in the nourishment refrigerator on the Second Floor North Wing. This has the potential to affect 31 out of 35 residents who eat orally residing on the Second Floor North Wing out of 94 residents in the facility at the time of the survey.The findings included: Record review of the Use and Storage of Food Brought by Family or Visitors Policy and Procedure (revision date March 20223); Policy Statement-It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident; Policy Explanation and Compliance Guidelines: 2) All food items that are already prepared by the family or visitor brought in must be labeled with content and dated and a) The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.Observation of the nourishment refrigerator on the Second Floor North Wing…

    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
  • Potential for harm · D2026-02-20 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to collaborate and coordinate with hospice representative for one (#5) out of one sampled resident receiving hospice services as evidenced by: facility staff failed to obtain and keep nursing notes in the hospice folder for Resident#5 since December 2025 when Resident started with hospice. There were seven residents receiving hospice care residing in the facility at the time of survey. The findings included:On 02/19/26 at 1:00 PM Resident#5 was in bed with eyes closed and call light in reach. Oxygen was in progress at 2 Liters per minute, no apparent distress.Record review of Resident #5's clinical records revealed Resident #5 was admitted on [DATE] with diagnosis that included but not limited to: Encounter for Palliative Care and Heart Failure.Record review of a significant change in status minimum data set reference dated 12/12/25 indicated Resident #5 has moderate cognitive impairment and receiving hospice care.Record review of a care…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · 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 interview and record review, the facility failed to demonstrate effective plans of action were implemented to correctly identify repeated deficient practices in the problem areas of F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761Medication Storage. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's Quality Assurance and Performance Improvement policy and procedure dated 1/2026 indicated: These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.Policy: The facility, will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators…

    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
  • Potential for harm · Dcited before2026-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow infection control protocol when storing medical equipment for two (#38, #46) out of two sampled residents as evidenced by: 1) Observation of an incentive spirometer not stored in a dated plastic bag. 2) Observation of an enteral syringe dated 2/16/26 stored at the bedside of Resident#46 for two days. There were 94 residents residing in the facility at the time of survey. The findings included: Resident #38Observation on 02/17/2026 at 8:25 AM revealed an uncovered incentive spirometer stored at Resident #38's bedside.Record review Resident#38's clinical records indicated the resident was admitted on [DATE] with diagnosis that included but not limited to: Cerebral Ischemia.Record review of a Modification of interim payment minimum data set (MDS) reference dated 12/22/25 revealed Resident #38 had no cognitive impairment and received respiratory therapy for seven days.Record review of a care plan initiated: 12/13/2025 revised:…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-02-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 observation, record reviews and interviews the facility failed to develop a comprehensive care plan for one (Resident #2) and failed to implement care plan for two (Resident # 6 and Resident # 7) out of seven sampled residents. As evidenced by a fall care plan was not developed for Resident #2 who is at high risk for falls; and staff failed to implement Care Plan interventions to prevent worsening of wounds for Resident # 6 and Resident #7. The findings included: Resident #2 On 02/24/2025 at 11:10 AM Resident #2 was observed sitting in his wheelchair watching television, no distress noted. Review of Resident #2's the clinical revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but were not limited to, History of Falling and Osteoarthritis. Record review of Nurses Notes dated 12/09/2024 revealed during rounds, the resident was noted lying on the floor on his left side beside the bed. Resident remained alert and verbally responsive, no acute distress…

    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 · Ecited before2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 and interview, the facility failed to implement infection control standards and procedures related to Soiled Utility Rooms. As evidenced by during focused observations the three Soiled Utility rooms in the facility were found to be unlocked. There were 98 residents residing in the facility at the time of the survey. The findings included: On 01/28/25 at 10:09 AM Focus tour with the surveyor and Registered Nurse Infection Control Preventionist -The two soiled utility rooms on the second floor and the soiled utility room on the first floor were observed to be unlocked. Infection preventionist stated the soiled utility rooms are unlocked during the day. Interview on 01/28/25 at 10:24 AM Licensed Practical Nurse Supervisor, first floor (Staff B), stated herself and the nurses on the first floor have the keys to the soiled utility room, the door is supposed to always remain locked and if staff needs to enter the soiled utility room, they have to ask the nurses or her to unlock the soiled utility room. Interview on 01/30/25 at 07:45 AM Director of Nursing (DON) stated…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-30 · 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 observations, record review and interviews, the facility failed to provide an environment free from accidents for Resident #24, as evidenced by, observations of electric and hand razors on the Resident # 24's nightstand. There were 98 residents residing in the facility at the time of the survey. The findings included: During an observation on 01/29/25 at 09:08 AM Resident #24 was observed watching television. An electric and a disposable razor was noted on the resident's nightstand (Photo evidence). During an observation on 01/30/25 at 08:56 AM, Resident #24 was observed eating breakfast. The razors were still on the nightstand at the resident's bedside. Review of Resident #24's medical records revealed the resident was admitted on [DATE]. Clinical diagnoses include but not limited to: Parkinson's disease with dyskinesia, without mention of fluctuations and Type two Diabetes. Review of the Physician's Orders Sheet (POS) revealed Resident #24 has no orders associated with the use of razors for activities…

    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 · D2025-01-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (Resident #27) out of 25 sampled residents. As evidenced by, during several observations, Resident #27's oxygen was being administered via nasal cannula at the incorrect rate. There were 98 residents residing at the facility at the time of the survey. The findings included: On 01/27/25 at 07:44 AM Resident # 27 was asleep in bed; Oxygen (02) via Nasal cannula (NC) noted running at 2 liters per minute (LPM). On 01/28/25 at 07:35 AM Resident #27 was in bed asleep, 02 running at 2 LPM via NC. On 01/29/25 at 07:54 AM resident in bed awake, 02 running at 2 LPM via NC, no distress noted. Review of Resident # 27's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Respiratory disorders in diseases classified elsewhere, Respiratory failure, unspecified with hypoxia. Review of the Physician's Orders…

    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 before2025-01-30 · 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 and interview, the facility failed to ensure the proper rotation of Dietary Medication supplements. As evidenced by, during observation of first floor's Medication Storage Room, two nutritional supplements were found to be expired. There were 98 residents residing in the facility at the time of the survey. The findings included: On [DATE] at 11:13 AM, During Medication Storage Room observation with Registered Nurse (Staff A), two Vanilla Nutritional Drinks were found in the 1st floor medication storage room with an expiration date of [DATE]. Interview on [DATE] at 12:13 PM, Registered Nurse (Staff A) stated: these supplements are used for residents during medication administration as prescribed, particularly residents who do not want their medications with water. The nurses and the nursing supervisors check the medication storage rooms daily and on each shift. Interview on [DATE] at 10:27 AM, the Director of nursing (DON) stated: Nurses are responsible for checking the medication storage…

    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 · E2023-09-14 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 bed hold policies upon discharge to the hospital for three Residents (Residents #4, #13 & #25) out of 16 sampled residents. The findings included: 1) Review of the medical records for Resident #25 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to. Adult failure to thrive, Anorexia, Gastrostomy status. Resident #25 was discharged to the hospital on [DATE]. The resident was readmitted on [DATE]. Further Review of Resident #25's medical records revealed: Resident #25's Bed hold policy form for Discharge Return Anticipated on 08/11/2023 was not completed. Review of the discharge summary progress note for Resident 25 dated 08/11/2023 timestamped 14:30 documented: Upon rounds, Resident observed with blood coming out of his mouth. Assessment done, Resident profusely with blood and clotting coming from mouth. Unable to find the cause of bleeding with resident keeping mouth shut. Vital…

    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 · Ecited before2023-09-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure 1) Hand hygiene was conducted between residents during dining and 2) The food service staff were wearing hair restraints properly. The certified nursing aide (CNA) was observed passing breakfast trays to residents without practicing hand hygiene and a Food Service Worker was serving on the lunch tray line without the hair net covering the entire head. This has the potential to affect fifty three residents out of fifty eight residents who eat orally residing in the facility. The findings included: 1) Record review of the Infection Prevention and Control Program Policy and Procedure, revised 8/15/2022 documented: Policy-This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 4) Standard Precautions: b) Hand hygiene shall be…

    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
  • Potential for harm · E2023-09-14 · tag F0847 — pattern
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewed, informed the residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. The findings included: Record review for the Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility's Optional Dispute Resolution Agreements/Binding Arbitration Agreement form documented the following: Resident #34 signed and dated the agreement on 12/29/2022, Resident # 6 signed and dated the agreement on 1/16/2022 and Resident #46 signed and dated the agreement…

    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
  • Potential for harm · E2023-09-14 · tag F0848 — pattern
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewe. The binding arbitration agreements did not provide for the selection of a neutral arbitrator agreed upon by both parties. The findings included: Record review for the Arbitration Agreements on the facility's letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility Optional Dispute Resolution Agreements/Binding Arbitration Agreements documented the following: Resident #34 signed and dated the Arbitration Agreement on 12/29/2022, Resident #6 signed and dated the Arbitration Agreement on 1/16/2022 and Resident #46 signed and dated the Arbitration Agreement on 7/10/2023 and the Arbitration Agreements…

    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
  • Potential for harm · Dcited before2023-09-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to promote resident's dignity and respect for one (Resident #15) out of 16 sampled residents. As evidenced by a facility staff person standing while feeding a resident and calling residents who need assistance with eating, feeders. The findings included: Record review of the Infection Promoting/Maintaining Resident Dignity Policy and Procedure, revised 8/02/2022 documented: Policy-It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1) Staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Observation of Staff G, CNA (Certified Nursing Assistant) on 9/12/23 at 8:09 AM, revealed the CNA standing over the bed of Resident #15 and feeding her breakfast from the breakfast tray. On 9/12/23…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · 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 a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for one (Resident #13) out of four residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were 58 residents residing in the facility at the time of the survey. The findings included: Record review of the Resident's Rights Regarding Treatment and Advance Directives Policy and Procedure, revised 4/2023 documented: Policy-It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. Policy Explanation and Compliance Guidelines: 1) On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure two residents (#12 & #301) out of 16 sampled residents were free from the use of physical restraints. As evidenced by resident's bed positioned in a concave position ( the head and foot of the bed were elevated) and one bedside chair was positioned on each side of the bed preventing the resident from getting out of the bed without assistance. There were 58 residents residing in the facility at the time of the survey. The findings included: 1. During Observation 09/11/23 at 10:48 AM, Resident #12 was in bed, awake, crying out for someone in Spanish. The residents bed was in a concave position with the head and feet elevated. There was one bedside chair on each side of the bed and the chairs were placed close to the bed. On 09/12/23 at 07:53 AM, Resident #12 was observed in bed asleep, and the bed was in a low position. The bed was observed in a concave position, sunken in the middle, the head and feet were elevated, there was one…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-14 · 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 the Quarterly Minimum Data Set (MDS) assessment was accurate related to Ostomy (including urostomy, ileostomy, and colostomy), for one (Resident #12) out of 16 residents sampled. The findings included: Record review of Resident #12's Quarterly Minimum Data Set (MDS) with a Reference Date of 07/23/2023, Section H for Bowel and Bladder documented, the resident has an Ostomy (including urostomy, ileostomy, and colostomy), and is always incontinent of bowel and bladder. During Observation on 9/12/23 at 10:00AM, it was observed Resident #12 did not have an Ostomy (including a urostomy, ileostomy, and colostomy), skin observation did not reveal any signs of having an ostomy. Further review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Parkinson's disease, Unspecified dementia, unspecified severity, without behavioral disturbance,…

    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 · D2023-09-14 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 an enteral feeding was administered as prescribed and dated correctly for one (Resident #46) out of 16 sampled residents. The findings included: During observation on 09/11/23 at 08:06 AM, resident #46 was in bed asleep. Glucerna 1.2 tube feeding (TF) was infusing at 70 milliliters per hour (ml/hr.), with a water flush at 50ml/hr. The Glucerna 1.2 formula was dated 9/8/23, the water flush was dated 9/8/23, and the tube feeding syringe was dated 9/11/23. On 09/12/23 at 07:58 AM, resident #46 was observed in bed. The bed was in the lowest position, the head of the bed was elevated, and the tube feeding was infusing at 85 ml/hr., the water flush was infusing at 50 ml/hr. The Glucerna 1.2, water flush and the syringe were dated 9/12/23. On 09/13/23 at 09:35 AM, resident #46 was observed in bed and the head of bed was elevated. The tube feeding was infusing at 85ml/hr., the water flush was infusing at 50ml/hr. The Glucerna 1.2, water…

    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

“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

$35,500 in federal fines across 1 penalty.

  • $35,500 — penalty dated 2023-09-14

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.6+1.4 vs chain
Health inspection 3 of 52.7+0.3 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 5 of 53.4+1.6 vs chain
The other 78 homes this chain runs (chain average 2.6★, per CMS)
1 of 5Beavercreek Health And RehabBeavercreek, OH 1 of 5Bradford Heights Nursing & RehabilitationHopkinsville, KY 1 of 5Centerville Health And RehabDayton, OH 1 of 5Clayton Rehabilitation and Healthcare CenterClayton, NC 1 of 5Dade City Health And Rehabilitation CenterDade City, FL 1 of 5Englewood Health And RehabEnglewood, OH 1 of 5Fulton Nursing and Rehabilitation, LLCFulton, KY 1 of 5Gainesville Health and RehabilitationGainesville, FL 1 of 5Garden View Health And Rehabilitation CenterVero Beach, FL 1 of 5Hertford Rehabilitation and Healthcare CenterHertford, NC 1 of 5Longwood Health And Rehabilitation CenterLongwood, FL 1 of 5Lotus Village Center for Nursing and RehabilitatioSparta, NC 1 of 5Magnolia Creek Nursing And RehabilitationCovington, TN 1 of 5Mills Nursing & RehabilitationMayfield, KY 1 of 5Mountain Ridge Health and RehabilitationMonticello, KY 1 of 5Naples Health And Rehabilitation CenterNaples, FL 1 of 5Southpoint Rehabilitation and Healthcare CenterDurham, NC 1 of 5Spring View Nursing & RehabilitationLeitchfield, KY 1 of 5Sunrise Point Health And Rehabilitation CenterRockledge, FL 1 of 5Windsor Rehabilitation and Healthcare CenterWindsor, NC 1 of 5Winter Park Care And RehabilitationWinter Park, FL 1 of 5Xenia Health And RehabXenia, OH 2 of 5Accordius Health at Rose Manor LLCDurham, NC 2 of 5Barren County Nursing and RehabilitationGlasgow, KY 2 of 5Bellbrook Health And RehabBellbrook, OH 2 of 5Cherokee Park RehabilitationLouisville, KY 2 of 5Clinton PlaceClinton, KY 2 of 5Collierville Nursing And Rehabilitation, LlcCollierville, TN 2 of 5Eden Rehabilitation and Healthcare CenterEden, NC 2 of 5Fairpark Health And RehabilitationMaryville, TN 2 of 5Glenview Health and RehabilitationGlasgow, KY 2 of 5Green Acres HealthcareMayfield, KY 2 of 5Jamestown Place Health And RehabJamestown, OH 2 of 5Lilac At Bayview, TheSaint Augustine, FL 2 of 5Madisonville Health and Rehabilitation, LLCMadisonville, KY 2 of 5Midtown Center For Health And RehabilitationMemphis, TN 2 of 5Pelican Health at CharlotteCharlotte, NC 2 of 5River Grove Health And RehabilitationLoudon, TN 2 of 5Stonecreek Health and RehabilitationPaducah, KY 2 of 5Sycamore Heights Health and RehabilitationLouisville, KY

Showing 40 of 78; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LILAC SNF HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/03/2022
PALMS NH HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/03/2022
SILVER PALMS FL OPERATIONS HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 06/03/2022
PANA, SARAHIndividualW-2 MANAGING EMPLOYEEsince 06/03/2022
GORELICK, BATYAIndividualCORPORATE OFFICERsince 06/03/2022

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.

$8.0M
Net patient revenuemost recent cost report
-3.7%
Operating marginrevenue minus expenses
$3.0M
Related-party expense36% of expenses
Who pays — share of resident-days
Medicaid 47%Medicare 34%Other / private 19%

This home reported $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 36% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$453per resident / day
operating cost
$13,785per month
≈ monthly operating cost
$437per day
avg. revenue, all payers

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

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 686125. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-20, 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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