The Lodge Healthcare And Rehabilitation Center
635 SE 17th Street, Ocala, FL 34471 · For profit - Limited Liability company · 99 certified beds · (352) 629-7921 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,737 in federal fines (most recent 2025-02-27)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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
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 | 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 fell from 4 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.
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 | 2.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.3% | 0.9% | worse 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 | 11.8% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.1% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.5% | 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 table | 2.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.4% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.58 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.54 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
55.2% 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 136 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.2% 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 98 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 32% 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 | 55.2%CMS range 47.1–62.7 | 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 8.5–15.5 | 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 | 59.2% | 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 | 74.5% | 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 | 40.8% | 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 | 96.0% | 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 | 96.0% | 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 | 88.2% | 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 | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.1%CMS range 4.4–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 99 beds and averages 91.4 residents a day — about 92% occupied, or roughly 8 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.88 on weekdays — 14% thinner on weekends. RN hours go from 0.48 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.
- Immediate jeopardy · J2025-02-27 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents with allergies were provided foods that were free from allergens for 1 (Resident #297) of 12 residents sampled who had food allergies. Resident #297 had a peanut allergy. On 2/23/2025 at 7:00 PM, Resident #297 was provided with a [NAME] Buddy snack by Staff G, Certified Nursing Assistant. Staff G did not review Resident #297's meal ticket or Resident #297's electronic medical record to determine her allergies. At approximately 10:00 PM Resident #297 consumed several bites of the cookie and began to experience a burning and itching sensation in her throat. Resident #297 notified facility staff and was treated with medication for an allergic reaction. A peanut allergy is a condition that causes the body's germ-fighting immune system to react to peanuts. An allergic response to peanuts usually occurs within minutes after exposure. Peanut allergy signs and symptoms can include skin reactions, such as hives, redness or swelling. Itching or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food was stored under sanitary conditions by failing to label and date food items in the facility kitchen walk in cooler, in 1 of 3 nurses' station nourishment areas, and in 1 of 3 nourishment room refrigerators.Findings include:During an observation on 6/7/26 at 9:16 AM of the kitchen's walk-in cooler, located on a shelf was a small igloo cooler with no label or date. The contents inside consisted of a glass container with a plastic blue lid, the contents in the glass container were unidentifiable, and there was no label or date on the contents. During an interview on 6/7/26 at 9:20 AM Staff H, Cook, stated that there should be no personal food in the refrigerator and the contents should have been labeled and dated. During an interview on 6/8/26 at 8:45 AM the Certified Dietary Manager, stated absolutely no personal food should be kept in the walk-in kitchen refrigerator.During an observation on 6/7/26 at 9:30 AM of the nourishment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide necessary grooming and hygiene services for 1 of 3 residents, Resident #21, sampled for activities of daily living (ADLs). Findings include:Review of Resident #21's clinical record documented medical diagnoses to include dementia, fractured left femur requiring orthopedic aftercare, embolism and thrombosis (clots in blood stream) of the left lower extremity, falls, and dislocated shoulder.Review of Resident #21's care plan dated 5/21/2026 documented the resident had a self-care deficit with dressing, grooming, and bathing related to impaired mobility, left femur fracture, and generalized weakness. Interventions included gathering and setting up supplies for care, allowing the resident time to participate in ADLs, encouraging assistance as needed, and explaining care during provision of services.Review of Minimal Data set (MDS) admission dated 5/27/2026 Section GG documented the resident required Substantial/Maximal Assistance with bathing.During an observation on 6/7/2026 at 11:00 AM, Resident #21 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 of 3 residents, Resident #110 reviewed for PICC access devices. Findings include:Review of Resident #1's clinical record documented the resident was admitted on [DATE] to the facility with diagnosis that include but not limited to cellulitis (infection in skin) of left lower limb, cellulitis of right lower limb, methicillin resistant staphylococcus aureus infection (bacterial infection), local infection of the skin and subcutaneous tissue (first layer of skin), non-pressure chronic ulcer of left lower leg. During an observation on 6/9/2026 at 06:03 AM Resident #110 was lying in the bed. There was a PICC line inserted into the resident's left arm. Over the PICC line insertion site there was a transparent dressing covering the insertion site. Under the transparent dressing was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were securely stored in accordance with accepted professional principles for 4 of 5 resident halls.Findings include: 1) During an observation on 6/7/2026 at 9:52 AM, Resident #94 was observed resting in bed. A bottle of Nystatin 100,000 units/gram topical powder was observed sitting on the resident's dresser. (Photographic evidence obtained). During an interview on 6/7/2026 at 9:52 AM, Resident #94 stated, That powder is for my rash on my breast. 2) During an observation on 6/7/2026 at 10:02 AM, Resident #78 was observed sleeping in bed. A bottle of Hydrogen Peroxide 3% Topical Solution was observed on the resident's bedside table. (Photographic evidence obtained). During an interview on 6/7/2026 at 9:55 AM, the Director of Nursing (DON) stated that medications should not be left at the bedside and that his expectation is for staff to follow the facility policy regarding the storage of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-10 · 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 resident care equipment was cleaned and disinfected between uses in accordance with facility policy for 1 of 3 sit-to-stand assistive devices, Device #7, failed to conduct hand hygiene, and failed to wear personal protective equipment (PPE) while conducting wound care for Resident #66. Findings include:1) During an observation on 6/7/2026 at 10:20 AM, the Sit-to-Stand assistive device, Device #7, was observed on the [NAME] Hall with a maroon-colored substance splattered on the floor/platform portion of the device.During a subsequent observation with the Director of Nursing on 6/8/2026 at 1:20 PM, the Sit-to-Stand assistive device, Device #7, was observed on Boston Hall with the same, maroon-colored substance splattered on the floor/platform portion of the device. (Photographic evidence obtained).During an interview on 6/8/2026 at 1:22 PM, the Director of Nursing stated, It is our expectation that the equipment is cleaned before and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · 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
Based on observation, interviews, and record reviews, the facility failed to notify the provider and resident representative of a change in condition for 1 (Resident #397) of 5 residents reviewed for intravenous therapy. Findings include: During an observation on 2/23/2025 at 10:30 AM, Resident #397 was observed lying in bed with the head of bed elevated. She had a single lumen peripherally inserted central catheter (PICC) line in her right upper arm with a transparent dressing dated 2/9/2025. The dressing was intact around the insertion site but was noted to be partially lifted on the bottom right inside corner and brownish stains on the outside of the dressing. Review of the physician's order for Resident #397 dated 2/13/2025 read, Discontinue IV line right upper extremity [RUE] one time only for dc [discontinue]. Review of the Medication Administration Record (MAR) for Resident #397 documented the PICC line was discontinued on 2/13/2025 by [Staff O's initials] at 1358 [1:58 PM]. During an interview on 2/26/2025 at 9:19 AM, Staff O, Licensed Practical Nurse (LPN) stated, When I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · 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
Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive care plan for 2 (Resident #63 and #71) of 4 reviewed for respiratory services. Findings include: Review of Resident #71's admission record documented an admission date of 9/20/2024 with diagnosis that included chronic obstructive pulmonary disease, shortness of breath, acute respiratory failure with hypoxia, and pleural effusion (fluid around the lungs). An observation on 2/23/2025 at 9:40 AM, Resident #71's oxygen concentrator was set on 3 liters. An observation on 2/24/2025 at 2:15 PM, Resident #71's oxygen concentrator was set on 3 liters. Review of Resident #71's physician's order dated 9/22/2024 read, Oxygen at 2 liters/minute via nasal cannula with humidification when on the concentrator. May be without humidification when on a tank. Review of Resident #71's care plan dated 7/25/2024 read, [Resident #71's name] has a potential for complication of respiratory distress related to a diagnosis of COPD. Goals included resident will be able to maintain patent airway and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 3 (Resident #2, #301, and #397) of 7 residents reviewed for intravenous lines, medication administration and unnecessary medications. Findings Include: 1) During an observation on 2/23/2025 at 10:30 AM, Resident #397 was observed lying in bed with the head of bed elevated. She had a single lumen peripherally inserted central catheter (PICC) line in her right upper arm with a transparent dressing dated 2/9/2025. The dressing was intact around the insertion site but was noted to be partially lifted on the bottom right inside corner and brownish stains on the outside of the dressing. During an interview conducted on 2/23/2025 at 10:30 AM, Resident #397 stated, I have an IV (intravenous line) for my antibiotics because I have an infection. Review of the admission record documented that Resident #397 was admitted to the facility on…
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 before2025-02-27 · 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
Based on observations, interviews and record reviews, the facility failed to ensure residents received the correct oxygen flow rate for 3 (Resident #63, #65, and #71) of 4 residents reviewed for respiratory services. Findings include: During an observation on 2/23/2025 at 9:40 AM, Resident #71's oxygen concentrator was set on 3 liters. During an observation on 2/24/2025 at 2:15 PM, Resident #71's oxygen concentrator was set on 3 liters. During an interview on 2/24/2025 at 2:18 PM, Resident #71 stated that she does not operate or have knowledge of how to adjust the oxygen concentrator. Review of Resident #71's physician's order dated 9/22/2024 read, Oxygen at 2 liters/minute via nasal cannula with humidification when on the concentrator. May be without humidification when on a tank. During an interview on 2/24/2025 at 2:30 PM, Staff A, License Practical Nurse (LPN), stated the prescribed order calls for the O2 (oxygen) was for 2 liters. Staff A confirmed that the oxygen was set at 3 liters and should have been 2 liters per the physician's order. During an interview on 2/25/2025 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 · D2025-02-27 · 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 reviews, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 6.98 percent. Findings include: During an observation on 2/25/2025 at 8:44 AM, Staff H, Registered Nurse (RN), without hand hygiene began to pour Resident #58's medication. Staff H entered Resident #58's room and without hand hygiene handed Resident #58 his medication cup. Staff H handed Resident #58 his Styrofoam cup which contained water. Staff H handed Resident #58 his nasal spray. Resident #58 self-administered two nasal sprays on each nostril. Staff H performed hand hygiene before exiting Resident #58's room. During an interview on 2/25/2025 at 8:52 AM, Staff H, RN, stated, [Resident #58's Name] should only do one spray per nostril not two sprays in each nostril. We did not follow the physician order. I should have reminded him [Resident #58] he was to do one spray per nostril before handing him the nasal spray. Review of Resident #58's physician's order dated 12/5/2024 read, Fluticasone Propionate Nasal…
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 10 citations
- Potential for harm · Dcited before2025-02-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 6 medication carts and 2 of 6 hallways reviewed for unsecured medications. Findings include: 1) During an observation on [DATE] at 9:43 AM, Resident #47 was lying in bed. There was a white oval tablet with numbers 112 on top of the nightstand. (photographic evidence obtained) During an interview on [DATE] at 9:43 AM, Resident #47 stated, I do not know what that medication is. During an interview on [DATE] at 3:21 PM, the Director of Nursing stated, The medications should not have been unattended in her [Resident #47] room. 2) During an observation on [DATE] at 10:24 AM, Resident #43 was sitting up in bed. There was a bottle of Aspercreme Lidocaine Cream on top of nightstand. (photographic evidence obtained) During an interview on [DATE] at 10:24 AM, Resident #43 stated, The cream is for…
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 before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 reviews, the facility failed to ensure food was safely and properly stored and labeled in the walk-in cooler and freezer and that all equipment was clean, in good repair, or disposed of properly. Findings include: A tour was conducted of the kitchen on 2/23/25 at 9:07 AM. An observation was made of the hand washing sink with no paper towels available and of a live roach on the overflowing trash can located at the hand washing sink. A walk-through tour of the kitchen was conducted on 2/23/2025 at 9:12 AM with Staff M, the morning cook. An observation was made of a large pan of raw meat product in the walk-in cooler with no label or date. An observation was made of two large boxes on the floor in the walk-in freezer. An interview was conducted with Staff M, morning cook on 2/23/2025 at 9:15 AM. Staff M stated that the pan of raw meat was pork and that she had not dated or labeled it yet. Staff M stated that the boxes should not have been on the floor in the freezer. A follow-up tour was made to the kitchen on 2/24/2025 at 6:30 AM with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 Based on observations, interviews and record reviews, the facility failed to maintain complete and accurately documented medical records for 3 (Resident #2, #301, and #397) of 7 residents reviewed for intravenous lines, medication administration and unnecessary medications. Findings include: Review of the admission record documented that Resident #397 was admitted to the facility on [DATE] with diagnosis that included metabolic encephalopathy, dysphagia, oropharyngeal phase, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, morbid (severe) obesity due to excess calories, muscle weakness, anxiety disorder, unspecified, major depressive disorder, recurrent, moderate, acquired absence of kidney, essential (primary) hypertension, chronic kidney disease, unspecified, personal history of other venous thrombosis and embolism, and peripheral vascular disease. Review of Resident #397's Medication Administration Record (MAR) documented a physician's order with a start date of 1/21/2025…
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 before2025-02-27 · 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 observations, interviews, and record reviews, the facility failed to follow infection control standards during for hand hygiene for 4 of 7 residents reviewed during medication administration and follow enhanced barrier precautions for 1 (Resident #78) of 2 for enteral medication administration. Findings include: During an observation on 2/25/2025 at 8:39 AM, Staff H, Registered Nurse (RN), exited a resident room and without performing hand hygiene and began to pour medications for Resident #36. Staff H entered Resident #36's room and without performing hand hygiene handed Resident #36 her medication cup. Staff H handed Resident #36 her Styrofoam cup which contained water. Staff H exited Resident #36's room without performing hand hygiene and returned to the medication cart. Staff H, without hand hygiene, began to pour Resident #58's medication. Staff H entered Resident #58's room and without hand hygiene handed Resident #58 medication cup. Staff H handed Resident #58 his Styrofoam cup. Staff H handed Resident #58 his nasal spray. Staff H performed hand hygiene before…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 Based on record review and interview, the facility failed to ensure that the resident records were complete and accurate for 1 of 3 residents reviewed, Residents #4. Findings include: Review of Resident #4's admission record revealed the resident was admitted on [DATE] with the diagnoses that included cellulitis of right lower limb, cystitis, muscle weakness, difficulty walking, morbid obesity, hypertension, anemia, and hyperlipidemia. Review of Resident #4's physician order dated 12/9/2022 read, Tramadol HCl [Hydrochloride] tablet 50 mg [milligram], give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #4's Controlled Drug Disposition log revealed that on 1/13/2024 at 5:30 AM, one Tramadol 50 mg tablet was taken from Resident #4's stock by Staff A, Registered Nurse (RN), and wasted by Staff B, Licensed Practical Nurse (LPN). Staff B's initials had a line marked through her initials and error written with Staff B's initials printed beside the error. Review of Resident #4's Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
3. During an observation on 11/14/2023 at 9:47 AM, Resident #26 was receiving oxygen at 1.5 liter per minute (lpm). During an observation on 11/15/2023 at 8:25 AM, Resident #26 was receiving oxygen at 1.5 lpm. Review of Resident #26's physician orders dated 10/26/2023 reads, Oxygen at 4 liters/minute via nasal canula every shift related to Chronic Respiratory Failure with Hypoxia. During an interview on 11/15/2023 at 8:30 AM, Staff C, LPN, stated that Resident #26's oxygen should be set at 4 lpm. Review of the facility policy and procedure titled Oxygen Administration with the last review date of 1/25/2023 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as prescribed by the physician for 3 of 4 residents reviewed for oxygen administration, Residents #32, #26, and #61.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 1 of 7 medication carts and failed to ensure the medications were secured in 3 out of 6 units. Findings include: During an observation of 300 Hall Medication Cart on 11/13/2023 at 9:36 AM with Staff A, License Practical Nurse (LPN), there were eight pre-poured medication cups. There were two stacks of three medication cups stacked on top of each other. During an interview on 11/13/2023 at 9:36 AM, Staff A, LPN, stated, I pre-pour all my medication before starting medication pass and label the medication cups. This is how I always do it. It follows the facility protocol. During an observation of 300 Hall Medication Cart on 9:40 AM, the Director of Nursing opened the top drawer and stated to Staff A, LPN, This is not allowed. During an observation of Resident #40's room on 11/13/2023 at 10:43 AM, there was one bottle of Peridex (Chlorhexidine Gluconate 0.12%) Oral Rinse on top of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0641 — isolatedEnsure 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, interview, and record review, the facility failed to ensure minimum data set assessments were accurate for 1 of 2 residents reviewed for dental services, Resident #75, and 1 of 4 residents reviewed for discharge, Resident #93. Findings include: 1. During an observation on 11/13/2023 at 10:34 AM, Resident #75 was sitting up in bed. Resident #75 had missing teeth on the top and bottom gums. During an interview on 11/13/2023 at 10:34 AM, Resident #75 stated, I am missing teeth, which makes it difficult for me to chew. Review of Resident #75's physician order dated 9/28/2023 reads, Regular diet pureed texture, thin consistency, pt [patient] is vegan, no milk product, no meat, nutritional fruit drink in cup with meals tid [three times a day]. Review of Resident #75's Nutrition Risk Evaluation dated 9/27/2023 reads, 07. Physical/Mental Function: A. Physical and Mental Functioning: b. Out of bed with assistance, motor agitation (tremors, wandering), limited feeding assistance, supervision while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain appropriate parameters of nutritional status for 1 of 5 residents reviewed for nutrition, Resident #75. Findings include: During an observation of Resident #75 on 11/13/2023 at 1:16 PM, review of the meal ticket reads, Puree Vegan Small Portions. Pureed Mashed Potatoes, Pureed Broccoli Cuts, Hot Coffee or Hot Tea, Orange Nutritious Juice Supplement [marked with NA (not applicable)]. During an interview on 11/13/2023 at 1:16 PM, Resident #75 stated, I am vegan and do not get the protein I need. During an observation of Resident #75 on 11/14/2023 at 8:34 AM, review of the meal ticket reads, Puree Vegan Small Portions. Pureed Oatmeal, Hot Coffee or Hot Tea, Orange Nutritious Juice Supplement [marked with NA (not applicable)]. During an observation of Resident #75 on 11/14/2023 at 12:54 PM, review of the meal ticket reads, Puree Vegan Small Portions. Pureed Buttered Spaghetti, Pureed Italian Vegetable Medley, Hot Tea, Orange Nutritious Juice Supplement [marked with NA (not applicable)]. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 facility policy and procedure review, the facility failed to ensure the stored food items were labeled and dated. Findings include: During the initial tour of the kitchen on 11/13/2023 at 9:15 AM, there were two bags containing food items with no label or date in the walk-in freezer. During an interview on 11/13/2023 at 9:29 PM, the CDM identified the food as country chicken and confirmed that they are unlabeled. The CDM stated, Everything needs to be dated and marked with the name. During the tour of the facility on 11/13/2023 at 9:33 AM, there were one opened bottle of orange juice with no label and date, and a bag containing three boxes of food items with no date in the refrigerator located in bistro area. During an interview on 11/13/2023 at 9:35 AM, the CDM identified the food items in the undated bags as brisket, mashed potato, and noodles, The CDM confirmed the bottle of orange juice and the food items were not dated. Review of the facility policy and procedure titled P&P Refrigerated Storage issued on 1/1/2022 and last reviewed on…
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
$17,737 in federal fines across 1 penalty.
- $17,737 — penalty dated 2025-02-27
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 GOLD FL TRUST II — 36 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 | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE LODGE SNF HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/27/2022 |
| OLIVER, TONYA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
2 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.
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 105196. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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.