Alwyn C Cashe State Veterans Nursing Home

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 112 beds and averages 101.6 residents a day — about 91% occupied, or roughly 10 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 5.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.05 is at or above 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 4.63 hrs/resident/day on weekends vs 5.57 on weekdays — 17% thinner on weekends. RN hours go from 1.41 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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

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.

22 citations, most serious first. The 14 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · J2025-09-05 · 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 protect the residents' right to be free from neglect by not ensuring the staff maintained a secure environment and implemented measures to mitigate the risks to prevent elopement for 1 of 7 residents reviewed for elopement, of a total sample of 11 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was outside the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 8/07/25 at approximately 4:32 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until day shift staff coming to work found him in the front vestibule at approximately 6:00 AM. The facility failed to ensure the unit was secured and that resident #1 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-09-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement, of a total sample of 11 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was outside the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 8/07/25 at approximately 4:32 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until staff located him in the front entrance hall outside the facility at approximately 6:00 AM. The facility failed to ensure resident #1 was adequately supervised to ensure vulnerable residents did not exit 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 · Past Non-Compliance
• Actual harm · G2024-09-14 · 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 interview and record review, the facility failed to ensure freedom from a physical restraint that inhibited movement and activity for 1 of 2 residents reviewed for restraints, of a total sample of 10 residents, (#1). The facility's failure to promote resident #1's rights to be treated with respect and dignity and to be free from abuse resulted in psychosocial harm. Using the reasonable person concept there was potential for outcomes such as continued agitation and anxiety, loss of dignity, dehumanization, and feelings of fear and imprisonment. Resident #1, a cognitively impaired resident, was inappropriately restrained in his wheelchair and he struggled to move freely and stand. Improper use and monitoring of an improvised restraint placed resident #1 at risk for skin breakdown, injury during attempts to free himself, and accidents including falls and strangulation. Findings: Cross reference F741. Review of the medical record revealed resident #1, a [AGE] year-old male, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-09-14 · tag F0741 — failed to have staff trained for behavioral health — isolated
  Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
  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 the Memory Care Unit had sufficient staff with appropriate competencies and skill sets to meet the needs and ensure the safety of 1 of 4 residents reviewed for behavioral symptoms, of a total sample of 10 residents, (#1). The facility's failure to ensure there were adequate staff to supervise and monitor residents on the specialized Memory Care Unit; and failure to ensure staff demonstrated competencies related to recognizing behavior patterns and implementing appropriate approaches, resulted in psychosocial harm. Using the reasonable person concept there was potential for outcomes such as continued agitation and anxiety, loss of dignity, dehumanization, and feelings of fear and imprisonment for resident #1, and placed all residents on the unit at risk. Resident #1, a cognitively impaired resident, was physically restrained by nursing staff as a method to manage his verbal and physical behavioral symptoms and address his safety needs. Findings:…

  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 · D2025-12-23 · tag F0559 — isolated
  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
  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 notify the family representative in writing of a room change for 1 of 3 residents reviewed for Resident's Rights, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from another nursing home on 4/03/25 and re-admitted from an acute care hospital on 8/12/25. The record noted the resident changed rooms on 11/26/25 because a private room was no longer medically necessary. In an interview on 12/23/25 at 1:30 PM, the Social Worker said it was the facility's practice to notify the resident/family representative verbally in person or over the telephone of room changes. She said a handwritten log of changes was kept by the Social Services Department. She checked the log and said it indicated on 11/25/25, resident #1's family representative was contacted by telephone and notified of the room change. She said she also recalled discussing it with her the next…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-23 · 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, interview, and record review, the facility failed to develop an individualized comprehensive care plan to include a pacemaker and compression stockings for 1 of 3 residents reviewed for quality of care, of a total sample of 4 residents, (#1).Findings: Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from another nursing home on 4/03/25 and re-admitted from an acute care hospital on 8/12/25 with diagnoses that included cognitive communication deficit, dementia, type 2 diabetes mellitus, chronic venous hypertension (high pressure in veins) with inflammation of bilateral (both) lower extremities (legs/feet), atherosclerotic (hardening of arteries) heart disease, chronic atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (ineffective pumping/fluid buildup), and edema (fluid retention/swelling). The most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 10/11/25 showed resident #1…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide expected provision of care and follow physician's orders for compression stockings for 1 of 3 resident reviewed for quality of care, of a total sample of 4 residents, (#1).Findings: Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from another nursing home on 4/03/25 and re-admitted from an acute care hospital on 8/12/25 with diagnoses that included dementia, type 2 diabetes mellitus, chronic venous hypertension (high pressure in veins) with inflammation of bilateral (both) lower extremities (legs/feet), atherosclerotic (hardening of arteries) heart disease, congestive heart failure (CHF) (ineffective pumping/fluid buildup), and edema (fluid retention/swelling). The most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 10/11/25 showed resident #1 scored 10 out of 15 on the Brief Interview for Mental Status that indicated moderate cognitive…

  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 · D2025-12-23 · tag F0840 — isolated
  Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
  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 Cardiology services were provided per physician's orders for 1 of 3 residents reviewed for administration, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, a [AGE] year old male was admitted to the facility from another nursing home on 4/03/25 and re-admitted from an acute care hospital on 8/12/25 with diagnoses that included dementia, type 2 diabetes mellitus, chronic venous hypertension (high pressure in veins) with inflammation of bilateral (both) lower extremities (legs/feet), atherosclerotic (hardening of arteries) heart disease, chronic atrial fibrillation (abnormal heart rhythm), congestive heart failure (CHF) (ineffective pumping/fluid buildup), and edema (fluid retention/swelling). The most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 10/11/25 showed resident #1 scored 10 out of 15 on the Brief Interview for Mental Status that…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-27 · tag F0550 — failed to protect resident dignity and rights — pattern
  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 treat each resident with respect and dignity by failing to recognize each resident's individual preference whether to wear a clothing protector at meals for 31 residents observed on the memory care unit out of a total sample of 25 residents. Findings: On 2/24/25 at 11:59 AM, in the Freedom memory care unit dining room, facility staff were observed putting clothing protectors on all 19 resident without first asking if they wanted to wear one. Staff informed residents they were putting the clothing protector on them, but did not ask the resident their preference. On 2/25/25 at 12:08 PM, Certified Nursing Assistant (CNA) G was observed as she put clothing protectors on residents without first asking them if they wanted to wear one. A short time later at 12:35 PM, a total of twelve residents dining on the Patriot Unit were all wearing clothing protectors over their clothes before lunch was served. On 2/27/25 at 12:01 PM, CNA H was observed while she put clothing protectors on residents without first asking them if…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-27 · 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, interview and policy review, the facility failed to establish and maintain 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 when linen was folded without demonstrating proper folding techniques and hygiene protocols. Findings: On 02/27/25 at 1:34 PM the facility's laundry area was observed. The clean area and the dirty section were separated by a door. In the clean area a laundry aide was observed at the folding table and also in the room was the administrator, housekeeping manger and the laundry supervisor. The laundry aid began folding a bed sheet. The bed sheet was folded in half, then the aid placed the bed sheet against his/her body and folded it again. The laundry aide said he/she had infection control training but could not remember the date. When informed that he/she was holding the linen against his/her body, the aide appeared to get irritated and tossed the bed sheet on previously folded items. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-27 · 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 interview, and record review, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for 2 of 2 residents reviewed for comprehensive care plans out of a total sample of 25 residents, (#10 and #49). Findings: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy, obstructive sleep apnea, dysphagia and type 2 diabetes. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/30/24 revealed resident #49 had short-term and long-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment revealed resident #49 was on a mechanically altered therapeutic diet and was dependent on staff for eating. A care plan initiated 11/19/24 indicated resident #49 had a feeding self-care deficit. Interventions included staff to provide assistance with eating and drinking. The care plan did…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-27 · 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 observation, interview, and record review the facility failed to provide appropriate care and services to maintain and clean a Continuous Positive Airway Pressure (CPAP) machine for 1 of 1 residents reviewed for respiratory services, of a total sample of 25 residents, (#49). Findings: Resident #49 was admitted on [DATE] with diagnoses including dementia, metabolic encephalopathy, dysphagia, obstructive sleep apnea (OSA), Diabetes Mellitus (DM) Type II, and was assessed to be dependent for all activities of daily living (ADL). On 02/26/25 at 12:39 PM, resident #49's spouse stated the CPAP machine was working fine but the distilled water used in the machine was still in the cannister and staff needed to empty it daily, then leave the canister to dry. On 2/26/25 at 12:41 PM, Registered Nurse (RN) C was asked to come into resident #49's room to observe the CPAP machine. Observations at that time noted water remained in the cannister and it was not clean. RN C stated it was everyone's responsibility to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-27 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent medication errors greater than 5 percent (%) for 3 of 4 residents sampled for medication administration, (#29, & #18), of a total sample of 25 residents. There were 4 errors in 30 opportunities by 2 of 3 nurses observed, for a medication error rate of 13.3 %. Findings: 1. Resident #29 was most recently admitted to the facility on [DATE] with diagnoses that included unspecified dementia, stroke, chronic leg ulcer, rash and pruritic (itchy skin). Review of physician orders for February 2025 revealed an order for Lidocaine adhesive patch, medicated 5 per cent (%), administer 5%, topically. Special instructions included apply patch daily for 12 hours on lower back, then remove. Other orders included Resident #29 had an additional physician order for Lac-Hydrin (ammonium lactate) lotion, 12% administer 12% topically which was to be administered twice a day at 10:00 AM and 2:30 PM for dryness of bilateral extremities. On 2/25/25 at 9:58…

  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 · E2025-01-24 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  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 implement its policy and procedures for the prohibition of abuse and neglect related to providing staff education, conducting a thorough incident investigation, and protecting residents in response to an allegation of neglect for 1 of 2 residents reviewed for neglect, of a total sample of 4 residents, (#1); and failed to minimize the risk for neglect for residents who had abnormal diagnostic test results. Findings: Review of the facility's policy and procedure for Abuse, Neglect and Exploitation / Misappropriation of Property, revised on 3/01/24, revealed the facility's intent to achieve and maintain an abuse-free environment. The document indicated the seven components of the abuse prohibition program were screening, training, prevention, identification, investigation, protection, and reporting. The procedure defined neglect as the failure to provide necessary goods and services and the .failure to make reasonable effort to protect a resident from…

  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

“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.

Fines & penalties

$68,731 in federal fines across 11 penalties.

• $17,345 — penalty dated 2025-09-05
• $5,249 — penalty dated 2025-01-24
• $5,249 — penalty dated 2025-01-24
• $8,018 — penalty dated 2024-09-14
• $8,783 — penalty dated 2024-09-14
• $4,140 — penalty dated 2024-02-20
• $3,764 — penalty dated 2024-02-12
• $9,032 — penalty dated 2024-01-22
• $2,258 — penalty dated 2024-01-08
• $1,748 — penalty dated 2024-01-02
• $3,145 — penalty dated 2023-12-11

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 FLORIDA DEPARTMENT OF VETERANS' AFFAIRS — 7 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 →

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

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

What families pay in FL