Conway Lakes Health & Rehabilitation Center

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.

51.1% 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 423 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.6% 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 189 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 0.75 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 112.0 residents a day — about 93% 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 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.59 hrs/resident/day on weekends vs 4.16 on weekdays — 14% thinner on weekends. RN hours go from 0.73 to 0.55 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%. 1 administrator has left in the past year.

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.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-02-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record revealed resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE], 12/17/24, and 1/15/25. Her diagnoses included Alzheimer's disease, dementia, falls, muscle weakness and fracture of shafts of humerus on the right and left arms. Review of the admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/22/24 revealed resident #5's BIMS score of 0 out of 15, which indicated severe cognitive impairment. The assessment indicated resident #5 had no behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The MDS showed she required partial/moderate assistance for eating and upper body dressing, substantial/maximal assistance for oral hygiene, shower/bathe, lower body dressing and personal hygiene and was dependent on staff for toileting hygiene. The MDS assessment noted resident #5 was independent with rolling from left to right in bed, sit to lying and lying to sitting on the side…

  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
• Immediate jeopardy · Jcited before2025-02-01 · 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 2. Review of the medical record revealed resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE], [DATE], and [DATE]. Her diagnoses included Alzheimer's disease, dementia, falls, need for assistance with personal care, muscle weakness and fracture of shafts of humerus on the right and left arms. Review of the admission Minimum Data Set (MDS) assessment with dated [DATE] revealed resident #5's BIMS score of 0 out of 15, which indicated severe cognitive impairment. No behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The Preferences for Customary Routine and Activities section noted it was somewhat important for her to have snacks available between meals and very important for her to choose her own bedtime. The MDS showed she required partial/moderate assistance for eating and upper body dressing, substantial/maximal assistance for oral hygiene, shower/baths, lower body dressing and personal hygiene and was dependent on staff 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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 necessary care and services were provided to promote healing and prevent infection of a facility acquired pressure ulcer for 1 of 2 cognitively impaired residents reviewed for pressure ulcer management, of a total sample of 20 residents, (#1). The facility's failure to ensure timely and adequate care and treatments for pressure injury and infection resulted in actual harm for a cognitively impaired resident at risk for development of pressure wounds. Resident #1 subsequently was transferred to a higher level of care with an admitting hospital diagnosis of sepsis with hypotension, and sacral wound. Resident #1 was placed on Hospice services on [DATE] and expired four days later on [DATE]. Findings: Resident #1, a [AGE] year-old-male was admitted to the facility on [DATE]. His diagnoses included type II diabetes mellitus, vascular dementia, Parkinson's disease, atrial fibrillation, and atherosclerotic heart disease. Resident #1 was transferred 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 · E2025-09-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure food was safely stored and/or discarded in the areas of the main reach-in coolers, the pot/pan sink sanitizing solution was at the correct concentration and failed to ensure food preparation surfaces were not cross-contaminated during production in accordance with professional standards for food service safety. Findings:1.On 9/08/25 at 9:36 AM, an initial walk-through tour of the kitchen was conducted with the Dietary Manager (DM). In the reach-in cooler a white plastic container had a label that read: Turkey Prepared date 7/07/25, Use by 7/10/25. The DM confirmed the date on the label of the white plastic container read, Turkey Prepared date 7/07/25 Use by 7/10/25 and should have been discarded almost two months prior. (Photo evidence obtained) 2. On 9/08/25 at approximately 9:45 AM, the sanitizing solution in pot/pan sink was tested and was <100 parts per million (ppm). The sanitizing solution concentration should have been 150 - 200 ppm along with the contact time per the manufacturer's…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, and record review, the facility failed to ensure referrals to the appropriate state designated authority for Preadmission Screening and Resident Review (PASARR) Level II evaluation and determination were made for two of three residents reviewed for PASARR, of a total sample of 25 residents, (#11, and #80). Findings:1.Record review of resident #11's most recent Level l PASARR, dated 2/08/24, revealed resident #11 was assessed as having, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. A review of the Facility Resident Matrix dated 9/08/25 indicated resident #11 had a diagnosis and/or was being treated for PTSD (Post Traumatic Stress Disorder); [Resident #11 name].On 9/10/25 at 11:50 AM, the Director of Nursing (DON) stated the facility did not have documentation that indicated resident #11's Level I PASRR had been revised to show the diagnosis of PTSD, nor was a Level II PASARR screening initiated.2. Record review revealed resident #80 had a Level I PASARR completed on 5/16/22.…

  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 · D2025-09-11 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in one of two residential halls in the facility, (100s hall, resident #7). Findings:Review of resident #7's medical record revealed diagnoses that included sepsis, bacteremia, urinary tract infection, type II diabetes, and need for assistance with personal care. Review of active physician orders revealed no orders related to self-administration of medications. Review of the Minimum Data Set assessment revealed resident #7 had severely impaired cognition. On 9/09/25 at 9:49 AM, resident #7 was in his room in bed. Two pills were observed on the bedside table. Resident #7 explained why the nurse had left the pills on the table, saying, that's my medicine they left me to take. (Photo evidence obtained) On 9/10/25 at 8:00 AM, the Unit Manager (UM) confirmed resident #7's medications shouldn't have been left at bedside by the nurse. The Unit Manager verified a self-administration order was needed otherwise the nurse should not leave medications with residents to take on their…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview the facility failed to maintain infection control practices by not keeping the urine collection bag and the tubing off the floor and away from unsanitary surfaces for one of one resident reviewed for urinary catheters, of a total sample of 25 residents, (#7).Findings:On 9/08/25 at 10:51 AM, resident #7's catheter bag was found to be clipped to a trash can located at the side of his bed. The base of the urine collection bag was resting on the floor. (Photo evidence obtained)On 9/08/25 at 12:38 PM, resident #7's catheter bag was lying flat on the floor of his room.On 9/09/25 at 10:15 AM, the catheter bag was again clipped to the trash can with the base of the collection bag lying on the floor. On 9/10/25 at 9:17 AM, in resident #7's room, the Director of Nursing (DON) confirmed resident #7's urinary catheter bag clipped to the trash can. A few minutes later the DON stated she was the Infection Prevention Nurse and verified it was not appropriate for the urinary collection catheter bag to be attached to the trash can. She confirmed the catheter urine…

  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 before2025-07-02 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 thoroughly investigate and report an allegation of neglect and an injury of unknow origin resulting in serious bodily injury to the Agency for Healthcare Administration (AHCA). The facility failed to report the allegation to AHCA within the federally required 2-hour timeframe, and the 5-day investigation report lacked sufficient detail, as required under federal regulation, for 1 of 1 resident reviewed for neglect, of a total sample of 8 residents, (#1).Findings:Resident #1 was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/09/24. Her most recent diagnoses included speech and language deficits after a stroke, reduced mobility, history of falling, muscle weakness, fracture of upper end of right humerus, and osteoarthritis.Review of the Minimum Data Set Quarterly assessment with Assessment Reference Date 3/09/25 revealed resident #1's was nonverbal, and cognitively impaired with bilateral upper extremity…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-02 · 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, implement, and revise a person-centered, comprehensive care plan to address communication needs for 1 of 4 residents reviewed for care planning, of a total sample of 8 residents, (#1).Findings: Cross Reference F689 Review of the medical record revealed resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her most recent diagnoses included stroke with residual speech and language deficits, impaired mobility, right humerus fracture, type 2 diabetes, and osteoarthritis. Review of the Minimum Data Set (MDS) signification change in condition assessment with Assessment Reference Date (ARD) of 6/10/25 revealed resident #1's preferred language was Spanish. Resident #1 had bilateral upper extremities impairment and was dependent on staff for all Activities of Daily Living, mobility and transfers. The MDS quarterly assessment with ARD of 3/09/25 showed resident #1's preferred…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) followed facility protocol when transferring a physically and cognitively impaired vulnerable resident from bed to wheelchair; and failed to ensure staff transferred residents safely for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7:00 AM to 3:00 PM shift CNA transferred the resident by herself without the use of a gait belt. After CNA A transferred resident #1 from her bed to the wheelchair she transported her to the dayroom. Hours later, when resident #1 was taken back to her room by the next shift CNA, she noticed a bruise on the resident's right upper arm (RUA) and notified the nurse. Resident #1 was assessed by her assigned Registered Nurse (RN)…

  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 · D2025-07-02 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the appropriate level of transfer assistance for a cognitively and physically impaired vulnerable resident and failed to ensure nursing staff demonstrated competency in all aspects of the transfer process. The facility failed to validate staff retained education provided and monitor Certified Nursing Assistants (CNAs) for adherence to facility transfer processes for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7 AM to 3 PM shift CNA transferred the resident by herself without the use of a gait belt. After CNA A transferred resident #1 from her bed to the wheelchair, she spent approximately six hours in the dayroom. Resident #1 was taken back to her room by the 3 to 11 PM shift CNA, who…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-02 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, and record review, the facility failed to ensure effective implementation of policies, including thorough monitoring of previously identified areas of concern and adequate tracking of performance to verify improvement measures were realized and sustained. Findings: Review of the facility's policy titled QAPI (Quality Assurance and Performance Improvement)/Risk Management Program, dated 2017, read, The purpose of QAPI is to take a proactive approach to continual improvement of the care is given to residents, . The policy also referenced the QAPI Guiding Principles, stating, . QAPI focuses on systems and processes in order to examine and improve care or services in areas that are identified through the performance improvement plan (PIP) teams, as needing attention and setting priorities for action based on the information gathered. Data is obtained through the QAPI process from caregivers, residents, healthcare practitioners, families and others in the community, in order to systematically clarify areas of concentration focusing on root cause to determine proper…

  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 · D2025-06-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide appropriate care and services to a long-term resident with a suprapubic catheter (SPC) after hospitalization for 1 of 3 residents reviewed for urinary catheters, of a total sample of 4 residents, (#2). Findings: Review of the medical record revealed resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included quadriplegia (paralysis that affects all limbs and body from the neck down), traumatic brain injury, and neuromuscular dysfunction of the bladder. Review of the annual Minimum Data Set assessment with Assessment Reference Date of 4/11/25 revealed resident #2 was in a persistent vegetative state. The assessment indicated he had an indwelling catheter. A suprapubic catheter is a surgically implanted device that helps to drain urine from your bladder through your abdomen. It is important to keep the area around the suprapubic catheter clean, to flush the catheter regularly to prevent clots 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan 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

$94,672 in federal fines across 6 penalties.

• $4,147 — penalty dated 2025-06-10
• $4,147 — penalty dated 2025-06-10
• $6,227 — penalty dated 2025-06-10
• $61,636 — penalty dated 2025-02-01
• $6,180 — penalty dated 2024-08-22
• $12,335 — penalty dated 2024-08-22

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 CLEAR CHOICE HEALTHCARE — 8 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 8 rows in the source record cover these 5 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.

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.

This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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