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Westminster Towers

70 West Lucerne Circle, Orlando, FL 32801 · Non profit - Corporation · 120 certified beds · (407) 841-1310 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 20241 immediate-jeopardy citation$22,133 in federal fines
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,133 in federal fines (most recent 2025-03-04)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
810 Lucerne Ter · (407) 632-1010 · Call to confirm hours
Pharmacy
1234 Main St
Grocery
9 W Gore St · (407) 241-2853 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.8%8.7%15.4%better
Long-stay residents who lose too much weight4.7%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.9%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.4%2.5%3.3%better
Long-stay residents whose ability to walk worsened14.8%9.5%16.1%typical
Long-stay residents on antianxiety or hypnotic medication6.9%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.4%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control2.8%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 table2.4%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine98.6%94.7%79.4%better
Short-stay residents rehospitalized after admission20.5%26.1%22.6%typical
Short-stay residents with an outpatient ER visit3.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.882.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.701.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

66.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 226 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.6%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
61.5%U.S. median 56.6%
Met the expected recovery
0.63U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 61.5% 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 96 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 0.63 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 44% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.6%CMS range 61.5–71.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.5–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.3%98.7%Oct 2024–Sep 2025CMS 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 stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.5–9.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.06
RN hours/ resident / day
0.36
LPN hours/ resident / day
2.28
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.83
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 93.4 residents a day — about 78% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.40 hrs/resident/day on weekends vs 3.82 on weekdays — 11% thinner on weekends. RN hours go from 1.15 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2025-03-13)
4
at the previous standard inspection (2023-08-03)

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

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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

  • Immediate jeopardy · J2025-03-04 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of code status in an emergency for 1 of 13 residents reviewed for advance directives, (#1). On [DATE] at approximately 7:00 PM, resident #1 was observed unresponsive in her bed. Registered Nurse (RN) A took her vitals and notified RN C resident #1 had passed away. RN A failed to verify resident #1's code status and failed to provide CPR per her wishes. Emergency Medical Services was never called. The facility failed to honor the resident's wish to be resuscitated and the physician order for Full Code status. The facility's failure to ensure staff followed procedures related to honoring an advance directive to provide lifesaving measures including CPR for a resident on hospice care contributed to resident #1's death. This action placed all residents who received hospice care at risk of not having their wishes honored. This failure resulted in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-13 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 interview, and record review, the facility failed to follow physician orders and ensure the comprehensive care plan was implemented for 1 of 5 residents reviewed for unnecessary medications and medication regimen, of a total sample of 34 residents, (#43). Findings: Review of resident #43's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 1/13/25. Her diagnoses included atrial fibrillation, hypertension (HTN), type 2 diabetes, and stroke. Review of resident #43's comprehensive care plan with a cardiac focus revised on 3/12/25 revealed potential for altered cardiovascular status. The interventions included, Administer cardiac medications as ordered . Monitor vital signs as ordered. Review of resident #43's medical record revealed a physician order dated 1/13/25 for Hydralazine 100 milligrams (mg) three times a day (TID) for HTN. The order directed the nurses to hold the medication if the systolic blood pressure (SBP) was less…

    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 before2025-03-13 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 residents' self-administration of medication for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 33 residents, (#57, and #83). 1. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including drug-induced secondary Parkinsonism, bipolar disorder, hypertensive heart disease, and dementia. A review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 12/23/24, revealed resident #57 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating he was cognitively intact. On 3/10/25 at 1:58 PM, resident #57 was sitting on the right side of his bed. His nightstand was observed with a one-ounce Neosporin ointment. He stated he used it on the small rash on his right thigh. On 3/10/25 at 2:05 PM, the resident's nightstand was observed by primary Registered Nurse (RN) C. She acknowledged the Neosporin ointment on the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-13 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 a written summary of the baseline care plan was provided to 1 of 2 residents reviewed for care plans, (#390); and failed to provide a written summary of the baseline care plan within the required time frame for 1 of 2 residents reviewed for care plans, (#546), of a total sample of 34 residents. Findings: 1. Resident #390, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included right ankle osteomyelitis, asthma, generalized anxiety disorder, and open wound, right foot. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 15 of 15. On 3/10/25 at 2:46 PM, resident #390 stated he did not recall receiving a written summary of his initial care plan. Review of the resident's Baseline Care Plan Assessment with effective date of 2/23/25, and lock date of 2/24/25, revealed signatures for staff 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide showers per resident preference and as scheduled for 1 of 2 resident reviewed for Activities of Daily Living (ADLs), of a total sample of 34 residents, (#75). Findings: Review of resident #75's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on [DATE]. His diagnoses included atrial fibrillation, chronic pain syndrome, spinal stenosis (narrowing of the space around the spinal cord or nerves) and fusion of spine. Review of resident #75's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 2/17/25 revealed he had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. The MDS assessment showed resident #75 was dependent on staff for showers/baths and required extensive assistance for personal hygiene. The MDS assessment noted no rejection of care necessary to obtain goals for his health 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 date of correction
  • Potential for harm · D2025-03-13 · 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 obtain an outside eye specialist appointment for 1 of 1 residents reviewed for care coordination, of a total sample of 34 residents, (#45). Findings: Review of resident #45's medical record revealed an admission date of 6/24/22. His diagnoses included quadriplegia unspecified (paralysis), slurred speech, polyneuropathy, and mild vascular dementia with anxiety. His record included that he had no known allergies. His annual Minimum Data Set, dated [DATE] indicated his Brief Interview of Mental Status score was 13/15, meaning his cognition was intact. Review of resident #45's medical record revealed a current order that resident #45 may have vision consults as needed for medical necessity with a start date of 6/24/22. Review of resident #45's current medications included artificial tears solution 1% drop in both eyes two times a day for eye irritation, with a start date of 3/06/25. Review of resident #45's January 2025 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 interview, and record review, the facility failed to ensure documentation was accurate and complete for 1 of 1 resident reviewed for accidents, of a total sample of 34 residents, (#55). Findings: Resident #55, a 98- year-old male was admitted to the facility on [DATE]. His diagnoses included heart failure, weakness, unsteadiness on feet, difficulty walking, dementia, cardiac pacemaker, and acute embolism and thrombosis of right femoral vein Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was moderately impaired with a brief interview for mental status score of 8 of 15, moderate cognitive impairment. The assessment indicated the resident required substantial/maximal assistance for toileting hygiene, and partial/moderate assistance for sit to stand, and for chair/bed-to chair transfer. A care plan for at risk for falls and injuries related to need for physical assistance, and weakness was initiated on 1/13/25. Interventions included,…

    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 · D2024-08-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report timely an alleged violation of neglect for 1 of 1 resident reviewed for neglect, of a total sample of 3 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, abnormalities of gait and mobility and major depressive disorder. Review of the Minimum Data Set admission assessment with assessment reference date of 7/15/24 revealed resident #1 had a Brief Interview for Mental Status score of 10/15 which indicated she had moderate cognitive impairment. The document indicated she used a wander/elopement alarm daily. A care plan for wandering and at risk for elopement was initiated 7/08/24. Interventions included the use of a wander/elopement alarm daily. Review of resident #1's progress notes for the month of August 2024 revealed she was unable to be located on the morning of 8/07/24 during rounds by the 7:00 AM - 3:00 PM nurse. A facility search was initiated. The facility…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-21 · 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 prevent elopement for 1 of 1 resident reviewed for actual elopement, of a total sample of 3 residents reviewed for elopement, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, abnormalities of gait and mobility and major depressive disorder. Review of the Minimum Data Set admission assessment with assessment reference date of 7/15/24 revealed resident #1 had a Brief Interview for Mental Status score of 10/15 which indicated she had moderate cognitive impairment but did not exhibit disorganized thinking. The document indicated she used a walker for independent mobility and did not have any impairment to her upper or lower extremities. The assessment revealed resident #1 wore a wander/elopement alarm daily. Review of the medical record revealed an elopement evaluation dated 7/05/24. The evaluation indicated resident #1 wandered and had 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-14 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 physician's order was obtained for medications at bedside for 1 of 3 residents reviewed for pressure ulcer care, of a total sample of 8 residents, (#2). Findings: Resident #2, an [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included cellulitis to his right lower limb, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcer to his right and left buttocks. Review of the resident's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 14 out of 15. The assessment revealed the resident had impairment in functional limitation in range of motion on both sides of his upper and lower extremities. On 5/13/24 at 10:32 AM, resident #2 was sitting in his wheelchair in his room to the right of his bed. His tray table was positioned in front of him, and a tube of Ammonium lactate 12% cream, and 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-14 · 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 wound care for pressure ulcers was completed per physician's orders for 2 of 3 residents reviewed for pressure ulcers, of a total sample of 8 residents, (#1, and #2). Findings: 1. Resident #1, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of tongue, gastrostomy, and pneumonia. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 1/02/24 revealed the resident had an unstageable pressure ulcer to his sacrum, and pressure ulcers to his left and right ischium, stages were not documented. Documentation on the Wound Physicians wound evaluation and summary management dated 3/14/24 revealed the resident had a stage IV pressure wound to his coccyx which measured 3.3 x 2.3 x 1.2 centimeters(cm) with undermining of 3.5 cm at 12 o'clock position. The dressing treatment plan was Gentamicin ¼ strength Dakins solution, Santyl, and gauze roll…

    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
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-05-14 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 ensure a Peripheral Inserted Central Catheter (PICC) line dressing was changed as per physician's order, and professional standard of practice to prevent the potential for infection for 1 of 8 residents, (#2). A PICC is a thin, flexible tube that is inserted into a vein in the upper arm . It is used to give intravenous fluids, . chemotherapy, and other drugs. (retrieved on 5/31/24 from www.cancer.gov). Findings: Resident #2, an [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included cellulitis to his right lower limb, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcer to his right and left buttocks. Review of the resident's Minimum Data Set admission assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 14 out of 15. The assessment revealed the resident was on antibiotic therapy and had a central line for intravenous (IV)…

    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 before2024-05-14 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 interview, and record review, the facility failed to ensure medical records were accurate regarding a Peripheral Inserted Central Catheter (PICC) line dressing for 1 of 1 residents reviewed for PICC lines, of a total sample of 8 residents, (#2). A PICC is a thin, flexible tube that is inserted into a vein in the upper arm . It is used to give intravenous fluids, . chemotherapy, and other drugs. (retrieved on 5/31/24 from www.cancer.gov). Findings: 1. Resident #2, an [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included cellulitis to his right lower limb, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcer to his right and left buttocks. Review of the medical record revealed a physician order dated 5/03/24 to change the PICC line dressing every 7 days on the evening shift. On 5/13/24 at 10:32 AM, a PICC line was observed on the resident's right upper arm. The dressing to the PICC line was dated 5/04/24. Review of the resident'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to honor resident preferences for showers for 1 of 3 residents reviewed for choices, of a total sample of 34 residents, (#101). Findings: Resident #101 was admitted to the facility on [DATE]. Her diagnoses included wedge compression fracture of thoracic vertebra, weakness, difficulty walking, low back pain, and history of falls. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 7/23/23, revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13/15. Assessment of resident #101's daily preferences revealed it was somewhat important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and noted she required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the resident's clinical records revealed the resident was scheduled for showers on Monday, Wednesday, and Friday on the 7…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 that an accurate comprehensive, Minimum Data Set assessment was completed for 1 of 34 sampled residents who were admitted to the facility, (#36). Findings: Resident #36 was admitted to the facility on [DATE] with diagnoses that included Cardiovascular disease, unspecified, Polyneuropathy, unspecified, Diabetes Mellitus, Depression, essential hypertension, cerebral ischemia, Chronic Obstructive Pulmonary Disease, Pulmonary fibrosis, chronic kidney disease, There was no inclusion of Hypothyroidism listed under the diagnosis section on the resident's admission record. Review of the resident's Agency for Health Care Transfer Form 5000-3008 provided to the skilled facility by the transferring hospital documented the diagnosis of Hypothyroidism under the category of Medical Conditions. Review of the resident's History and Physical from the transferring hospital documented the resident with a diagnosis of Hypothyroidism. Review of the resident'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 2 of 5 residents reviewed for PASRR that were later identified with Intellectual Disability (ID) or Serious Mental Illness (SMI) out of a total sample of 34 residents, (#76, #48). Findings: 1. Review of resident #76's medical record revealed the resident was admitted to the facility on [DATE] from a nursing home. The resident had diagnoses that included autism, bipolar disorder, major depressive disorder, frontal lobe (brain) syndrome, dementia, malnutrition, failure to thrive, and sarcopenia (progressive skeletal muscle disorder). The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 7/19/2023 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively intact. The assessment showed he rejected evaluation or care for health and well-being 1 to 3 days out of 7, required staff supervision 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · 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 interview and record review the facility failed to ensure blood glucose monitoring was conducted as per the physician's orders for 1 of 1 resident of a total sample of 34 residents, (#358). Findings: Resident #358, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses including acute kidney failure, Rhabdomyolysis, dementia, and diabetes type II. Record review of the resident's active physician's orders revealed an order dated 7/27/23 for blood glucose monitoring (accuchecks) two times per day. A Physician note dated 7/27/23 read, Patient's blood sugar was in the 145 and daughter wants blood sugars to be checked. The physician's plan on 7/27/23, and 7/31/23 included: monitor accuchecks. On 8/01/23 at 11:03 AM, resident #358 stated prior to his admission to the facility, he had blood sugar monitored daily. Record review of the resident's clinical records revealed no documentation of blood glucose monitoring. On 8/02/23 at 3:56 PM, the resident's physician orders were reviewed with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment regarding hospice services for 1 of 3 residents reviewed for hospice services, of a total sample of 35 residents, (#17). Findings: Resident #17 was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included cerebral atherosclerosis, Alzheimer's disease, dementia, and anxiety disorder. A physician order dated 7/07/21 revealed the resident was on hospice services for diagnosis of cerebral atherosclerosis. Review of the resident's clinical records revealed documentation by hospice staff of visits made, and services provided for the residents from 7/06/21- September 2021. Documentation in the resident's physical chart revealed the name, the team number, and contact information of the hospice provider for services rendered to resident #17. The admission MDS assessment with ARD 7/12/21 revealed the question in section J1400 prognosis: Does the resident have a condition 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-07 · 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 person-centered care plan for hospice and ensure care plans reflected the goals of hospice services for 1 of 3 residents reviewed for hospice services, (#17); and failed to develop a person-centered care plan for intravenous antibiotic therapy for 1 of 1 resident reviewed for antibiotic therapy, (#34), of a total sample of 35 residents. Findings: 1. Resident #17 was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included cerebral atherosclerosis, Alzheimer's disease, dementia, and anxiety disorder. A physician order dated 7/07/21 revealed the resident was on hospice services for diagnosis of cerebral atherosclerosis. Review of the resident's clinical records revealed documentation by a hospice agency of visits made and services provided for the resident from 7/06/21 through September 2021. Documentation in the resident's medical record revealed the name, the team number, and contact information of the hospice…

    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 before2021-10-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nail care for 1 of 4 dependent residents reviewed for activities of daily living (ADL) care, of a total sample of 35 residents, (#59). Findings: Resident #59 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, contractures of both hands and his left upper arm, and stroke with partial paralysis. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 8/26/21 revealed resident #59's cognition was moderately impaired, with a Brief Interview for Mental Status score of 12/15. Resident #59 was assessed as being totally dependent on staff for personal hygiene and he required extensive assistance with dressing. Resident #59 had functional limitation in range of motion and impairments of his upper and lower extremities on both sides. On 10/04/21 at 9:57 AM, and on 10/05/21 at 9:36 AM, resident #59 sat in his motorized wheelchair. The resident's fingernails on both hands were long 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 date of correction
  • Potential for harm · Dcited before2021-10-07 · 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, record review and interview, the facility failed to ensure wheelchair anti-tippers were positioned correctly to prevent accidents for 1 of 5 residents reviewed for falls and accident hazards, of a total sample of 35 residents, (#44). Findings: Resident #44 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and diabetes. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status evaluation was not done because the resident was rarely or never understood. The MDS assessment noted resident #44 required extensive assistance of one staff member for transfers and locomotion on the unit and used a wheelchair for mobility. On 10/04/21 at 3:34 PM, resident #44 was seated in his wheelchair in the third-floor common area. The back of the resident's wheelchair had anti-tippers that were not positioned correctly. The anti-tipper devices were positioned upwards, pointing towards the ceiling instead of downwards, towards the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-10-07 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids 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 dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice, for 1 of 1 resident reviewed for IV catheters of a total sample of 35 residents, (#34). Findings: Resident #34 was admitted to the facility on [DATE] with diagnoses including joint replacement for left hip fracture. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Review of the physician orders reflected a midline catheter was inserted on 9/15/21. Another order dated 9/17/21 read, Change IV dressing every week and as needed. A midline catheter is inserted into a vein near the elbow or upper arm and ends in a vein below the armpit. A midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments. (retrieved on 10/18/21 from www.drugs.com). A review of the Medication Administration Record showed the resident's midline IV dressing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$22,133 in federal fines across 2 penalties.

  • $5,980 — penalty dated 2025-03-04
  • $16,153 — penalty dated 2025-03-04

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 WESTMINSTER COMMUNITIES OF FLORIDA — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 54.3-1.3 vs chain
Health inspection 2 of 53.7-1.7 vs chain
Staffing 3 of 54.3-1.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 8 homes this chain runs (chain average 4.3★, 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 / managerTypeRoleSince
BELL, WILLIAMIndividualCORPORATE DIRECTORsince 01/01/2015
DYE, STEPHENIndividualCORPORATE DIRECTORsince 01/01/2015
HILLENMEYER, JOHNIndividualCORPORATE DIRECTORsince 01/01/2015
MADDUX, CARLENIndividualCORPORATE DIRECTORsince 01/01/2022
MOCK, JEFFREYIndividualCORPORATE DIRECTORsince 01/01/2022
SHELLEY, LINDAIndividualCORPORATE DIRECTORsince 01/01/2022
KEITH, HENRYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/1994
WESTMINSTER SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/1980
DIAZ, RICARDOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
LEHMAN, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025

CMS files one row per role, so the 13 rows in the source record cover these 10 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.

1 organizational owner 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.

$13.5M
Net patient revenuemost recent cost report
-106.7%
Operating marginrevenue minus expenses
$2.6M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 51%Medicare 14%Other / private 34%

This home reported $2.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$718per resident / day
operating cost
$21,838per month
≈ monthly operating cost
$347per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105757. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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