Ormond Rehabilitation And Nursing Center
103 Clyde Morris Blvd, Ormond Beach, FL 32174 · For profit - Limited Liability company · 60 certified beds · (386) 673-0450 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (56%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.5% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.3% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 14.4% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.2% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.5% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 93.8% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.1% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.3% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 80.5% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.9% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.38 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
61.0% 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 249 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 98 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.0%CMS range 55.2–68.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.3%CMS range 7.2–12.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 5.0–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 55.2 residents a day — about 92% occupied, or roughly 5 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 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.13 hrs/resident/day on weekends vs 3.72 on weekdays — 16% thinner on weekends. RN hours go from 0.85 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-06-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 refund was issued to the resident or resident representative within 30 days from the resident's date of discharge from the facility for 1 resident sampled for refunds, Resident #2.The findings include: Review of Resident #2's records revealed the resident was admitted to the facility on [DATE] and discharged from the facility on [DATE]. On [DATE] at 9:45 am, a phone interview was conducted with Resident #2's brother who stated he had not received a refund after Resident #2 expired on [DATE]. He explained that he had called the facility several times but never got a return call. During an interview on [DATE] at 1:22 pm, the Business Office Manager (BOM) was asked to explain the refund process following a discharge. She stated that refunds are issued within 30 days of discharge. When asked how she determines refund amounts, she stated she has a packet that she uses for everyone. She fills out the needed information to determine the amount to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0694 — isolatedProvide 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
Based on interviews, record review, and facility policy review, the facility failed to ensure a peripherally intravenous (IV) used for the administration of intravenous fluids was removed in accordance with professional standards following the discontinuation of the IV for one (Resident #1) of three residents reviewed for intravenous care. Resident #1 was discharged home with the peripheral IV remaining in her arm.The finding include:On 4/2/26 at 9:30 AM, a phone interview was conducted with Resident #1's daughter. When asked about her mother's discharge from the facility, she stated, It was concerning that the facility would send her mother home with an IV, and thankfully she was ok from it.Review of Resident #1's medical record revealed an admission date of 1/23/26, and discharge date of 2/13/26. The resident's medical diagnoses included essential hypertension, unspecified atrial fibrillation, and supraventricular tachycardia, unspecified.Review of the physician's order dated 1/31/26 revealed, Ok for peripheral IV placement for fluids. A second physician's order revealed, Sodium…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-27 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the kitchen food service observations, staff interviews, and a review of facility records and policies and procedures, the facility failed to maintain dietary equipment in safe and sanitary condition to prevent the outbreak of foodborne illness, with the potential to affect any resident who consumed ice from the facility's kitchen, by failing to maintain and clean the ice machine to prevent contamination/biological growth. Food safety and sanitation are important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of waterborne microorganisms to avoid a potential source of pathogen exposure.The findings include: During a follow up visit to the kitchen on 08/26/2025 at 11:20 AM, the ice machine located outside the kitchen's main door's ice diverter was covered with a slimy, pink substance. The 2025 ice machine cleaning log hanging on the side of the ice machine documented cleaning on 08/24/2025. (Photographic evidence obtained) During this follow up visit, the Regional Food Service Director verified with his personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and a review of the facility's policy and procedure for Falls and other facility documentation, the facility failed to implement a comprehensive person-centered care plan for one (Resident #10) of 27 residents whose care plans were reviewed for falls. Fall mats were ordered for Resident #10 but were not in place, which could result in fall injuries. The findings include: On 8/24/25 at 11:30 a.m., Resident #10 was observed lying in a high bed with an air mattress and 1/4 side rails. The resident was asked if he had fallen and he replied yes. He reported several falls and having gone to the hospital after one fall. He could not remember the date, only that the fall was recent. On 8/25/25 at 9:30 a.m., the facility's matrix was reviewed. The matrix revealed that the resident had fallen with a major injury. On 8/25/25 at 2:30 p.m., Resident #10 was observed lying in bed. No fall mats were at bedside. His room and bathroom were checked, but there were no fall mats 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.
- Potential for harm · D2025-08-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #28) of 27 residents in the survey sample whose care plans were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. Failure to administer medications as ordered by the physician has the potential to cause a negative outcome to the resident's physical, mental, or psychosocial health and well-being. The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his medications were missed. He stated they were sometimes late or not provided at all.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-27 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure residents' medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for one (Resident #28) of a total survey sample of 27 residents whose records were reviewed. Resident #28, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition, stated he was not receiving his medications as ordered, and a review of his medical record for August 2025 revealed that on numerous dates, five medications were not signed off by nursing as having been administered. The resident's record must reflect the care and services provided to the resident.The findings include: On 08/24/2025 at 1:33 PM, Resident #28 stated he believed some of his medications were missed. He stated they were sometimes late or not provided at all. Resident #28 could not identify a particular medication that was late or missed. A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-19 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 resident record review, interviews, and review of the facility's transfer/discharge policy, the facility failed to ensure required documentation was completed prior to transfer/discharge for 1 (Resident #1) of 3 residents reviewed for transfer/discharge, from a total sample of 7 residents. The findings include:Clinical record review indicated that Resident #1 was admitted to the facility on [DATE], re- entry on 9/7/22 and discharged on 7/31/25. His diagnoses included aftercare following joint replacement, type 2 diabetes mellitus, dementia without behavior, metabolic encephalopathy, anxiety disorder, need assistance with personal care, heart failure and neurogenic arthritis.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/19/25, indicated that the resident had a Brief Interview for Mental status score of 11 out of 15 possible points, indicating moderate cognitive impairment. Review of the physician's orders dated 7/31/25 for Resident #1 revealed he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-23 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 observations conducted in the central kitchen. The findings included: Review of the facility's policy, titled, Sanitation, dated November 2017, revealed the following: All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair and shall be free from breaks, corrosion, open seams, cracks, and chipped areas. Kitchen waste not disposed of by mechanical means shall be kept in clean, leak-proof, nonabsorbent, tightly closed containers and disposed of daily. 1. In a tour of the central kitchen on 05/20/24 at 8:55 AM, accompanied by the facility's Food Service Director (FSD), the following were noted: a. The floor around the kitchen and behind the stove area was noted dirty with pieces of scattered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-23 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to dispose of refuse in a sanitary manner for two of two observations conducted in the main dumpster area. The findings included: Review of the policy, titled, Garage and Rubbish Disposal, dated April 2022, revealed the following: All garbage and rubbish containing food waste shall be kept in containers. All containers shall be provided with tight-fitting lids or covers, and such containers must be kept covered when stored or not in continuous use. Each container must be thoroughly cleaned at least daily on the inside and outside so as not to contaminate food, equipment, utensils, or food preparation areas. Garbage and rubbish containing food wastes shall be stored to be inaccessible to vermin. Storage areas shall be always kept clean and shall not constitute a nuisance. All garbage and rubbish shall be disposed of daily. Outside dumpsters provided by garbage pick-up services must be kept closed and free of litter around the dumpster area. 1. In an observation conducted on 05/20/24 at 8:50 AM in the main…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to treat residents in a dignified manner while providing care and services for 3 of 22 sampled residents (Residents #15, #38, and #247). The findings include: 1. A review of Resident #15's medical record revealed that the resident was originally admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia. A review of the resident's Minimum Data Set (MDS) assessment, dated 03/15/24, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. On 05/20/24 at 9:29 AM, an observation was made of Licensed Practical Nurse (LPN) J administering medications in the hallway to Resident #15, who was located next to the medication cart outside of room [ROOM NUMBER]. During an interview with LPN J on 05/23/24 at 11:30 AM, she stated she had worked at the facility for three years. When asked if medications were administered to 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.
Show the remaining 13 citations
- Potential for harm · D2024-05-23 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 observation, interviews, policy and record review, the facility failed to provide showers per resident preference for 1 of 3 residents sampled for shower choices (Resident #146). The findings included: On 05/20/24 at 11:17 AM, Resident #146 was interviewed. She stated she was not given a choice of the number of showers she could receive. She was told that her shower days were Wednesdays and Saturdays on the 3-11 shift. She was not given a preference of whether she wanted a morning or evening shower, or if she wanted to have a shower more than twice a week. She said she would like more showers but was not given that option. A review of Resident #146's medical record revealed that she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, Type 2 diabetes, and hypertension. Her Brief Interview for Mental Status (BIMS) score was 15 out of 15 possible points on the Resident Interview & Staff Assessment, dated 05/16/24. This indicated the resident was cognitively intact. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain a safe, sanitary, and homelike environment for two (one across from room [ROOM NUMBER] and the other across from room [ROOM NUMBER]) of two shower rooms and 5 of 38 resident rooms, affecting Residents #12, #146, #248, #247, and #197. The findings include: On 05/20/24 at 9:45 AM, an observation was made in Resident #12's room of the wall behind the bed with peeling paint, and the light fixture on the wall behind the head of the bed with one of three light bulbs not working. On 05/20/24 at 10:00 AM, an observation was made in Resident #146's room of walls and baseboards with peeling paint, and the light fixture on the wall behind the head of the bed with two of three light bulbs not working. On 05/20/24 at 10:16 AM an observation was made in Resident #248's room of the wall behind the head of the bed with mismatched paint, and the light fixture on wall behind the head of the bed with one of three light bulbs not working. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to 1) Implement a smoking care plan for two (Residents #7 and #28) of 22 sampled residents, and 2) Implement an Enhanced Barrier Precaution (EBP) care plan for one (Resident #247) of 22 sampled residents. The findings include: 1. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Synovitis and Tenosynovitis and Generalized Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #7 dated 03/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Smoking Evaluation for Resident #7 dated 05/22/24 documented in Section AA, Is resident a smoker - yes. Review of the Care Plan for Resident #7 dated 05/22/24 with a focus on the resident smokes when signed out off of the property. The goal was for the resident to continue to be a safe smoker throughout next review date. The interventions included: Encourage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 interviews and record reviews the facility failed to identify a pressure ulcer on admission for 1 of 1 residents sampled for pressure ulcers (Resident #247). The findings included: Review of the facility's policy titled: Pressure Injury Protocol dated 02/17/18 included the following in part: All residents will be assessed for their risk of developing pressure injury using a standardized and approved assessment tool upon admission and periodically throughout their stay. Residents with an existing pressure injury and those with a history of pressure injury fall into the category of High Risk for development of further pressure injuries. An appropriate interdisciplinary plan of care will be developed within 72 hours of admission to reduce the risk of pressure injury and aid in the prevention of new pressure injuries. Record review for Resident #247 revealed the resident was admitted to the facility on [DATE] with diagnoses included: Other Gram-Negative Sepsis and Abscess of Liver. Review of the Minimum…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interviews and record reviews the facility failed to identify and evaluate residents who smoke for 2 out of 55 residents who were identified for smoking (Residents #7 and #28). The findings included: Review of the facility's policy titled Free of Accident Hazards/Supervision/Devices dated 08/2022 included in part: It is the policy of this facility to ensure it provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes Identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary. Review of the facility's policy titled: Smoke Free Facility Policy with no date included in part: The facility shall establish and maintain a smoke-free environment, inclusive of all tobacco products and electronic cigarettes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 observation, interviews, record review and policy review, the facility failed to provide an anchor for catheter tubing for 1 of 1 resident observed for catheter care (Resident #25). The findings included: The policy of the facility titled Catheter Care, Urinary dated April 2022 revealed Key Procedural Points .Check to see that the catheter remains secured with a leg strap, if applicable, to reduce friction and movement at the insertion site. and Steps in the procedure Secure catheter utilizing a leg band, if applicable. Resident #25 was admitted to the facility on [DATE] with diagnoses that included Unspecified fracture of second thoracic vertebra, Hypertension, and Neuromuscular dysfunction of the bladder. Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Set with an assessment reference date of 03/29/24. This indicated the resident was cognitively intact. A review of the physician's orders for catheter care for Resident #25 revealed an order for Urinary Catheter:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to identify a significant weight loss and provide nutritional interventions in a timely manner for 2 of 5 residents reviewed for nutrition (Resident #10 and Resident #199). The findings included: A review of the facility ' s policy titled Weighing and Weight at-risk protocol dated April 2022, showed the following: Complete all weights with re-weights on the following parameters: 0-175 pounds-variances of 4 pounds for loss or gain. Nursing and Dietitian to review weights for significant weight loss and at-risk weight loss and determining variances with re-weights as noted above. Interventions in place: notify the Dietitian of newly identified significant weight loss, review the needs for fortified foods, diet liberalization, frequent foods that the Resident likes, and frequent meals or snacks. It further showed that intakes should be reviewed at a minimum weekly, and the narrative documentation should include areas identified and measures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each Resident received care and services for the provision of hemodialysis consistent with professional standards of practice for two of the two residents reviewed for Dialysis (Resident #196 and Resident #201). The findings included: A review of the facility policy titled Dialysis dated 04/2022 revealed that A communication process must be established between the nursing home and the dialysis facility to be used 24 hours a day. The care of the Resident receiving dialysis services must reflect ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff. The communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record. 1. Resident #196 was admitted to the facility on [DATE] with a diagnosis of end-stage renal disease and dependence on renal dialysis. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the correct diet order per the physician's orders for one (1) of 5 sampled residents, Resident #200, reviewed for nutrition. The findings included: Record review documented Resident #200 was admitted on [DATE] with diagnoses of protein-calorie malnutrition, Dysphagia, and type 2 Diabetes. The documented Brief Interview of Mental Status (BIMS) score dated 05/17/24 revealed a score of 11, indicating mild to moderate cognitive impairment. In an observation conducted on 05/20/24 at 12:00 PM, Resident #200 was in his room with the lunch meal. The meal ticket on the lunch tray revealed the following: a mechanically ground diet with mechanically ground roasted red potatoes and mechanically ground lemon chicken. The lunch meal on the plate showed mechanically ground chicken and pieces of red potatoes that were about 2 inches long, not mechanically ground. In this observation, Resident #200 stated that he has a poor appetite and only ate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0826 — isolatedProvide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
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, interviews, policy and record review, the facility failed to obtain a physician order for Occupational Therapy (OT) prior to commencing OT for 1 of 1 sampled resident reviewed for rehabilitation (Rehab) services, Resident #146. The findings included: The policy of the facility, titled, Physician's Therapy Orders, dated April 2022 documented, Therapy services must be ordered by a licensed physician / licensed nurse practitioner. All therapy services provided to the resident must be ordered in writing by the resident's physician / nurse practitioner. Record review documented Resident #146 was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Type 2 Diabetes, and Hypertension. On the Resident Interview & Staff assessment dated [DATE], it was documented the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. The resident expressed at this time that she thought she should be getting more…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, policy and record review, the facility failed to ensure accuracy of records for a resident with a PICC (peripherally inserted central catheter) line dressing for 1 of 1 sampled resident sampled for PICC line, Resident #247; and failed to document a resident-to-resident interaction for 2 of 3 sampled residents reviewed for accidents, Resident #26 and #28. The findings included: The facility's policy, titled, Charting and Documentation, revised July 2017 and September 2023, documented, Documentation in the medical record will be objective (not opinionated or speculative), complete, accurate and timely. A late entry must indicate the date and time of the occurrence. 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included Muscular dystrophy, Severe intellectual disabilities, and Cognitive communication deficit. The record documented the Brief Interview for Mental Status (BIMS) score was 15 on the quarterly minimum data set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the observations, interviews, and record review, the facility failed to ensure staff were made aware of residents on Enhance Barrier Precautions (EBP) for 1 of 11 sampled residents on EBP (Resident #247); failed to use appropriate Personal Protective Equipment (PPE) for 1 of 11 sampled residents on EBP (Resident #247); and failed to maintain Contact Isolation Precautions as ordered for 1 of 3 sampled residents on Transmission Based Precautions (TBP) (Resident #199). The findings included: Review of the facility's policy, titled, Enhanced Barrier Precautions [EBP] with a revised date of 03/30/24 included, in part: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for three (Residents #26, #38, and #11) of 23 residents in the sample. An unnecessary drug is any drug, when used without adequate monitoring. The findings include: 1. A review of Resident #26's medical record revealed the resident was admitted on [DATE]. Diagnoses included encounter for surgical aftercare following surgery on circulatory system; type 2 diabetes mellitus without complications; paroxysmal atrial fibrillation; atherosclerotic heart disease of native coronary artery, and anxiety disorder. A review of the Physician's Order Sheets for [DATE], revealed the following active orders: Amiodarone 200 mg (milligrams) by mouth daily; Atorvastatin 40 mg by mouth daily; Eliquis 5 mg by mouth twice a day; Lorazepam 0.5 mg by mouth every 8 hours for agitation; Seroquel 100 mg by mouth daily for anxiety disorder; psych 9psychiatry) to evaluate for anxiousness; monitoring 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BENJAMIN LANDA — 48 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.5 | +0.5 vs chain |
The other 47 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 47; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ORMOND REHABILITATION AND NURSING MEMBER, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/07/2022 |
| APJA OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| FLNHO CAPITAL GROUP LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| GPJA OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| JACKSONVILLE 4 MEMBER OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| JACKSONVILLE 4 OPCO PARTNERS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| JFLNHO CAPITAL GROUP, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| MKJA OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| RPJA OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| SLJA OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| ZBL-18 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| LANDA, JUDY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| LOWY, SHLOMO | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| PLATSCHEK, ALEXANDER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/07/2022 |
| STRUNK-GAMEL, GWENDOLYN | Individual | W-2 MANAGING EMPLOYEE | — | since 10/08/2022 |
| BRECHER, HAL | Individual | CORPORATE OFFICER | — | since 10/07/2022 |
11 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 $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105458. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, 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.