Aviata At The Palms
2600 Highlands Blvd N, Palm Harbor, FL 34684 · For profit - Limited Liability company · 120 certified beds · (727) 785-5671 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- inspectors cited 4 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (38) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- about 22% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
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 | 2 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 held steady at 1 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 | 9.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 3.4% | 4.6% | 6.5% | better |
| 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 | 0.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.7% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.3% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.4% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.8% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.77 | 2.13 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.43 | 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.
27.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.0% 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 59 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 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 27.8%CMS range 14.9–45.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 8.3–18.7 | 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 | 39.0% | 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 | 40.7% | 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 | 30.5% | 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 | 97.6% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 1.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 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 120 beds and averages 111.0 residents a day — about 92% occupied, or roughly 9 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 3.07 hrs/resident/day on weekends vs 3.32 on weekdays — 8% thinner on weekends. RN hours go from 0.30 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
38 citations, most serious first. The 14 most serious are shown; the remaining 24 are one tap away and print in full.
- Immediate jeopardy · J2025-11-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the resident's right to be free from neglect for one resident (#3) out of two residents reviewed for neglect and abuse. The facility neglected to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and supervision as needed. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and 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.
- Immediate jeopardy · Jcited before2025-11-20 · 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 observations, interviews, and record review, the facility failed to ensure residents were free from avoidable accidents for two residents (#3 and #2) out of three residents reviewed for accidents.The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision was not observed. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and 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.
- Immediate jeopardy · J2025-11-20 · 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 review, the facility failed to ensure residents were provided the correct physician ordered therapeutic diet for one resident (#3) out of twenty-three residents sampled with texture-modified diets. The facility failed to provide Resident #3 with the correct physician ordered diet which resulted in the resident choking, and required staff to execute the Heimlich maneuver. Resident #3's physician ordered diet on 11/9/25 was a controlled carbohydrates (CCHO) diet, pureed texture, and regular/thin consistency due to advanced dementia and swallowing difficulties. The resident was provided a regular consistency meal for lunch. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on 11/18/25. The findings of Immediate Jeopardy were determined to be removed on 11/20/25 and the severity and scope was reduced to a D after verification of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2025-11-20 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#3, #11, and #2) out of eleven residents sampled related to: 1) failure to prevent accidents resulting in a choking and a fall incident; 2) failure to follow physician orders and care plan for therapeutic diets and positioning; and 3) failure to follow speech therapy recommendations for positioning and assistance when eating. The facility failed to provide Resident #3 with the correct physician ordered diet and resulted in the resident choking, which required staff to execute the Heimlich maneuver. Resident #3's care plan and speech therapy evaluation showed the resident needed assistance with dining and one to one supervision. Observations of the resident during the lunch dining on 11/17/25 and 11/18/25 revealed he was not in the upright position when eating, which increased the risk of choking, and one to one supervision…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, and interviews the facility failed to provide a homelike, safe, clean and sanitary, and pest free environment for four (#7, #16, #17, #18) out of four residents reviewed. Findings included:1. On 4/13/2026 at 10:32 AM an observation was made of the facility's maintenance shed full of debris on the inside; a toilet, a black bin with garbage in it, wooden platforms stacked on one another, a bathroom commode, a wheelchair, an opened safe, two large-industrial portable air conditioning units with bio growth present, multiple garbage cans, and carts scattered around the shed.On 4/13/2026 at 10:34 AM an interview was conducted with Staff L, Maintenance Assistant (MA). Staff L, MA stated they are waiting for the Maintenance Director to come up with a solution for all of the supplies and items present outside of the maintenance shed and is waiting for direction on what to do with the items outside of the shed since the shed is full.2. On 4/13/2026 at 11:07 AM an observation was made 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 · E2026-04-13 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure voiced concerns from resident council meetings were documented as a grievance and acted upon during two meetings (held on 1/5/26 and 2/4/26) out of three meeting minutes reviewed, as well as three food committee meetings (held on 3/10/26, 3/24/26, and 4/7/26) out of three meeting minutes reviewed.Findings included: On 4/13/26 at 1:40 p.m., an interview was conducted with Resident #23. He said Staff E, Activities Assistant documented the resident council minutes. Resident #23 said the residents expressed their concerns, they were written in the meeting minutes, but there was no follow-through or resolution. He said it was the same old and new business concerns every month.A review of Resident #23's minimum data set (MDS) assessment, dated 1/8/26, revealed under section C - cognitive patterns, a brief interview for mental status (BIMS) score of 15, indicating cognitively intact.On 4/13/26 at 1:58 p.m., an interview was conducted with Staff E, Activities Assistant. She confirmed she wrote down the resident council…
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 · E2026-04-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services that is in accordance with professional standards of practice were provided related to: 1. ensuring oxygen was administered per physician orders for one resident (#10) out of two reviewed for oxygen therapy; 2. Failed to provide tracheostomy care according to professional standards of practice for two residents (#10, #12) out of two residents reviewed for tracheostomy care.Findings included:1.On 4/13/26 at 09:53 a.m., Resident #10 was observed in bed with a trach mask, delivering 2 liters per minute of oxygen at 28% humidity. There were red specks appearing to be dried blood in the trach mask. There were large amounts of tannish white secretions leaking out of trach mask onto a wash cloth which was under the trach mask. There was free water observed in lower portion of tubing prior to a water collection bag. The collection bag was placed on its side next to Resident #10 in bed. There were no dates on the oxygen tubing and trach tubing. Condensation was present 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 · Ecited before2026-04-13 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies related to intravenous (IV) therapy for two residents (#20, #21) of three sampled for IV therapy and failed to ensure tracheostomy care was completed competently for two residents (#10, #12) of two sampled residents.Cross reference F695Findings included:Review of an employee list of IV certifications, provided by Human Resources (HR), showed 15 out of 19 LPNs with IV certification expired on [DATE].Interview on [DATE] at 6:55 p.m. Human Resources (HR) stated, The person before me may have had a list of all the LPN certifications, however I was only able to verify the IV therapy certifications that I could put my eyes on for four LPNs on the list I gave you. HR stated, The list includes all the licensed practical nurses, and I entered [DATE] as an expiration date because I don't have documentation of their IV therapy certification.During an interview on [DATE] at 7:01 p.m., the Director of Nursing…
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 · D2026-04-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to ensure Activities of Daily Living (ADL) were provided to maintain grooming and personal hygiene for one (#19) resident of one resident reviewed for ADL care. Findings include:On 4/13/2026 at 3:38 PM an observation was made of Resident #19 sitting in their wheelchair with a blanket pulled over their head/face. The resident was wearing sweatpants that were soaked through from the briefs being overly wet and not changed from the 7-3 shift or the start of the 3-11 shift. In Resident #19's lap area were paper towels soaked in a yellow body fluid. Resident #19 was unable to communicate their needs.A review of Resident #19's admission record revealed an admission date of 4/10/2024 with diagnoses to include unspecified dementia, cognitive communication deficit, need for assistance with personal care, persistent mood (affective) disorder, anxiety disorder, and stage 3 chronic kidney disease.A review of Resident #19's Quarterly Minimum Data Set (MDS) assessment, dated 3/25/26, in section C - cognitive patterns revealed a Brief…
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 · D2026-02-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the physician was notified of blood sugar levels (BSLs) that were outside parameters for one (Resident #2) of two residents sampled.Findings included:Resident #2 was readmitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes with diabetic peripheral angiopathy without gangrene and long-term use of insulin.Review of Resident #2's Medication Administration Record (MAR) for January 2026 revealed Novolog FlexPen subcutaneous solution pen-injector 100 UNIT/ML (milliliters) (insulin Aspart). Inject per sliding scale: 150-200 + 4 Units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 units = 12 units. Notify MD (medical doctor) if BS (blood sugar) less than 70 or greater than 400; 401-450 = 14 units subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia. Start date 10/29/25. D/C (discontinued) date 1/26/26.The order…
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 · D2026-02-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 interviews, the facility failed to ensure a resident with contractures received care and services to prevent on-going decline in physical abilities and deconditioning for one (Resident # 1) of one resident observed. Findings include:On 02/23/2026 at 9:45 AM Resident #1 was observed lying in bed right hand was observed with fingers touching palm, no splint or support. On 02/23/2026 at 12:14 PM Resident #1 was observed lying in bed. He was unable to verbally communicate but able to shake his head when asked questions. His right hand was observed with fingers touching palm, with no splint or support.On 02/23/2026 at 2:00 PM Resident #1 was observed lying in bed. His neck pillow was observed lying on top of the sheet over the stomach. The right hand was observed with fingers touching palm with no splint or support.Review of Resident #1's admission Record revealed an admission to the facility initially on 10/09/2025 and readmitted on [DATE] with diagnoses to included but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-09 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three (#147, #47 and #68 ) of four residents reviewed had dressings changed appropriately and per physician orders. The facility failed to ensure one (#37) of one resident had a splint applied and documented as ordered. Findings included: 1. During an interview on 08/06/24 at 10:46 a.m., Resident #147 stated he had a wound on his hand and arm. Resident #147 stated the dressing was dirty because the facility had not changed it. Resident #147 stated the facility changed it when he was first admitted to the facility but then did not. An observation on 08/06/24 at 10:46 a.m., revealed Resident #147 had dressings on his right hand/wrist area and another on the upper right arm that was visibly soiled and not dated. The dressing on his right-hand/wrist area had a brown dirty looking substance on the dressing and was not dated. Resident #147 gave (State Agency) SA Surveyor verbal permission to take a picture of the right hand/wrist and arm…
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 · E2024-08-09 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure one Dietary Manager out of one Dietary Manager met at least one of the minimum qualifications for the position. Findings included: During an interview on 08/06/24 at 9:00 a.m., Staff B, Dietary Manager (DM) identified as the facility's Dietary Manager. Review of the dietary staff credentials, provided by the facility, showed a Servsafe Certification for Staff A, Corporate Area Support Manager (CASM) with an expiration date 11/12/26. During an interview on 08/06/24 at 1:41 p.m., the Administrator stated Staff A, CASM was not full time and goes between two facilities. The Administrator stated Staff A, CASM was not on the employee list because he was a Traveler and worked for a contracting company. A review of the Nursing Home Key Staffing Form identified Staff B, Dietary Manager as the Dietary Manager for the facility. A review of the Active Employee Report provided by the facility, showed Staff A, CASM was not an employee listed for the facility. During an interview on 08/06/24 at 1:55 p.m., Staff B, Dietary Manager…
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 · D2024-08-09 · 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, record review, and interview, the facility failed to ensure one resident (#81) out of three residents reviewed for resident rights had their choices honored. Findings included: An observation on 08/06/24 at 10:26 a.m. revealed Resident #81 was in his room laying in bed with a hospital gown on. During an interview on 08/06/24 at 10:26 a.m., Resident #81 stated, no one was assisting him out of bed when he asked to get up. Resident #81 stated he asked for assistance to get out of bed daily, but no one would assist him. Resident #81 stated staff seemed too busy and I'm getting tired of being put off with no help. Resident #81 stated he even requested to talk with the Director of Nursing (DON) and had not had that request honored . An observation on 08/06/24 at 1:37 p.m., Resident # 81 remained in his bed with the same hospital gown. During an interview on 08/06/24 at 3:37 p.m., Resident # 81 stated he informed his nurse earlier that he would like assistance getting out of bed and into his…
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 24 citations
- Potential for harm · Dcited before2024-08-09 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#55) of five sampled residents. During an interview on 8/6/2024 at 4:55 p.m., Resident #55 stated, I have spoken to several nurses when I returned from the hospital as I want to be a Full Code and change my Health Care Surrogate (HCS). I know this conversation occurred prior to 7/2/2024. I met with the Director of Social Services (DSS), discussed the [HCS] and request of being a full code. The DSS came back and told me everything was taken care of. Resident #55 continued to state never receiving the requested copies from the DSS and kept checking with the nurses regarding the changes and wanting to be a Full Code. Resident #55 stated, On [7/2/2024] the physician stated I was capable of making my own decisions. Still, I was not changed to a Full Code. I've seen the DSS at the nurses' cart, while the cart was at my door. Although, the DSS would state…
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 before2024-08-09 · 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 observation, interview, and record review, the facility failed to ensure a clean and home like environment in two (#311 and #405 B) of sixty-one rooms observed. Findings included: 1. A review of the facility's work order #7384 for room [ROOM NUMBER], created on 7/27/24 at 12:42 p.m. showed ac leaking. A review of the facility's work order #7374 for room [ROOM NUMBER] B, created on 7/25/24 at 1:29 p.m., showed air conditioner running water on the floor. On 8/6/24 at 10:08 a.m., wet linen was observed piled under the Packaged Terminal Air Conditioner (PTAC) in room [ROOM NUMBER]. The resident in the room said the PTAC had been leaking for about a month. The room was muggy with a musty odor. (Photographic Evidence Obtained.) On 8/7/24 at 9:45 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained). On 8/8/24 at 9:52 a.m., the same observation was made in room [ROOM NUMBER] (Photographic Evidence Obtained).) 2. On 8/6/24 at 10:46 a.m., a blanket with a yellow ring and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-09 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 the accuracy of the Preadmission Screening and Resident Review's (PASRRs) and obtain a Level II screening when appropriate for three (#44, #11, and #46) of six residents sampled for PASRR's. Findings included: 1. A review of Resident #44's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The record revealed the resident had the following diagnoses prior to the readmission: - Paranoid schizophrenia, onset 4/1/22. - Psychotic disorder with delusions due to known physiological condition, onset 4/1/22. - Recurrent moderate Major Depressive Disorder, onset 10/1/22. - Mild Dementia in other diseases classified elsewhere with other behavioral disturbance, onset 10/1/22. - Unspecified hallucinations, onset 4/2/21. - Other sexual dysfunction not due to a substance or known physiological condition, onset 10/27/23. - Other schizoaffective disorders, onset 5/11/21. - Delusional disorders, onset 6/10/20.…
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 · D2024-08-09 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 and implement an effective discharge plan for one (#449) of three residents reviewed. During an interview on 8/8/2024 at 12:16 p.m. with Resident #449, she stated her discharge was not arranged. She said she was admitted to the facility from the hospital after a motor vehicle accident. She stated the physician stated the benefit would come from therapy. She stated, Everything was going well, then the insurance company thought I should be discharged . I had to appeal. Each time I had to be the one to follow up on if the appeal was granted etc. The Social Service Director (SSD) hardly assisted at all. The [SSD] asked when I was admitted , if I would be going home, with who and if I would need home health care at home. On 3/13/2024 the facility told me I would be discharging [the next day]. No other information was provided to me. I arranged to borrow a walker from a friend and the facility permitted me to borrow a wheelchair. At discharge 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 · D2024-08-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to follow the pharmacist recommendations to monitor for behaviors for two residents (#76 and #89) of two Medication Regimen Reviews (MRR) reviewed. Findings included: 1. Review of Resident #76's admission record showed an admission date of 5/31/24, with diagnoses to include bipolar disorder. Review of Resident #76's order summary report, active orders as of 8/7/24 showed the following: Trazadone 50 mg daily for depression Review of Resident #76's August 2024 Medication Administration Report (MAR) showed Trazodone 50 mg was administered daily at 9:00 a.m. Review of Resident #76's care plan showed risk for complications related to the use of psychotropic drugs, initiated on 6/3/24. Interventions included monitor for continued need of medication as related to behavior and mood. Monitor for side effects and consult the pharmacist as needed, initiated on 6/3/24. Review of Resident #76's Pharmacist's Report to Nursing, dated 6/7/24 showed this resident was currently receiving psychotropic medication with required behavior monitoring…
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 · E2022-04-22 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review and interviews, the facility failed to ensure the resident or the responsible party for three residents (#47, #25, and #30) of four residents sampled for hospital transfers were provided with a written notice of transfer. Findings included: 1. Review of the admission Record revealed Resident #47 was initially admitted to the facility on [DATE] with a readmission date of 03/12/22. Resident #47 had multiple diagnoses to include quadriplegia, chronic osteomyelitis, acquired absence of right leg above the knee and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 was his own responsible party and had one emergency contact noted. On 04/21/22 at 9:30 a.m. Resident #47 confirmed he was transferred to the hospital on [DATE] and returned on 03/12/22. Review of the medical record revealed Resident #47 was transferred to the hospital on [DATE] through 03/12/22 to treat a wound on the resident's right lower leg. Further review of the resident's medical record revealed upon…
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 · E2022-04-22 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 staff interview, record review and review of the facility policy, the facility failed to ensure three residents (#47, #128, and #25) or their representatives were provided a notice of bed hold policy when the residents were transferred to the hospital of four residents reviewed for hospital transfers. Findings included; 1. Review of the admission Record revealed Resident #47 was initially admitted to the facility on [DATE] with a readmission date of 03/12/22. Resident #47 had multiple diagnoses to include quadriplegia, chronic osteomyelitis, acquired absence of right leg above the knee and neuromuscular dysfunction of the bladder. Further review revealed Resident #47 was his own responsible party and had one emergency contact noted. On 04/21/22 at 9:30 a.m. Resident #47 confirmed he was transferred to the hospital on [DATE] and returned on 03/12/22. Resident #47 reported he wasn't able to return to his same room immediately. He reported he had to be in another part of the facility for a certain number…
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 · E2022-04-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure medications were stored and labeled properly in two (300-hall 1 and 300-hall 2) of four medication carts and one (south) of two medication rooms. Findings included: On 4/19/22 at 5:15 p.m., an attempt was conducted to observe medication administration with Staff U, Licensed Practical Nurse (LPN). Staff U opened the top drawer of the 300-hall 1 medication cart and removed a medication cup with medications in it and then entered Resident #40's room. When the Staff U returned to the medication cart, she stated she had administered the resident a chewable Vitamin C and the scheduled Oxycodone. Staff U then removed a blister card of Doxycycline tablets from the medication cart, dispensed a tablet into a medication cup, left the card of tablets on the top of the medication cart, and re-entered Resident #40's room. She came back out and stated she had signed out the Oxycodone and confirmed she had pre-dispensed medications due 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.
- Potential for harm · D2022-04-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, facility policy and record reviews, the facility failed to ensure the interventions on the resident centered care plan were revised, related to wearing a left-hand soft orthosis for contracture management for one resident (#15) of thirty-eight residents sampled. Findings included: On 04/18/22 at 10:04 a.m. Resident #15 was observed with a left hand contracture, not wearing a soft hand orthosis device. A second observation on 04/18/22 at 12:59 a.m. of Resident #15 was conducted. Resident #15 was sleeping in a (medical recliner chair) and not wearing a left hand soft hand orthosis device. On 04/19/22 at 9:19 a.m. Resident #15 was observed to be lying in bed, not wearing a soft hand orthosis device, and a certified nursing assistant (CNA) was in the room. A second observation on 04/19/22 at 10:02 a.m. of Resident #15 was conducted. Resident #15 was seated in the (medical recliner chair) in the activities room, and not wearing a left hand soft hand orthosis device. On 04/20/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-22 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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 reviews, it was determined the facility failed to arrange a physician ordered appointment for eye surgery in a timely manner for one resident (#38) out of a sample of thirty eight residents. Findings included: An interview with Resident #38 on 04/18/2022 at 11:50 a.m. revealed the resident lying in bed with the lights off. He stated a couple of months ago, he had a concern and asked his nurse if she could schedule an appointment due to his vision becoming cloudy and experiencing blurriness. Resident #38 was still concerned at this time, and explained the blurriness is getting worse. A review of the admission Record revealed Resident #38 was readmitted to the facility on [DATE] and initially admitted on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia and unspecified severe protein-calorie malnutrition. A review of the Order Summary Report, dated 04/20/2022, for the dates of 01/01/2022 - 01/31/2022 revealed a physician order for: Refer 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.
- Potential for harm · D2022-04-22 · 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 observation, interviews, and record reviews, the facility failed to ensure a Stage IV pressure ulcer was treated in a manner to promote healing and prevent infections for one resident (#45) out of 14 facility residents with pressure injuries. Findings included: Resident #45 was admitted to the facility on [DATE] with a diagnoses, including Type 2 Diabetes Mellitus with foot ulcer (onset 12/22/21), morbid (severe) obesity due to excess calories, and unspecified complication of skin graft (onset 1/9/22). An observation was conducted, on 4/20/22 at 2:19 p.m., with Staff M (Agency Licensed Practical Nurse/LPN) of the wound care for Resident #45. The resident was observed lying on the bed as the staff member removed the gray non-slip sock from the resident's left foot. The staff member did not place a barrier under the resident's foot as she removed the elastic bandage from the area and exposed the rolled gauze underneath. Staff M began pulling at the tape holding the rolled gauze and tearing at the rolled…
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 · D2022-04-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to ensure one (#31) of two sampled residents reviewed for enteral feedings received nutritional support as ordered. Findings included: Resident #31 was admitted on to the facility in 2018 with diagnoses to include unspecified protein-calorie malnutrition, subsequent encounter for diffuse traumatic brain injury without loss of consciousness, persistent vegetative state, and gastrostomy status. An observation on 4/18/22 at 10:39 a.m., identified an opened (spiked) bottle of Jevity 1.5 calorie connected to a nutrition pump. The manufacturer label identified the enteral nutrition bottle held approximately 1000 milliliters (ml)/ 33.8 fluid ounces/1 liter of liquid. The label indicated the bottle was hung at 12:00 PM on 04/17/22 with a run rate of 55 ml per hour (hr). The observation revealed the bottle contained approximately 700 ml, indicating the resident had received approximately 300 ml since the bottle was hung, approximately 22 hours and 39 minutes prior to the observation. The observation on 4/18/22 at 2:01…
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 · D2022-04-22 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 medical record review, the facility failed to arrange transportation to a medical appointment, which resulted in a delay of care and treatment, for one resident (#43) of 38 sampled residents. Findings included; During an interview conducted with Resident #43 on 4/18/22 at 1:12 p.m., he reported he had an appointment for a follow up with his orthopedic surgeon in (City) approximately ten days ago and wanted to see him again because he was having a high amount of pain. Resident #43 stated he had a follow up appointment with his orthopedic surgeon in (City) scheduled for 4/19/22 at 1:30 p.m. The facility was to arrange the transportation. Review of the admission Record revealed Resident #43 was admitted to the facility on [DATE] with multiple diagnoses to include orthopedic after care, fracture of left femur, fracture of shaft of left tibia, fracture of left fibula and foot drop. Resident #43 was identified as his own responsible party. A review of the Minimum Data Set (MDS), dated [DATE],…
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 · D2022-04-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 reviews, and interviews, the facility failed to ensure medications were monitored for behaviors related to the administration of psychotropic medication(s) and failed to clarify a dosage for Acetaminophen for one (Resident #178) of five residents sampled for unnecessary medications. Findings included: Resident #178 was admitted to the facility on [DATE] with diagnoses which included metabolic Encephalopathy, alcoholic cirrhosis of liver without ascites, delirium due to known physiological condition, unspecified hallucinations, unspecified anxiety disorder, and unspecified recurrent major depressive disorder. An observation on 4/18/22 at 11:41 a.m., was conducted with Resident #178. The resident was observed sitting on the side of the bed. On 4/20/22 at 11:05 a.m., the resident was observed lying in bed covered with a blanket. A review of Resident #178's April 2022 Order Summary Report as of 4/20/22 at 1:56 p.m. included the following: - Acetaminophen Tablet - Give 2 tablet by mouth…
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 · D2022-04-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (Residents #74 and #47) of five residents observed. These errors constituted a 7.41% medication error rate. Findings included: 1. On 4/19/22 at 11:45 a.m., an observation of medication administration with Staff T, Registered Nurse (RN), was conducted with Resident #74. The staff member dispensed the following medications: - Novolog FlexPen - 2 units. Staff T held the pre-filled Insulin FlexPen upright without a needle and stated there was no air bubble so it was all clear. Staff T wiped the end of the syringe and dialed it to 2 units. Staff T injected the 2 units into the upper left extremity of Resident #74. Staff T stated she would have primed the Novolog pen if there was room for an air bubble. 2. On 4/20/22 at 8:36 a.m., an observation of medication administration with Staff…
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 · D2022-04-22 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility's quality assurance (QA) and assessment committee failed to implement an effective plan of action to correct deficient practice identified during the recertification survey and complaint survey originally conducted 4/18/22 through 4/22/22 as evidenced by: 1) failure to ensure an allegation of neglect was reported to state agencies for one (#5) of three residents sampled for abuse and neglect (F609), 2) failure to ensure allegations of abuse and neglect were thoroughly investigated for two (#5 and #7) of three residents sampled for abuse and neglect (F610), 3) failure to monitor for behaviors and side effects for psychotropic medications and failure to limit as needed psychotropic medications to 14 days for two (#1, #5) of three residents reviewed for psychotropic medications (F758), and 4) failure to ensure the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and twelve errors were…
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 · D2021-02-18 · tag F0554 — isolatedAllow 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 observations, record reviews, and interviews, the facility failed to ensure medications were consumed during medication administration for one resident (Resident #54) out of the sampled forty-four residents. Findings included: On 02/15/21 at 1:15 p.m., a cup with nine medications was observed on the bedside table next to the bed in Resident #54's room (photographic evidence obtained). Resident #54 reported that the nurse gave her the pills without pudding and that she could not take them without pudding because she had difficulty swallowing pills. On 02/15/21 at 1:55 p.m., Staff A, Licensed Practical Nurse (LPN), reported that she always watches Resident #54 take her pills and that she takes them with pudding and water. Staff A stated that she did not know where the cup of pills came from. A review of the admission Record revealed that Resident #54 was initially admitted into the facility on [DATE] with a primary diagnosis of osteonecrosis left femur. Section C of the admission 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 · Dcited before2021-02-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 that their policy related to identifying and arranging an appropriate representative to make health care decisions was implemented for one Resident (#231) of forty-four residents sampled. Findings included: A review of the facility policy titled Resident Rights Regarding Treatment and Advance Directives, with implementation date of 11/21/2021 revealed: Policy Explanation and Compliance Guidelines: 5. The facility will identify or arrange for an appropriate representative for the resident to serve primary decision maker if the resident is assessed as unable to make relevant health care decisions. A record review for Resident #231 indicated she was originally admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Traumatic Subarachnoid Hemorrhage with loss of consciousness of unspecified duration, Gastrostomy, and Tracheostomy. A continued record review revealed no advance care planning…
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 · D2021-02-18 · 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, interview, medical record review and facility policy review, the facility failed to ensure that a resident centered care plan was developed and implemented related to wearing a Wander Guard Device/Bracelet for one (Resident #24) of forty-four residents in the sample group. Findings included: On 02/18/2021 at 3:00 p.m., Resident #24 was observed to be walking with an unidentified Certified Nursing Assistant, (CNA) into his resident room, and as he lifted his leg up to step forward his pants moved slightly, showing a white Wander Guard Device/Bracelet on his ankle. A medical record review for Resident #24 indicated he was admitted on [DATE] with multiple diagnoses that included Cerebral Infarction, Aphasia, Atrial Fibrillation and Cognitive Communication Deficit. A record review of active Physician Orders revealed that Resident #24 did not have an order to wear a Wander Guard Device/Bracelet. Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-02-18 · 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 record reviews and interviews, the facility failed to perform full body skin assessment weekly for one resident (Resident #72) out of the sampled forty-four residents. Findings included: A review of the admission Record revealed that Resident #72 was originally admitted into the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, pressure ulcer of sacral region, and pressure ulcer of right ankle. A review of Section C of the Nursing Home Comprehensive Minimum Data Set (MDS) dated [DATE] revealed that Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section M of the MDS revealed that Resident #72 was at risk for pressure ulcers/injuries. A review of the Order Summary Report with active orders as of 02/18/2021 revealed that there was not an order for skin assessments. A review of the Medication Administration Record and Treatment Administration Record dated February 2021 revealed that there was no…
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 before2021-02-18 · 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
Based on observation, interview and record review the facility failed to ensure a resident's fall on 2/6/21 was investigated to ensure effective interventions were in place after a previous fall on 2/3/21 for one (Resident #65) of two sampled residents. Findings included: Review of Resident #65's medical record showed their diagnoses included Repeated falls. Review of the nursing progress notes dated 2/6/21 at 10:46 p.m. revealed the resident fell. The nursing observations, evaluation, and recommendations were: Resident confused and tries to walk unassisted. Review of the resident's care plan reflected the a focus area of at risk for fall related injury created on 2/8/21 to include interventions: anticipate needs, provide prompt assistance, follow facility fall protocol, and report falls to physician and responsible party. Review of the fall risk evaluation dated 2/6/21 at 10:32 p.m. reflected a score of 14 for at risk for falls. During an interview with the Director of Nursing (DON) on 2/18/21 at 02:54 PM the DON confirmed the resident had a change in condition on 2/6/21 but did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-02-18 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure food was dated and labeled in two of two nourishment refrigerators. Findings included: On 02/15/21 at 10:15 a.m., the nourishment room on the 100 hall was observed. Temperatures were missing from the Refrigerator Temperature Log for 02/11, 02/12, 02/13, and 02/14. Inside the refrigerator were the following foods with no label or date: an opened bottle of Gatorade, an opened orange juice, a brown bag that held a plastic bag of unknown food, a container of opened ice cream, a frozen to go fast food cup, an opened bag of pizza rolls, 3 sandwiches in plastic bags, and an open carton of French vanilla with an expiration date of 02/04/21. On the counter was an uneaten breakfast tray with eggs and toast. The Certified Dietary Manager (CDM) reported that breakfast was at 7:30 a.m. The nourishment room on the 300 hall was observed. Inside the refrigerator were the following foods with no label or date: two frozen to go fast food cups, an opened package of sausage, and a plastic container of carrots. At 10:25…
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 · D2021-02-18 · tag F0840 — isolatedEmploy 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 record reviews and interviews, the facility failed to schedule outside appointments in a timely manner for one resident (Resident #13) out of the one sampled resident. Findings included: On 02/15/21 at 12:30 p.m., Resident #13 reported that he had been trying to get an appointment scheduled for months with a urologist. The resident reported that he spoke to the Social Services Director (SSD) about scheduling the appointment and he reported that there were issues with his Medicaid. The admission Record revealed that Resident #13 was admitted into the facility on [DATE] with a primary diagnosis of multiple sclerosis (MS). Section C of the Quarterly Minimum Data Set (MDS) revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. On 11/18/20, a physician's note revealed that Resident #13 wanted to see a urologist. The resident's levels of testosterone needed to be checked before a referral to the urologist. There were no notes that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-02-18 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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, medical record review and policy review, the facility failed to follow their policy and procedure related to providing education, and obtaining consent for the influenza vaccination, for one resident (#39), of five sampled residents that were reviewed for of immunization documentation. Findings included: Record review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 39's Brief Interview For mental Status (BIMS) score was 15, (indicating cognitively intact); and Section O, listed under Influenza Vaccine as not receiving one, with no choice selected for the area of reason not given. A record review of Resident #39's Immunization report revealed that the resident consented to receive the Influenza Vaccination, in the right Deltoid on 10/10/2020. A further record review of the Electronic Medical Record (EMAR) was conducted and read Fluzone Quadrivalent Suspension filled Syringe 0.5 ml (influenza Vac Quad. Inject 0.5 ml intramuscularly)…
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 AVIATA HEALTH GROUP — 50 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 | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 49 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 49; 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 | Since |
|---|---|---|---|
| HIGHLANDS BLVD PARENT LLC | Organization | DIRECT OWNERSHIP INTEREST | since 11/15/2023 |
| ASP FL LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/15/2023 |
| FREUND, NOCHUM | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/15/2023 |
| PROCTOR, SAMANTHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/07/2025 |
| TARIQ, MARIUM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2024 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/27/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/28/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/28/2025 |
| HERSKOWITZ, ELIEZER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/28/2025 |
| HERSKOWITZ, YAAKOV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/28/2025 |
| TRAVITSKY, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/28/2025 |
| ASPIRE HEALTHCARE LLC | Organization | ADP OF THE SNF | since 11/15/2023 |
CMS files one row per role, so the 16 rows in the source record cover these 12 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.
3 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.
About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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 105394. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-09, 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.