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Oakpark Health And Rehabilitation Center

2851 Tampa Rd, Palm Harbor, FL 34684 · For profit - Limited Liability company · 180 certified beds · (727) 787-4777 Medicare & Medicaid certified

Call the home — (727) 787-4777 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Dec 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2626 Tampa Rd · (727) 781-5811 · Call to confirm hours
Pharmacy
32866 US Highway 19 N · (727) 202-2217 · Call to confirm hours
Grocery
3235 Tampa Rd · (727) 378-9453 · Call to confirm hours
Park
· Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.9%8.7%15.4%better
Long-stay residents who lose too much weight9.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened7.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.9%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers6.8%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control15.0%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table4.2%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine95.1%94.7%79.4%better
Short-stay residents rehospitalized after admission30.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit7.1%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.152.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.481.151.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

50.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 348 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.0%U.S. median 51.5%
Got home and stayed home
12.4%U.S. median 10.7%
Went back to hospital
48.1%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 48.1% 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 241 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 0.39 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.0%CMS range 44.4–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 10.3–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge44.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge39.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting99.1%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.7–10.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.871.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.58
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.41
Total nurse hours/ resident / day
0.47
RN hoursweekends
55.8%
Total nursing turnover
65.7%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 168.9 residents a day — about 94% occupied, or roughly 11 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.16 hrs/resident/day on weekends vs 3.51 on weekdays — 10% thinner on weekends. RN hours go from 0.62 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.

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

Inspection trend

12
deficiencies at the latest standard inspection (2025-12-11)
5
at the previous standard inspection (2023-08-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · D2026-01-12 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 did not ensure one resident (#1) out of three residents reviewed received appropriate treatment and services for mental disorders to attain the highest practicable mental and psychosocial well-being.Findings included: Review of Resident #1's hospital medication discharge instructions, dated [DATE], showed the resident received Nuplazid 34 mg daily. Review of Resident #1's facility physician orders showed:-Nuplazid Oral Capsule 34 MG (Pimavanserin Tartrate). Give 1 capsule by mouth one time a day for delusions. Dated 11/30/25. Review of Resident #1's Medication Administration Record (MAR) for December 1st-19th 2025 showed Nuplazid was not administered and was documented as waiting on delivery from pharmacy on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, 12/14, and 12/17/25. Nuplazid was signed off as being administered on 12/1, 12/2, 12/3, 12/4 12/5, 12/8, 12/9, 12/15, 12/16, 12/18, 12/19/25. Behavior monitoring on the MAR showed the only documented behaviors from…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-11 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a sufficient number of certified nurse assistants (CNAs) for four night shifts (4/6, 4/12, 4/26, and 6/21) of the twenty-seven night shifts reviewed. Findings:An interview was conducted with Resident #93 on 12/08/2025 at 11:18 a.m. The resident stated they must wait awhile for assistance to get a brief changed. The resident stated the staff do not bring water unless the residents ask for water. The resident stated they asked to have water a week ago at approximately 9:00 pm and it took until 2:00 a.m. to receive it. An interview was conducted with Staff B, Registered Nurse (RN) on 12/09/2025 at 4:25 p.m. She stated each unit usually has six Certified Nursing Assistants (CNAs) and two nurses. She said if somebody calls out for their shift, Then we try our best. She stated the Director of Nursing (DON), and nurses on the units communicate staffing needs to the Staffing Coordinator based on census. Staff B stated she is a unit manager, and she fills in if there are not enough nurses.An interview was conducted with…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure skin checks were completed for three Residents (# 6, #14, #35) out of eight residents sampled for skin integrity. Findings included: 1. On 12/09/2025 11:30 a.m. and at 3:00 p.m. Resident # 14 was observed lying down in bed with her call light within reach. She was observed groomed with no odors and no signs of distress. Review of an admission Record dated 12/11/2025 revealed Resident # 14 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinson's disease without dyskinesia, without mention of fluctuations, bipolar disorder, current episode mixed, moderate, major depressive disorder, recurrent, moderate. Review of Resident # 14's order summary revealed: Weekly skin checks every Friday for skin assessment. Dated 10/10/2025 Review of Resident # 14's Treatment Administration Record (TARSs) revealed: October 2025 Weekly skin checks were not documented as 1 out of 4 scheduled times completed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure post fall interventions were implemented to prevent future falls for four residents (#20, #78, #138, #149) out of seven residents sampled for falls. Findings included: 1) Review of a facility provided incident log showed Resident #138 had falls on 11/26/25 and 12/8/25. Review of admission Records showed Resident #138 was admitted on [DATE] with diagnoses including essential sarcopenia, other symptoms and signs involving the musculoskeletal system, paroxysmal atrial fibrillation and syncope and collapse. Review of Resident #138's progress notes showed: 11/26/25 3:25 p.m. Alerted by CNA [certified nursing assistant] that Pt [patient] was on the floor. Pt observed laying flat on his back, on side of bed by window. Noted skin tear to left shoulder blade, pt c/o [complaints of] left side/hip pain. Pt states he did hit head but is not hurting, no redness or deformities noted. Pt was assisted into bed. Pt declining PRN [as needed] pain medcaitons…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-11 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents related to dining and Activities of Daily Living (ADL) assistance with meals for three residents (#134, #50, and #168) observed in the dining room during three days (12/8/2025, 12/9/2025, and 12/10/2025) of three days dining was observed. Findings included: On 12/8/2025 at 12:50 p.m. the main dining room was observed during the lunch meal service. The main dining room revealed two sections, one large for residents who eat without assistance, and a smaller section where residents are assisted with their meals from staff. The smaller assistive section was observed with eight residents seated at various tables and with only one staff member in the room, who was Certified Nursing Assistant (CNA) Staff M. Staff M was observed seated at a table assisting a resident with eating assistance, where Resident #134 was also seated. Staff M was observed to only assist the table mate 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-11 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure proper infection control practices were implemented related to: 1) personal protective equipment (PPE), contact precautions, hand hygiene, soiled linen, and resident bathrooms on two out of three resident units observed; and 2) failed to properly sanitize the heel protector boot for one resident (#2) out of thirty-three sampled residents.Findings Included: An observation was conducted on 12/8/25 at 9:56 a.m. of the 100 unit shower room. The shower room was observed to have dirty linens in a pile on the floor, hanging on the shower chair, and on the rails in the shower. A Certified Nursing Assistant (CNA) was observed wheeling a resident into the shower room to have a shower prior to it being cleaned. An observation was conducted of the 100 hall lunch service on 12/8/25 at 12:18 p.m. A staff member was observed removing a tray from the tray cart, taking it into a resident room and setting the tray up for the resident. The 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-11 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain essential facility equipment in a clean and safe manner within the resident environment related to 1) failing to ensure the Packaged Terminal Air Conditioners (PTAC) system filters were clean and free of debris for four resident room PTAC systems (rooms 364, 266, 272, and 210) out of seven systems observed; 2) failing to ensure the PTAC system was free from leaks in one resident room PTAC system (room [ROOM NUMBER]) out of the seven systems observed; and 3) failing to ensure the ice machines were free of bio growth in one unit ice machine (300 unit) out of four ice machines observed. Findings included:On 12/8/2025 at 10:58 a.m., the PTAC unit in room [ROOM NUMBER] was observed with a puddle of water under the unit. Photographic evidence obtained.On 12/11/2025 at 10:06 a.m. observed another large puddle of water under the PTAC unit in room [ROOM NUMBER]. Photographic evidence obtained.On 12/11/2025 at 10:06 a.m. the PTAC filters…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to maintain and promote dignity for two of seventy-nine sampled residents (#134 and #13), related to: 1. Staff leaving resident with meal tray in front of her for long periods of time without assistance, and leaving resident and table soiled with liquid and food for long periods of time during four of four meals observed on 12/08/2025, 12/09/2025, 12/10/2025, and 12/11/2025; and 2. Not providing or assisting with provision of clothing leaving resident to wear hospital gowns every day. Findings included: 1. On 12/8/2025 from 12:50 p.m. through to 1:25 p.m. Resident #134 was observed seated at a table in the assistive dining room. She was seated at a table with a table mate and with one staff member, Staff M Certified Nursing Assistant (CNA) in the room. Staff M was observed assisting with eating with Resident #134's tablemate. At 12:50 p.m. Resident #134 had already been served and set up with her meal and most of her food had already…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 interviews and record review, facility did not ensure a resident representative was contacted immediately upon a change in condition for one resident (#178) out of three residents reviewed for change of condition. Findings included: An interview was conducted on [DATE] at 3:49 p.m. with the resident representative (RR) for Resident #178. The RR said he had been at the facility on [DATE] in the evening and Resident #178 was doing about the same as she had been doing, but her breathing was a little labored. The RR said he went home that evening and was not contacted by staff until approximately 7:30 a.m. on [DATE] letting him know Resident #178 passed away. He said he went to visit the resident every day, and staff knew he stayed with her. He said he was not contacted early in the morning when Resident #178's condition declined drastically. Review of admission Records showed Resident #178 was admitted on [DATE] with diagnoses including chronic respiratory failure, heart failure, and unspecified…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and facility policy, the facility failed to report an allegation of abuse for two (2) residents (# 20, #166) out of five (5) residents sampled.Findings included:On 12/09/2025 at 3:00 p.m. an observation was made of Resident #20 sitting in her wheelchair propelling up and down the hallway. Resident # 20 presented a little confused but stated she had no concerns.On 12/11/2025 at 10:00 a.m. an observation was made of Resident # 20 sitting in her wheelchair propelling up and down the hallway. She said she was getting ready to go to an activity.Review of Resident # 20 admission record revealed she was admitted to the facility on [DATE] with diagnoses to include but not limited to permanent atrial fibrillation, age-related osteoporosis without current pathological fracture, cognitive communication deficit.Review of Resident # 20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated Resident #20 is cognitively impaired.On…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2025-12-11 · tag F0645 — isolated
    PASARR 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 interviews and record review the facility did not ensure preadmission screening for mental disorders was completed accurately for three residents (#3, #149, and #88) out of thirty-three sampled residents.Findings included: 1. Review of admission Records showed Resident #3 was admitted on [DATE] with diagnoses including dementia, depression, and bipolar disorder. Review of Resident #3's PASRR Level I Screen, dated 7/23/25, indicated the resident had depressive disorder and bipolar disorder. However, Section II was marked No for the question Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? An interview was conducted on 12/11/25 at 7:14 p.m. with the DON. The DON reviewed Resident #3's medical record and PASRR Level I screen. She confirmed Resident #3 had a dementia diagnosis and she should have indicated that in Section II. The DON confirmed Resident #3's PASRR Level I screen was completed inaccurately. 2. Review…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide two of seventy-nine sampled residents, (#134 and #153) with Activities of Daily Living tasks to include 1. lack of Eating assistance during three meal observations and 2. lack of assistance with getting out of bed. Findings included: 1. On 12/8/2025 from 12:50 p.m. through to 1:25 p.m. Resident #134 was observed seated at a table in the assistive dining room. She was seated at a table with a table mate and with one staff member, Staff M Certified Nursing Assistant (CNA) in the room. Staff M was observed assisting with eating with Resident #134's tablemate. At 12:50 p.m. Resident #134 had already been served and set up with her meal and most of her food had already been pushed off the plate by her hands. Resident #134 also picked up a clear plastic cup of pink liquid and spilled it on the remaining food items on her plate. A large amount of liquid spilled all over the table, leaving a section of the tablecloth soiled. Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to maintain the use of a heart monitor per physician orders for one Resident ( # 138) out of twenty-four residents sampled.2- An observation was conducted on 12/8/25 at 11:57 a.m. of Resident #138's room. On the bedside table there was a round silver metal device with what appeared to be electrodes on a adhesive bandage. The resident was not present in the room at the time. Review of admission Records showed Resident #138 was admitted on [DATE] with diagnoses including essential hypertension, paroxysmal atrial fibrillation and syncope and collapse. Review of Resident #138's orders showed:12/4/25-Do not remove heart monitor. Cardiorenal vision will remove in 14 days. Press button on patient chest if he has a syncopal episode. Review of Resident #138's progress notes did not show any documentation as to why the monitor was no longer in place or that a provider was notified. An interview and observation was conducted on 12/10/25 at 3:15 p.m.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-02 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 provide sufficient staffing to adequately meet the residents' needs for nine residents (#131, #117, #26, #147, #144, #80, #72, #537, and #128) out of 63 residents sampled. Findings Included: 1. On 7/30/2023 at 9:10 a.m., an interview was conducted with Resident #131's family member. The family member said the 11:00 p.m.-7:00 a.m. shift was constantly understaffed, which had an impact on Resident #131 because he was always wet when she visited him in the morning. She said that she visited him before the morning shift started their assigned shift, so she knew that it was the night shift who left the resident wet. A review of the staffing assignment sheet, dated 7/30/2023, revealed Staff K, Registered Nurse (RN) worked as a nurse and a Certified Nursing Assistant (CNA) on the 11:00 p.m.-7:00 a.m. on the Medbridge unit. A review of the staffing assignment sheet, dated 7/31/2023, revealed Staff L, Licensed Practical Nurse (LPN) and Staff K, RN…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-02 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for four residents (#112, #286, #288, #42) of 30 residents sampled for PASARR Level II. Findings included: 1. Review of Resident #112's admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to anxiety disorder and bipolar disorder. Review of Resident #112's Preadmission Screening and Resident Review (PASARR), dated 1/19/22, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE] and 3/31/23, and an admission MDS, dated [DATE], Section I, Active Diagnoses, showed psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. An interview was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-02 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is 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, resident interview, and record review, the facility failed to 1. provide treatment and services to maintain or improve functional abilities for activities of daily living for one resident (#112) of two residents sampled and 2. failed to assist with meals and offer alternatives for one resident (#74) of seven residents sampled who required assistance with meals. Findings included: 1. A review of Resident #112's admission Record revealed she was readmitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included morbid (severe) obesity, cellulitis of left lower limb, type 2 diabetes mellitus, and sciatica of the left limb. An observation and interview were conducted on 7/30/23 at 11:50 a.m. with Resident #112. She was observed lying in bed watching television. She stated her only concern was that when she first came to the facility in January, she was ordered therapy, but she had bilateral sciatic problems with her legs with unbearable pain and she could 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 4. A review of Resident #40's admission Record showed diagnoses of ataxic gait, unspecified dementia, anemia, essential hypertension, history of falling, sarcopenia, weakness, atherosclerotic heart disease, and other symptoms and signs of concerning food and fluid intake. Review of the active physician orders as of 8/2/23 showed a physician order, dated 01/31/23, showed, Escitalopram Oxalate Tablet 5 mg- Give 5 mg by mouth one time a day for depression give with 10 mg to equal dose of 15 mg. A second physician order, dated 01/31/23 showed, Escitalopram Oxalate Tablet 10 mg- Give 10 mg by mouth one time a day for depression give with 5 mg to equal dose of 15 mg. A third physician order, dated 11/02/22 showed, Buspirone HCI Oral Tablet 5 mg- Give 5 mg by mouth two times a day for anxiety. The Medication Administration Record (MAR) was reviewed for June 2023 and July 2023 and showed Escitalopram Oxalate Tablet 5 mg, Escitalopram Oxalate Tablet 10 mg, and the Buspirone HCI Oral Tablet 5 mg were given per 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-02 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for two residents (#186 and #95) of six residents observed. These errors constituted a 11.43% medication error rate. Findings included: 1. On 7/31/2023 at 8:30 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #186. Staff B dispensed medications scheduled at 9:00 a.m. which included but not limited to the following medications: - Oyster Shell Calcium 500 mg (milligrams) - 3 tablets. During the observation Staff B searched the medication cart, dispensing three Oyster Shell Calcium tablets identifying the tablets contained calcium carbonate. Staff B reported they had contacted the pharmacy this morning about the resident's Sodium Bicarbonate and was told they were out of it, and the physician was notified already. Staff B documented, med not available at this moment, pharmacy notified and MD…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-08-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) recommended infection control guidelines, the facility failed to ensure infection control practices during an active COVID-19 facility outbreak were followed related to 1) donning of personal protective equipment (PPE) prior to entering designated COVID-19 person under investigation (PUI) rooms (307, 312, and 357); and 2) ensuring all direct care staff wore a well-fitted face mask while inside of the facility on two (300 hall and East Wing) of three hallways observed. Findings included: 1. An observation on 08/12/21 at 5:36 a.m. revealed personal protective equipment (PPE) requirement signage posted on the double entrance doors into the 300-unit hallway. The signage stated an N95 & [and] Face Shield Required Prior to entering unit. Photographic evidence obtained of the signage. Upon entering the 300-hallway unit, an observation on 08/12/21 at 5:37 a.m., revealed Staff G, Certified Nursing Assistant (CNA) entering…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure care plan interventions and physician orders were followed related to implementing contact precautions for one (Resident #347) of three residents sampled. Findings included: On 08/11/21 at 8:40 a.m. an interview with Resident #347 revealed him presenting with confusion and continually saying I can't see . it's so dark in here . where is my wife? . Where am I? Resident #347 had a catheter in place. Prior to entering the Resident's room, no precaution signage was observed on the doorway. A record review of Resident #347's admission Record Report revealed an admission date of 08/03/2021 with medical diagnoses of unspecified injury of the head, legal blindness as defined in the United States of America, and Escherichia Coli (E. Coli). A record review of Resident #347's MDS [Minimum Data Set] 3.0, dated 8/09/21, revealed under Section C- Cognitive Patterns a brief interview for mental status (BIMS) score of 8, indicating cognition problems without behaviors of inattention. Under Section G- Functional Status…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed, and fifteen late medications were verified for three (3) (Resident #51, # 295 and #347) of eight (8) residents observed. These late medications constituted a medication error rate of 55.56 percent. Findings included: On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff A, Licensed Practical Nurse (LPN), on the MED Bridge Wing, administering medications to Resident # 51. Staff A, (LPN) was seen administering the following medications: -Amiodarone HCL Tablet 100 milligrams (MG) orally, -Eliquis Tab 5 MG by mouth orally, every 12 hours -Furosemide Tablet 20 MG orally, one time a day -Potassium Chloride ER Tablet Extended Release 10 milliequivalents (MEQ) orally, three times a day -Spironolactone Tablet 50 MG orally, twice daily -Prednisone Tablet 1 MG orally, one time a day Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #51, revealed that 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and policy review, the facility failed ensure 1) removal of expired medications from one (Med Bridge Hall) of two medication storage rooms observed; and 2) medications were secured in one (Medication Cart A, East Wing) of five medication carts observed. Findings included: On 8/12/2021 at 3:55 p.m. an observation was made of Medication Cart A located on the East Wing. In the seventh draw from the top of the medication cart was a loose blue capsule. Staff D, (LPN) confirmed the presence of the unsecured medication. On 08/12/2021 at 02:45 p.m., an observation was conducted on Med Bridge Wing's, medication room and medications stored in the refrigerator. During the observation four (4) brown plastic envelopes containing Aplisol 0.1 milliliters (ML) Syringe (PPD), were observed with pharmacy labels that had the resident name, and expiration date located on each one. Observation of two (2) medications found to have expiration date of 08/05/2021 and the other two (2) had expiration dates of 08/04/2021 and 08/08/2021 respectively. Staff C, Registered Nurse…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-13 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 observations, interviews, and record review the facility failed to ensure coordination among departments which resulted in the failure of the facility's food and nutrition services system for accommodation of food choices and preferences for two (Residents #141 and #70) out of six sampled residents. Findings included: 1. Resident #141 was observed during the lunch meal on 08/10/21 at 12:10 p.m. Observation of his lunch tray revealed a plate with an entrée selection, a cup of coffee, a cup of iced tea, a serving of pudding, and a chocolate flavor frozen nutritional treat. The only meal ticket present with the tray revealed the following information: no allergies; nutritional treat supplement; beverages iced tea and water; diet soft & bite-sized (SB6). There was no other information printed on the ticket. Resident #141 said he did not like chocolate and had told the facility, but they said they only had chocolate flavor (for the supplement). He said lunches were generally too heavy and not great but that he…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASTON HEALTH — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 37 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Crescent Health And Rehabilitation CenterSarasota, FL 1 of 5Kensington Gardens Rehab And Nursing CenterClearwater, FL 1 of 5Nursing & Rehabilitation Center Of New Port RicheyNew Port Richey, FL 1 of 5Oak Haven Rehab And Nursing CenterAuburndale, FL 1 of 5Vero Beach Care CenterVero Beach, FL 2 of 5Baya Pointe Nursing And Rehabilitation CenterLake City, FL 2 of 5Capri Health And Rehabilitation CenterVenice, FL 2 of 5Creekside Health And Rehabilitation CenterSarasota, FL 2 of 5Fairway Oaks CenterTampa, FL 2 of 5Flagler Health And Rehabilitation CenterBunnell, FL 2 of 5Haines City Rehabilitation And Nursing CenterHaines City, FL 2 of 5Highlands Lake CenterLakeland, FL 2 of 5Indian River CenterWest Melbourne, FL 2 of 5North Port Rehabilitation And Nursing CenterNorth Port, FL 2 of 5Pensacola Nursing & Rehabilitation CenterPensacola, FL 2 of 5Riverwood CenterJacksonville, FL 2 of 5Sandgate Gardens Rehab And Nursing CenterFort Pierce, FL 2 of 5Sea Breeze Rehab And Nursing CenterVero Beach, FL 2 of 5Tierra Pines CenterLargo, FL 2 of 5Viera Del Mar Health And Rehabilitation CenterViera, FL 2 of 5Winter Garden Rehabilitation And Nursing CenterWinter Garden, FL 3 of 5Cedarbrook Health And Rehabilitation CenterFort Myers, FL 3 of 5Coquina CenterOrmond Beach, FL 3 of 5Eagleridge Health And Rehabilitation CenterFort Myers, FL 3 of 5Fouraker Hills Rehab And Nursing CenterJacksonville, FL 3 of 5Hillside Health And Rehabilitation CenterZephyrhills, FL 4 of 5Bridgeview CenterOrmond Beach, FL 4 of 5Coastal Health And Rehabilitation CenterDaytona Beach, FL 4 of 5Debary Health And Rehabilitation CenterDebary, FL 4 of 5Fernandina Beach Rehabilitation And Nursing CenterFernandina Beach, FL 4 of 5Island Lake CenterLongwood, FL 4 of 5Meadowpark Health And Rehabilitation CenterDunedin, FL 4 of 5Parkside Health And Rehabilitation CenterDeland, FL 4 of 5Ruleme CenterEustis, FL 4 of 5Seaside Health And Rehabilitation CenterDaytona Beach, FL 5 of 5Bayview CenterEustis, FL 5 of 5Osprey Point Nursing CenterBushnell, FL

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 / managerTypeRoleShareSince
OAKPARK REHAB HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/04/2023
BP OAKPARK TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/05/2023
LF OAKPARK TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST50%since 05/05/2023
WILDES, DONNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
BERARD, LORIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/06/2024
DILELLA, VINCENTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/06/2023
FERRONE, KARENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/02/2024
REYNARD-SURIANO, SUIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2023
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 05/05/2023

CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$11.9M
Net patient revenuemost recent cost report
-7.4%
Operating marginrevenue minus expenses
$560K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 12%Other / private 27%

This home reported $560K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$350per resident / day
operating cost
$10,629per month
≈ monthly operating cost
$326per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105708. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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