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Riviera Palms Rehabilitation Center

926 Haben Blvd, Palmetto, FL 34221 · For profit - Limited Liability company · 120 certified beds · (941) 722-0553 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse2 immediate-jeopardy citations$181,100 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $181,100 in federal fines (most recent 2025-06-05)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
931 10th St E · (941) 933-8103 · Call to confirm hours
Pharmacy
907 10th St E · (941) 404-4121 · Call to confirm hours
Grocery
655 10th St E · (941) 981-9732 · Call to confirm hours
Park
715 17th St E · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 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 rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased4.1%8.7%15.4%better
Long-stay residents who lose too much weight0.8%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.3%4.6%6.5%worse
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 injury1.8%2.5%3.3%better
Long-stay residents whose ability to walk worsened5.8%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers2.3%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control5.6%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table6.1%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%94.7%79.4%better
Short-stay residents rehospitalized after admission16.3%26.1%22.6%better
Short-stay residents with an outpatient ER visit2.1%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.122.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.481.151.80better

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

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

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

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

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

56.2% 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 186 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.2%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
70.5%U.S. median 56.6%
Met the expected recovery
0.54U.S. median 0.31
Therapy hours / resident / day
0.26hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 70.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 112 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF56.2%CMS range 47.7–63.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.9–14.310.7%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 discharge70.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge65.2%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 discharge54.5%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 identified98.3%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 setting96.2%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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.5%CMS range 3.5–8.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.60
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.05
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.55
RN hoursweekends
37.1%
Total nursing turnover
38.9%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.1 residents a day — about 91% 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.12 hrs/resident/day on weekends vs 3.60 on weekdays — 13% thinner on weekends. RN hours go from 0.62 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

8
deficiencies at the latest standard inspection (2025-06-05)
6
at the previous standard inspection (2023-01-26)

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.

19 citations, most serious first. The 12 most serious are shown; the remaining 7 are one tap away and print in full.

  • Immediate jeopardy · J2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 interviews and record review the facility failed to protect the resident's right to be free from neglect for one resident (#59) out of two residents sampled for abuse/neglect. The facility neglected to properly report, assess, document, and intervene in a timely manner for Resident #59 related to an unwitnessed fall with major injury that occurred on [DATE]. This lack of intervention resulted in physical pain and suffering for the resident until his death on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses to include: dementia, coronary artery disease, atrial fibrillation, hypertension,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2025-06-05 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for four residents (#59, #74, #29, and #35) out of forty residents sampled related to: 1) failure to recognize and provide treatment for an unwitnessed fall; 2) failure to follow physician orders for laboratory testing; 3) failure to provide a safe hazard free environment; and 4) failure to complete resident identification prior to administration of medications. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 and resulted in the determination of Immediate Jeopardy on 6/04/2025. The findings of Immediate Jeopardy were determined to be removed on 6/05/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses to include:…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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, record review and interviews, the facility failed to maintain a home-like environment for two rooms (124, 174) out of twenty-nine rooms sampled. Findings included: During a facility tour on 06/02/2025 at 9:30 a.m. room [ROOM NUMBER]'s bathroom was observed with a towel wrapped around the bottom of the toilet. During an interview on 6/2/2025 at 10:30 a.m. with Staff V, Certified Nursing Assistant (CNA), she stated she has to put a towel on the bathroom floor in room [ROOM NUMBER] for the resident's safety. She stated whenever the toilet is flushed, water leaks on the floor. She stated she had reported the problem to maintenance. During an interview 06/05/2025 at 10:37 a.m. with Staff X, Maintenance Assistant. Staff X stated he was notified about the toilet in room [ROOM NUMBER] a week ago, but he had to order a part to do the repair. He stated the parts came in last Thursday, but he did not have time to fix the toilet. During an interview on 06/05/2025 at 10:37 a.m. with Staff W, Regional…

    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 · D2025-06-05 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 monitor side effects of Antipsychotic and Antidepressant medications for one (Resident #82) out of five residents sampled. Findings Included: During an observation on 06/02/2025 at 10:12 a.m., Resident #82 was observed sitting in a wheelchair in her room sleeping. During an observation on 06/02/2025 at 1:16 p.m., Resident #82 was observed sleeping in a wheelchair in the 2nd floor dining room. Review of Resident #82's admission record revealed an admission date of 03/24/2025. Resident #82 was admitted to the facility with diagnosis to include Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. Review of Resident #82 Medicare 5 Day Minimum Data Set (MDS) dated [DATE], revealed Section C. Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) of 03 out of 15 showing severe cognitive impairment. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · 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 interviews and record review the facility failed to report an injury of unknown origin for one resident (#59) out of 40 sampled residents. Findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses to include: dementia, coronary artery disease, atrial fibrillation, hypertension, failure to thrive, major depression disorder, insomnia, and cardiac pacemaker. The resident was placed in Hospice care on 2/7/2025. A review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #59 had a Brief Interview of Mental Status score of 00, indicating severe cognitive impairment. A review of the Order Summary Report, dated May 2025, for Resident #59 revealed the following: -Regular diet, soft and bite sized texture, thin liquids consistency -Alerting bracelet: located on left ankle, check for placement every shift -Do Not Resuscitate, Palliative Care -Hospice Diagnosis: Cerebral Atherosclerosis -May go on leave with supervision -Citalopram Hydrobromide oral tablet 40 milligram (mg)…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a person centered care plan was implemented related to communication for one resident (#31) out of 24 residents sampled. Findings Included: During an observation on 06/02/2025 at 9:46 a.m., Resident #31 was observed lying in bed dressed in a hospital gown. Resident #31 was only able to respond to yes or no questions. Review of Resident#31 admission record revealed and admission date of 10/29/2021. Resident #31 was admitted to the facility with diagnosis to include Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Essential (Primary) Hypertension, Anemia, Unspecified, Hyperlipidemia, Unspecified, Aphasia, Muscle Weakness (Generalized), Other Abnormalities of Gait and Mobility, Dysphagia, Oral Phase, Personal History of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits. Review of Resident #31's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section B.…

    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 · D2025-06-05 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's 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 observation, interview, and document review, the facility failed to offer resident centered activities for two dependent residents (#77 and #99) of two reviewed for activities. Findings included : During an observation and interview on 6/4/25 at 12:33 P.M., Resident #99 was sitting in a wheelchair close to her over the bed table with a writing pad. When spoken to the resident pointed to her family member to respond. The family member said Resident #99 is not capable of doing activities on her own. The family member stated when the resident resided on the first floor he would take her outside. Review of Resident #99's admission record revealed an initial admission on [DATE] and an admission date on 5/30/25 with diagnoses to include apraxia (neurological disorder that affects movement), dysphonia (voice impairment), dysarthria and anarthria, disorder of the central nervous system, abnormalities of gait and mobility. Review of Resident #99's activities evaluation dated 5/30/25, revealed current interests…

    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 · D2025-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a safe environment free from hazards for one (Resident #29) out of 24 residents sampled. Findings Included: During an observation on 06/02/2025 at 9:55 a.m., A pink disposable razor was identified on top of the toilet bowl of Resident #29's bathroom. (photographic evidence obtained) During an interview on 06/02/2025 at 2:13 p.m., Resident #29 stated she uses the restroom in her room. She stated she was not sure whose razor was in the bathroom and thought it may belong to her roommate. During a phone interview on 06/04/2025 at 10:40 a.m., Resident #29's family member stated he would not bring in a razor for Resident #29 because it is sharp and would not be safe for her to use on her own. Review of Resident #29's admission record revealed a re-admission date of 05/15/2020 and an initial admission date of 01/08/2020. Resident #29 was admitted to the facility with diagnosis to include Hemiplegia and Hemiparesis Following Cerebral…

    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 · E2023-01-26 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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 observation, medical record review and interview, the facility failed to ensure care plans were revised to reflect the current care status for two residents (#66 and #3) of forty-two sampled residents, related to Activities of Daily Living (ADLs) for eating assistance (#66), and impaired mobility and contracture management (#3). Findings included: 1. On 1/23/2023 at 12:30 p.m. Resident #66 was observed in her room and lying on her side on top of the bed eating her lunch meal. Her lunch meal tray was on the bedside table which was positioned slightly above head level and she was observed feeding herself with no problems. She appeared slow to eat but comfortable and able to feed herself. No staff were present in the room from 12:30 p.m. to 1:08 p.m. when a staff member came to remove the lunch tray. On 1/24/2023 at 7:45 a.m. Resident #66 was observed resting comfortably in bed with her eyes closed and the lights off. Further observation at 7:56 a.m. revealed Staff B, Certified Nursing Assistant (CNA)…

    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 · E2023-01-26 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure communication between the facility and dialysis centers consistent with professional standards of practice for ensuring ongoing assessment and oversight of the resident before, during, and after dialysis treatments for three residents (#6, #97, and #90) out of three sampled residents. Findings included: 1. Interview was conducted with Resident #90 on 01/23/2023 at 11:31 a.m. She confirmed she received hemodialysis treatment at a community provider three days per week. She stated she was not aware of any communication forms sent between the facility and the provider. On 01/25/2023 at 2:32 p.m. the resident was interviewed and confirmed she had been to the dialysis center for treatment that day. Review of Resident #90's medical record was conducted. The admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis. The Minimum…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 observation and interview the facility failed to reasonably accommodate the needs for one resident (#5) related to not placing the call light within the resident's reach of six residents sampled for environmental concerns. Findings included: On 01/23/23 at 9:32 a.m. Resident #5 was heard calling from her room stating, Can you help me? Put this call light where I can reach it. Resident #5 was observed sitting in her wheelchair facing towards the foot of her bed. The call light was observed clipped to the head of the bed out of her reach. Staff K, Certified Nursing Assistant (CNA) came into Resident #5's room and moved the call light from the head of the bed to the foot of her bed and within her reach. Review of Resident #5's admission Record revealed she was re-admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side, polyneuropathy,…

    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 · Dcited before2023-01-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, the facility failed to ensure a care planned intervention related to having the bed positioned in the lowest position was implemented for one resident (#3) of forty-two sampled residents for three days (1/23/2023, 1/24/2023, and 1/26/2023) of four days observed. Findings included: On 1/23/2023 during a tour of the facility at approximately 10:45 a.m., Resident #3 was observed in her room lying in bed. Resident #3 was lying on a specialized mattress with raised bolsters to assist with fall prevention. The bed was elevated approximately three feet above its lowest position. The bed adjustment remote was placed on the foot of the bed and no staff were present in or around the resident's room. On 1/23/2023 at 2:00 p.m. Resident #3 was again observed in her room with the bed elevated approximately three feet from the lowest position with the remote at the foot of the bed. An attempt to interview the resident about her bed positioning indicated she was not able…

    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
Show the remaining 7 citations
  • Potential for harm · D2023-01-26 · 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, record review, and interview the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed with three errors identified for three residents (#451, #13, and #203) of eight residents sampled constituting a 10.00% medication error rate. Findings included: 1. A medication administration observation was conducted on 1/24/23 at 9:43 a.m. with Staff G Licensed Practical Nurse (LPN) for Resident #451. Staff G administered: -Amlodipine 10 milligram (MG) -Furosemide 20MG tablet -Aspirin 81MG tablet -Ferrous sulfate 325mg (65 Fe (iron)) MG tablet -2 tablets of Calcium Acetate 667 MG. At the time Staff G dispensed the Calcium Acetate medication, an observation was made of the Calcium Acetate order on the electronic medical record on 1/24/23 at 9:44 a.m. The medication was highlighted in red. Staff G, LPN indicated the medication order was red because it was late. Staff G confirmed it was scheduled to be given at 8:30 a.m. and confirmed it was over an hour after it was due. She confirmed 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 · D2023-01-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure the correct medical diagnosis was documented in a resident's medical record. The failed practice was true for one resident (#32) of 42 sampled residents. Findings included: A record review of Resident #32's medical record showed a diagnosis of Post Traumatic Stress Disorder (PTSD) that was initiated on 10/26/21. The quarterly Minimum Data Set (MDS), dated [DATE], showed PTSD in Section I - Active Diagnoses. There was no care plan focus for PTSD. There was no completed PASRR Level II. During an interview on 01/26/23 at 9:00 a.m. the Nursing Home Administrator (NHA) stated that a PASRR Level II would be looked into as to whether one had been completed or not. In an additional interview on 01/26/23 at 9:25 a.m. the NHA stated that Resident #32 did not have PTSD and that the diagnosis of PTSD on the medical diagnosis page was in error. The NHA stated that no one knew how the diagnosis was placed in error on Resident #32's medical record and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-14 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview and medical record review, the facility failed to maintain a dignified dining experience for one of thirty-four sampled residents (#20), during two of four days observed (5/11/2021, and 5/12/2021). Staff were observed not providing timely meal set up and eating assistance, stood up and behind the resident while assisting with eating, and stopped the meal feeding assistance several times to reposition a resident. Findings included: On 5/11/2021 at 11:58 a.m. the first floor dining room was observed for the lunch meal observation. There were six tables each table with a plastic see through partition to ensure resident social distancing while eating. There were seven residents in the room, seated in their wheelchairs or Broada reclining chairs and awaiting their meal service. At 12:01 p.m. staff brought in a tray cart and three employees began to serve and set up trays. At 12:02 p.m. a table was served with two residents. Resident #20, while seated in a reclining Broada chair…

    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 · Dcited before2021-05-14 · 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 review of resident medical records, the Medical Examiner's (ME) report, and facility policies/procedures and interviews with the Staffing Agency Administrator, Nursing Home Administrator (NHA), the Director of Nursing (DON), Regional Nurse Consultant (RNC), nursing staff members, the facility Medical Director, and Resident #71's family member the facility failed to correctly report an allegation of neglect for one (Resident #71) of thirty-four sampled residents. Findings included: Review of an Immediate Federal Report, #104360, filed by the facility on [DATE] revealed the reporting person was the Administrator, regarding Resident #71, the alleged perpetrator was Staff U, CNA (Certified Nursing Assistant), the date and time of the incident was [DATE] at 3:21 p.m., type of incident was listed as Neglect, and the resident's representative, Law Enforcement and the Abuse Registry had all been notified. The Description of the Incident was Resident #71 was observed on the floor by CNA, the Facility's Immediate…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-14 · tag F0623 — isolated
    Provide 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 medical record review, facility record review and staff interviews, the facility failed to ensure upon resident discharge from the facility, staff provided complete discharge notices to three of thirty-four sampled residents (#72, #121, and #33) and failed to send notice of discharge to the Ombudsman's office. Findings included: 1. On [DATE] review of resident #72's closed medical record revealed he had originally been admitted to the facility on [DATE]. Review of the progress notes dated [DATE] revealed Resident #72 was admitted with a fracture and for aftercare. Review of the Hospital discharge summary (Form 3008), dated [DATE] revealed resident was alert and oriented x 3. Review of the advance directives revealed resident #72 was his own responsible party and decision maker. Review of progress notes dated [DATE] revealed Resident #72 was discharged and sent to the Hospital. Review of a progress note dated [DATE] 17:00 (5:00 p.m.) Late entry revealed, Nurse observed the resident leaning against the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review the facility did not ensure appropriate labeling of three opened insulin pens of seven insulin pens in one medication cart (medication cart #1) of four medication carts on one of four nursing units (unit one). Findings included: On [DATE] at 12:45 PM an observation was conducted on unit one during the medication storage inspection of medication cart one with Staff F, LPN (licensed practical nurse). There were two insulin aspart pens and one Novolog insulin pen that were opened and did not have open dates labeled on them. Each pen had a bright orange sticker marked with open date: indicating they should be labeled with an open date. Staff F, LPN confirmed they had not been labeled with an open date, Staff F, LPN said the regional nurse had just been in checking the medication cart. The label on the Novolog pen indicated it had to be discarded twenty-eight days after opening. The insulin aspart labels indicated they needed to be discarded twenty-eight days after…

    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 · D2021-05-14 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual 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 record review, observations, interviews, and policy review the facility did not ensure food was served in a form the residents could tolerate and according their therapeutic diet orders for one (#60) of three residents receiving pureed diets without orders for mechanical soft snacks. Findings included: Resident #60 was admitted to the facility with a diagnosis of dysphagia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected that a brief interview for mental status (BIMS) could not be completed because Resident #60 is rarely/never understood, indicating severe cognitive impairment. Review of Section K, swallowing/nutritional status, reflected that Resident #60 was on a mechanically altered diet. Review of the physician ' s orders in the medical record reflected a diet order dated 7/30/20 Regular diet, Pureed texture. Review of the CNA (certified nursing assistant) care instructions in the medical record reflected Diet as ordered Puree diet, current…

    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

$181,100 in federal fines across 1 penalty.

  • $181,100 — penalty dated 2025-06-05

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SOVEREIGN HEALTHCARE HOLDINGS — 43 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 2 of 53.7-1.7 vs chain
Health inspection 1 of 53.2-2.2 vs chain
Staffing 4 of 53.1+0.9 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 42 homes this chain runs (chain average 3.7★, per CMS)
1 of 5Abercorn Rehabilitation CenterSavannah, GA 1 of 5Sunnybrook Rehabilitation CenterRaleigh, NC 2 of 5Lake Worth Rehabilitation CenterLake Worth, FL 2 of 5Monroe Rehabilitation CenterMonroe, NC 2 of 5Pinellas Point Nursing And Rehab CenterSaint Petersburg, FL 2 of 5Rocky Mount Rehabilitation CenterRocky Mount, NC 3 of 5Bayshore Pointe Nursing And Rehab CenterTampa, FL 3 of 5Lanier Rehabilitation CenterJacksonville, FL 3 of 5Lincolnton Rehabilitation CenterLincolnton, NC 3 of 5Medicana Nursing And Rehab CenterLake Worth, FL 3 of 5Port Orange Nursing And Rehab CenterPort Orange, FL 3 of 5Raleigh Rehabilitation CenterRaleigh, NC 3 of 5Tiffany Hall Nursing And Rehab CenterPort Saint Lucie, FL 3 of 5Treyburn Rehabilitation CenterDurham, NC 4 of 5Atlantic Shores Nursing And Rehab CenterMelbourne, FL 4 of 5Bonifay Nursing And Rehab CenterBonifay, FL 4 of 5Boulevard Rehabilitation CenterBoynton Beach, FL 4 of 5Braden River Rehabilitation Center LLCBradenton, FL 4 of 5Hunters Creek Nursing And Rehab CenterOrlando, FL 4 of 5Metro West Nursing And Rehab CenterOrlando, FL 4 of 5Northdale Rehabilitation CenterTampa, FL 4 of 5Ocala Oaks Rehabilitation CenterOcala, FL 4 of 5Orange City Nursing And Rehab CenterDebary, FL 4 of 5Pettigrew Rehabilitation CenterDurham, NC 4 of 5Royal Oaks Nursing And Rehab CenterTitusville, FL 4 of 5Sarasota Point Rehabilitation CenterSarasota, FL 4 of 5Silas Creek Rehabilitation CenterWinston-Salem, NC 4 of 5Warner Robins Rehabilitation CenterWarner Robins, GA 4 of 5Zebulon Rehabilitation CenterZebulon, NC 5 of 5Arbor Trail Rehab And Skilled Nursing CenterInverness, FL 5 of 5Boynton Beach Rehabilitation CenterBoynton Beach, FL 5 of 5Crestview Rehabilitation Center, LLCCrestview, FL 5 of 5Cypress Pointe Rehabilitation CenterWilmington, NC 5 of 5Fort Walton Rehabilitation Center, LLCFort Walton Beach, FL 5 of 5Jacksonville Nursing And Rehab CenterJacksonville, FL 5 of 5Macclenny Nursing And Rehab CenterMacclenny, FL 5 of 5Marianna Health And RehabilitationMarianna, FL 5 of 5Moultrie Creek Nursing And Rehab CenterSaint Augustine, FL 5 of 5Palm City Nursing & Rehab CenterPalm City, FL 5 of 5Parkview Rehabilitation Center At Winter ParkWinter Park, FL

Showing 40 of 42; 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 / managerTypeRoleSince
SOVEREIGN HEALTHCARE HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 05/19/2009
CRONQUIST 2015 FAMILY TROrganizationINDIRECT OWNERSHIP INTERESTsince 12/31/2015
JOHN J NOTERMANN BUSINESS TROrganizationINDIRECT OWNERSHIP INTERESTsince 11/12/2017
MANGINE, JOHNIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/25/2012
FL BONIFAY HOLDINGS, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 05/19/2009
HEALTH SERVICES PROPERTIES LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 05/19/2009
CHERY, DAWNIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/08/2017
KAAR, SUSANIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 10/01/2003
LANDY, FREDERICKIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 12/13/2022
SOUTHERN HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/19/2009
CRONQUIST, ROYCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2018
HAYWOOD, SANDRAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/23/2023
MELTON, DONALDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/15/2009
NOTERMANN, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
WALSH, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2017
NOTERMANN, BRENDAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 11/20/2025
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2025
SOVEREIGN HEALTHCARE DISBURSEMENTS LLCOrganizationADP OF THE SNFsince 05/19/2009
KELLY, MICHELLEIndividualADP OF THE SNFsince 02/01/2018

CMS files one row per role, so the 32 rows in the source record cover these 19 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.

8 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.

$12.7M
Net patient revenuemost recent cost report
+2.3%
Operating marginrevenue minus expenses
$608K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 10%Other / private 19%

About 71% 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 $608K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$333per resident / day
operating cost
$10,122per month
≈ monthly operating cost
$341per 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 105603. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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