Alexander "sandy" Nininger State Veterans Nursing
8401 W Cypress Dr, Pembroke Pines, FL 33025 · Government - State · 120 certified beds · (954) 985-4824 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $38,659 in federal fines (most recent 2025-01-09)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.0% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.2% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.6% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.1% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.6% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.1% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.1% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.2% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.8% | 8.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.5% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.3% | 94.7% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.25 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.35 | 1.15 | 1.80 | better |
* 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.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 113.1 residents a day — about 94% occupied, or roughly 7 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 5.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.02 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.58 is at or above 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 5.03 hrs/resident/day on weekends vs 5.78 on weekdays — 13% thinner on weekends. RN hours go from 1.18 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 24% is below 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-01-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to address a significant weight loss in a timely manner, failed to provide adequate nutritional supplements to prevent further significant weight loss, and failed to have effective communication between the multidisciplinary staff for 1 of 4 sampled residents reviewed for nutrition (Resident #103). The findings included: A review of the facility's policy titled, Dietitian, dated 12/30/24, showed the following: The Dietitian will work closely with the Interdisciplinary team, assess the nutritional needs of the residents, and collaborate effectively with other direct care staff and practitioners to assess and address nutritional issues with the facility population. A review of the facility's policy titled Facility Nutrition Program/Resident Nutrition Services dated 01/05/2018 showed the following: the Dietitian will help assess the nutritional needs and risk of all residents and ensure that appropriate meals and other nutritional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was observed during 3 of 3 visits conducted in the Main Kitchen. The findings included: 1. A tour of the Main Kitchen was conducted on 05/18/26 at 08:46 AM with the Dietary Manager (DM). The following items were observed: a. In the walk-in refrigerator, a full 6 inch deep, two third-sized hotel pan located on a shelf to the right of the entrance was observed with loosely wrapped raw white mushrooms. The pan was dated 05/08/26 and the mushrooms were observed to be browned and discolored indicative of spoilage. The DM stated mushrooms can be refrigerated for up to 30 days. b. In the food processing area, the convection oven was observed with a large amount of food residue on mainly the interior top and bottom. The bottom of the oven had a metal sheet tray which also had a large amount of food residue that was burnt onto the pan. c. In the cooking prep area, a knife drawer was noted 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.
- Potential for harm · Ecited before2026-05-21 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observations, interviews, and record review, the facility failed to: 1. Follow the approved menu for the lunch meal served to the residents on 05/18/26 with the potential to affect 63 residents with orders for regular texture foods. 2. Failed to provide all the menu items for 1 of 1 resident observed during the breakfast meal on 05/19/26. (Resident #65) 3. Failed to provide all the menu items for 1 of 1 resident observed during the lunch meal on 05/19/26. (Resident #43) 4. Failed to serve the correct portion size for residents on 05/20/26 with the potential to affect 7 residents with orders for bite sized consistency. The findings included: 1. The approved lunch menu on 05/18/26 documented the residents with regular texture diet consistency were to receive a 4-ounce (oz) portion of Chicken Marinated. During an observation on 05/18/26 at 11:51 AM, in the Delta Blue Dining Room, the portion of chicken served to the residents with a regular texture diet was observed to be smaller than 4 oz. On 05/18/2026…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-21 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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 observations, interviews and record review, the facility failed to provide pureed foods in a form to meet the needs of a total of 17 residents with orders for pureed foods. The findings included: The facility provided the guidelines from the International Dysphagia Diet Standardization Initiative 2.0 (IDDSI) dated July 2019 which were the guidelines used for the consistency of the pureed diets. The standards described pureed consistency as extremely thick and able to retain its shape. It further stated that it cannot be poured. Recipes for Pureed Sauteed Squash and Pureed Garlic Mashed Cauliflower provided by the facility described the consistency as able to hold its shape on a plate, does not flow easily, and cannot be poured. 1. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Depression, and Chronic Gingivitis. Review of the Significant Change Minimum Data Set (MDS) for Resident #9 dated 02/25/26 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Interview and record review, the facility failed to obtain informed consent for the use of Psychoactive medications for 1 of 4 residents reviewed for Dementia Care, Resident #98. The findings included:On 05/21/26 at 11:51 AM, a record review was conducted for the Dementia Care investigation for Resident #98. Resident #98 was determined to have been prescribed the following Psychoactive medications:Quetiapine 25 mg (Seroquel) 25 mg 1 tablet by mouth at bedtime for hallucinations. Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depressionDuloxetine (Cymbalta) 30 mg 2 capsule (60mg) by mouth once a day at 9:00 AM for depression. Psychoactive medications require informed consent prior when ordered by the Physician, Nurse Practitioner, or Physician's Assistant. Resident #98's records only have Informed Consent for Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depression. On 05/21/26 at 3:43 PM, an interview was conducted with the Administrator regarding Quality Assurance Performance Improvement (QAPI) initiatives for the facility. During the meeting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accuracy of diagnoses included on the PASARR (Preadmission screening and record review) for individuals with a mental disorder, for 3 of 4 residents reviewed (Residents #33, #34, and #7). The findings include: 1.) On 05/19/26 at 2:59 PM, during record review for Resident #33 a determination was made that the primary diagnosis for Resident #33 was identified on the PASARR as Dementia. The Admitting Diagnoses listed for Resident #33 included Chronic combined systolic (congestive) and diastolic (congestive) heart failure.Resident #33 had a Psychiatric evaluation after admission which identified the following psychiatric diagnoses:Major Depressive Disorder recurrent moderate;Post Traumatic Stress Disorder unspecified;Insomnia unspecified.None of these diagnoses were identified as a primary admitting diagnosis. On 05/20/26 at 10:41 AM, an interview was conducted with the Social Services Director (SSD) who is a Licensed Clinical Social Worker (LSCW).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to develop and implement a care plan with measurable goals and interventions for 1 of 5 residents reviewed for Behavior, Resident #7; and failed to follow care plan interventions for 1 of 2 residents reviewed for falls, Resident #65. The findings included: 1). Record review for Resident #7 revealed an admission date of 12/20/23. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 03/18/26, Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident displayed behaviors that included little interest in doing things 2-6 times during the 14-day look back period, feeling down, depressed, or hopeless 2-6 days of the 14-day look back period, and feelings of loneliness or isolations 'sometimes'. The assessment documented Resident #7 had psychiatric mood disorders at the time of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to investigate and update interventions to care plans to prevent additional falls for 1 of 2 residents reviewed for falls (Residents #65). The findings included: Review of the facility's policy titled, Falls and Fall Risk Managing, last revised on 09/05/24, stated the staff will identify interventions and implement a resident-centered fall prevention plan related to the resident's specific risks and causes to try to prevent the resident from falling. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Dementia, Benign Prostatic Hypertrophy, Chronic Kidney Disease Stage 3, Colon and Prostate Cancer. Review of the Quarterly Minimum Data Set (MDS) for Resident #65 dated 04/07/26 revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 04, which indicated the resident had severe cognitive impairment. The resident was dependent with toileting and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide care and services to meet the needs and prevent re-traumatizing of 2 of 5 residents reviewed for Behavior, (Residents #7, and #9). The findings included:1.) The Facility Assessment, most recently reviewed and revised on 03/27/26, documented:Services and care we offer based on our residents' needs:Mental health and behavior - Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. During an interview, on 05/21/2026 at 9:14 AM, with Staff C, Unit Clerk, when asked about training provided related to providing care to a resident with PTSD Staff C replied, We have in-services and we learn how to remain calm with them.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to document behavior monitoring for 1 of 4 residents reviewed for Dementia Care, (Resident #98).The findings include:On 05/21/26 at 11:51 AM, a record review was conducted for Resident #98 related to antipsychotic medications prescribed for a resident with a diagnosis of Dementia. The following medications were ordered for the reason provided:Quetiapine 25 mg (Seroquel) 25 mg 1 tablet by mouth at bedtime for hallucinations. Duloxetine (Cymbalta) 30 mg 1 capsule by mouth at bedtime for depression.Duloxetine (Cymbalta) 30 mg 2 capsule (60mg) by mouth once a day at 9:00 AM for depression.A review of the Medication Administration Record (MAR) for May 2026 revealed monitoring for the antipsychotic medication Quetiapine (Seroquel) but no monitoring was found for the Duloxetine (Cymbalta) an antidepressant. A review of progress notes revealed there were no notes found that identified behavior and/or mood changes related to depression or the use of the antidepressant Duloxetine.On 05/21/26 at 2:17 PM, 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.
- Potential for harm · Dcited before2025-07-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, interview and record review, the facility failed to 1) accurately document, assess and report a resident's change in skin condition and; 2) ensure appropriate notification of the resident's representative of a change in the resident's condition for 1 of 2 sampled residents reviewed, Resident #1.The findings included: 1) Review of the facility policy titled Skin Management provided by the Director of Nursing (DON) reviewed effective 04/23/12 documented .Ongoing Skin Checks Daily C.N.A. and/or other direct care giver skin checks: 1. The Certified Nursing Assistant (C.N.A.)/other direct care giver will conduct an inspection of the resident's skin daily when providing care, assisting with or providing bath/shower. 2. The Certified Nursing Assistant (C.N.A.)/other direct care giver will report to the Licensed Nurse any findings/concerns daily. Weekly Licensed Nurse skin checks: 1. The Licensed Nurse will complete full body inspection of the resident, and either: a. document 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.
Show the remaining 16 citations
- Potential for harm · Ecited before2025-01-09 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observations, interviews and record review, the facility failed to follow their own menu for fresh fruit, for 8 of 8 residents observed during dining (Resident #104, Resident #42, Resident #14, Resident #8, Resident #86, Resident #12, Resident #60, and Resident #35). The findings included: 1. Record review revealed that Resident #104 was admitted on [DATE] with diagnoses of Hypokalemia and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which is cognitively intact. In an interview conducted on 01/07/25 at 8:24 AM in the main dining room, Resident #104 was eating his breakfast meal. Resident #104 stated that they only get bananas twice a week if any, and that the rest of the week they do not get any fresh fruits. He then picked up his meal ticket and said, it says here that we are supposed to get fresh fruit for breakfast. 2. Record review revealed that Resident #42 was readmitted to the facility on [DATE] with diagnoses 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.
- Potential for harm · E2025-01-09 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide palatable, appetizing and flavorful food for 8 of 8 residents (Resident# 58, Resident# 43, Resident# 59, Resident# 73, Resident# 88, Resident# 17, Resident# 32, Resident# 70). The findings included: 1. A record review showed that Resident #58 was admitted on [DATE] with chronic kidney disease stage 3. The Minimum Data Set (MDS) quarterly dated 11/20/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 13, which indicates mild cognitive impairment. In an interview conducted on 01/06/2025 at 11:45 AM, this surveyor was stopped in the hallway by Resident # 58 who said that the food in the facility is disgusting. He stated that the food did not look appetizing, that he usually asks for his eggs over easy but one day he gets it and the next day he does not. This is because they alternate between pasteurized and unpasteurized eggs. Resident #58 further stated that the unpasteurized eggs are overcooked and have a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-09 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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 observations, record reviews, interviews, and policy review, the facility failed to provide the correct diet consistency for 9 residents on the Pureed consistency diet (Residents #41, #65, #25, #53, #11, #16, #45, #60 and #22). This had the potential to affect 14 residents that were prescribed the pureed consistency diet. The findings included: 1) During an observation of residents eating lunch in the Delta Blue dining area, on 01/06/25 at 12:10 PM, Resident #16, Resident #45, and Resident #11 were served the pureed entrée consisting of ham, brussel sprouts, and corn. The food appeared lumpy. 2) In an observation and interview with the FSD on 01/06/25 at 12:25 PM, the surveyor approached the Food Service Director (FSD) who was behind the steam table in the main dining room. Concerns about the pureed consistency were voiced by the surveyor. The surveyor requested a sample of the pureed lunch meal and the FSD asked a dietary aide to prepare a pureed meal plate. The FSD carried the pureed meal tray to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-09 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, sanitary conditions, and to ensure the prevention of foodborne illnesses for 106 of 112 residents. The findings included: During the initial tour of the kitchen on 01/06/25 at 9:30 AM, accompanied by the Food Services Director (FSD): 1. The walk-in refrigerator had a black plastic bag with a knot in it located on a shelf. When asked what was in the bag the FSD opened the bag and revealed that it was someone's personal food. It looked like it was chicken and vegetables in a plastic container. On the shelf below that there was transparent, white plastic wrap crumpled up into a ball. 2. The Arctic walk-in freezer had pieces of rubber on the floor. When asked what it was, a food service employee said that it fell off a pipe. 3. The metal backsplash connected to the Vulcan oven had streaks of black and brown debris on the area rising approximately 14 above the level of the stove top. 4. A clear plastic bin had white…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide residents' choices consistent with their interest assessments and care plan. Facility failed to honor resident choices regarding scheduled bedtime for 1 of 1 resident (Resident #114). The findings included: A record review showed that Resident #114 was admitted on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicated no cognitive impairment. A review of the admission MDS dated [DATE] section E showed that Resident #114 answered that it was very important for him to choose his bedtime. In an observation conducted on 01/06/2025 at 11:35 AM Resident #114 was still lying in his bed undressed. In an observation conducted on 01/08/2025 at 12:05 PM Resident #114 was seen in bed underneath the covers. In this observation Resident #114 said that he was waiting to get dressed and get out of bed. In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to address a grievance regarding hearing aids for 1 of 1 sampled resident (Resident #17). The findings included: A review of facility's policy titled, State of Florida, Department of Veteran's Affairs, Resident Grievances dated 08/04/2009, revised 10/18/2027, revealed the resident has the right to voice grievances to the facility. Number 1under the filing grievances section revealed that any resident, family member, or appointed resident representative may file a grievance concerning care, treatment, behavior of other staff members, theft of property or any other concerns regarding his or her stay in the facility. Number 3 revealed that grievance may be submitted orally or in writing and may be filed anonymously. Number 6 under the investigation and resolution of grievances section revealed that the resident and or resident's representative filing the grievance on behalf of the resident, will be informed of the findings of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide treatment and care, in accordance with professional standards for practice for 3 of 25 sampled residents (Resident #114, Resident #34, Resident #104). The findings included: 1) Record review showed that Resident #114 was admitted to the facility on [DATE] with Quadriplegia, C1-C4 incomplete. The Minimum Data Set (MDS) quarterly dated 12/18/2024 revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. A review of section GG indicated that Resident #114 needs partial to moderate assistance to roll left and right. In an interview conducted on 01/09/2025 at 1:30 PM Resident #114 stated that 3 weeks ago he was left on his bed for 2 hours in fetal position waiting for a suppository to help with defecation. He further stated Staff O, Certified Nurse Assistant (CNA), who starts her shift at 3:00 PM and came into his room and found him in fetal position on his bed sweating with his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a left hand splint as per Physician's order for 1 of 1 resident reviewed for Limited Range of Motion (Resident #19). The findings included: Record review revealed that Resident #19 was readmitted to the facility on [DATE] with diagnoses of Hypertension and Muscle Weakness. An order dated 11/30/23 revealed the following: apply left hand splint and left elbow protector for 8 hours (as needed) during AM hours and check skin before and after removal. The Quarterly Minimum Data Set( MDS) dated [DATE], showed that Resident #19 has a Brief Interview of Mental Status (BIMS) score of 13, which is low to moderate cognitive impaired. In an observation conducted on 01/06/25 at 11:00 AM, Resident #19 was observed in bed with a contracture (fingers curled and pulled towards the palm) on his left hand, and no left-hand splint in place. In this observation, Resident #19 stated that the left hand splint has not been placed on his left hand and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and policy reviews, the facility failed to provide adequate supervision during a Hoyer lift transfer for 1 of 1 sampled resident (Resident #45). This had the potential to affect 50 residents who used Hoyer lifts. The facility failed to ensure that the oxygen tank was secured for 1 of 1 sampled resident (Resident #44). The findings included: 1) According to the facility's policy and procedure on Safe Resident Handling and Lifting, revised 05/09/2018, employees will use mechanical lifting devices and/or other approved resident handling assistive devices in accordance with instructions and training. At least two people will be present to assist the resident during the use of mechanical lift equipment. Staff should refer to and comply with the resident's care plan prior to transferring or lifting residents. Review of the clinical record for Resident #44 revealed an admission date of 08/12/19. This resident's diagnoses included Unspecified Dementia, 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.
- Potential for harm · D2025-01-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 2 of 9 sampled residents reviewed during the controlled substance record review on the facility's Delta and Alpha wings, for Residents #38 and #44. The findings included: 1) Review of Resident #38's clinical record documented admission on [DATE] and readmission on [DATE], and had diagnoses that included: Dementia, Anxiety Disorder, Restlessness and Agitation, Unspecified Psychosis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #38 had a Brief Interview for Mental Status (BIMS) of 04, indicating severe cognitive impairment. Review of the Physician's Orders showed that Resident #38 had an order dated 12/19/24 for Alprazolam 0.5 mg tablet, give 1 tablet oral every 12 hours for 30 days for Psychosis/Agitation/Anxiety. On 01/09/25 at 11:00 AM, a review of Resident #38's Controlled Drug Record sheet received by the facility from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observations, interviews and record review, the facility failed to ensure a treatment cart was locked while unattended during facility tour; failed to ensure medication cart and medications were secured during medication administration observation; and failed to dispose of expired over the counter medications (OTC) during medication storage review. The findings included: Review of the facility's policy titled, Storage of Drugs and Biologicals, dated 05/04/16, included the following: In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments/containers Containers/compartments containing drugs and biologicals will be locked when not in use, including medication carts. Review of the facility's policy titled, Medication Administration, dated 12/31/21, included the following: During administration of medications, the medication cart will be kept closed and locked when out of sight of the personnel administering medication. No medications are kept on top of the cart. 1) During the initial tour of the facility conducted on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement CDC (Center for Disease Control and Prevention) guidelines and recommendations for Enhanced Barrier Precautions for 2 residents with wounds (Resident #61, and Resident #101). The findings included: According to CDC, Enhanced Barrier Precautions revealed the following: Everyone must clean their hands including when both entering and leaving the room. Providers and Staff must also; wear gloves and a gown for the following high-contact resident care activities: dressing; bathing-showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy; Wound Care any skin opening requiring a dressing. https://www.cdc.gov/long-term-care-facilities/media/pdfs/EBP-KeepResidentsSafe-Poster-508.pdf. 1). Record review revealed Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure it was adequately equipped with functioning emergency call device in 2 of 12 bathrooms on the Alpha Unit. The findings included: On 01/06/25 10:25 AM, an observation was made of the emergency call device pull cord in the bathroom for room [ROOM NUMBER], which was wrapped around grab bar (Photographic Evidence Obtained). On 01/06/25 11:38 AM, an observation was made of the emergency call device pull cord in the bathroom for room [ROOM NUMBER], which was wrapped around the grab bar and dragging on the floor (Photographic Evidence Obtained). During an interview conducted on 01/07/25 at 3:15 PM with Staff B, Certified Nursing Assistant (CNA) who stated she has worked at the facility for 3 years. When asked about call devices, she said each resident has one by their bed and there is one in each bathroom. When asked if the emergency call device pull cord in the bathroom should be wrapped around the grab bar she said no. During an interview conducted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the Physician's orders for wound treatment (Resident #4), and failed to obtain a physician order for wound care (Resident #5), for 2 of 3 sampled residents reviewed for wound care (Residents #4 and #5). The findings included: 1) Review of Resident #4's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The residents diagnoses included Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus and Unspecified Open Wound, Lower Leg. Review of Resident #4's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident was dependent on the staff to complete most the activities of daily living except eating. Review of the resident's care plan titled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to perform proper technique with catheter care for Resident #24 and failed to utilize a urinary catheter anchor for 3 of 14 residents identified with urinary catheters, Residents #24, #19, and #55. The findings included: 1. The facility's policy titled Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revised 6/9/17, has a section titled Maintenance/Care of Indwelling Urinary Catheters that has 6 steps. Step 5 states: Minimize the pull of catheter tubing by securing catheter to resident's body. 2. A procedure manual document from www.nursegroups.com, titled Indwelling Catheter Care, has numbered steps describing indwelling catheter care. Step 10 instructs: Perform perineal care with washcloths, soap, and warm water. Remember to clean front-to-back on female residents and under the foreskin of uncircumcised males. 3. On 09/13/23 at 9:35 AM, an observation was made of Staff A, a Certified Nursing Assistant (CNA), performing perineal care with catheter care on Resident #24. The CNA had all her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5 percent, as evidenced by three medication errors in 25 opportunities which resulted in a medication error rate of 12 percent, for 2 of 5 sampled residents (Resident #83 and #34). The findings included: Review of the facility's policy titled Medication Administration, dated 12/31/21 revealed that The individual administering the medication must check the label to verify the . right dosage . of administration prior to giving the medication. 1) A medication administration observation was conducted on 09/13/23 at 8:46 AM with Staff B, Licensed Practical Nurse (LPN) for Resident #83. Staff B stated she had taken Resident #83's vital signs previously-Blood Pressure (BP) 142/79 and Heart Rate (HR) 76. Staff B then prepared the following medications: 1) Aspirin 81 milligram (mg) 1 tablet 2) Multivitamin with Minerals 1 tablet 3) Duloxetine 20mg 2 capsules 4) Lisinopril 5mg-Staff B discussed this medication and that based on the blood pressure parameters ordered by 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$38,659 in federal fines across 1 penalty.
- $38,659 — penalty dated 2025-01-09
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CARTER, ALFRED | Individual | CORPORATE DIRECTOR | since 11/28/2011 |
| MILITELLO, LAWRENCE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2009 |
| SCRIMA, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 10/18/2016 |
| EVANCHO, WAYNE | Individual | ADP OF THE SNF | since 01/29/2025 |
CMS files one row per role, so the 5 rows in the source record cover these 4 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.
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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 106038. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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 →
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