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Pensacola Nursing & Rehabilitation Center

235 West Airport Blvd, Pensacola, FL 32505 · For profit - Limited Liability company · 120 certified beds · (850) 857-5200 Medicare & Medicaid certified

Call the home — (850) 857-5200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)
  • about 17% of its spending goes to commonly-owned related companies

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 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6431 N W St · (850) 494-4600 · Call to confirm hours
Pharmacy
6258 N W St · (850) 462-9555 · Call to confirm hours
Grocery
5800 N W St · (850) 542-4000 · Call to confirm hours
Park
N W St · Typically dawn to dusk
Place of worship
275 W Airport Blvd · (850) 696-6704

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 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 increased9.6%8.7%15.4%better
Long-stay residents who lose too much weight5.9%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.2%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.7%4.6%6.5%better
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 injury3.0%2.5%3.3%better
Long-stay residents whose ability to walk worsened6.8%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication14.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers7.0%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control18.3%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 table18.4%8.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.4%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine83.7%94.7%79.4%typical
Short-stay residents rehospitalized after admission27.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit19.2%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.872.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.671.151.80typical

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.

48.2% 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 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.2%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
44.8%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 44.8% 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 29 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF48.2%CMS range 32.1–60.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 6.7–15.010.7%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 discharge44.8%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 discharge27.6%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 discharge31.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified75.0%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 setting80.0%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 worsened1.9%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 hospitalization5.8%CMS range 2.9–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 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

0.73
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.45
Total nurse hours/ resident / day
0.66
RN hoursweekends
67.0%
Total nursing turnover
65.2%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.3 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.23 hrs/resident/day on weekends vs 3.55 on weekdays — 9% thinner on weekends. RN hours go from 0.76 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

12
deficiencies at the latest standard inspection (2026-04-09)
5
at the previous standard inspection (2025-01-09)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · Dcited before2026-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, review of the facility's policy and education, and review of Florida Administrative Code, the facility failed to ensure that residents who required ileostomy services received such care consistent with professional standards of nursing practice for 2 of 2 residents reviewed for ileostomy care (Resident #1 and #2).The findings included:On 06/24/2025 at approximately 8:30 AM, an initial tour of the facility was conducted. Resident #1 and Resident #2 were identified as having ileostomies (a surgical procedure that diverts digestive waste out of the body by connecting the lowest part of the small intestine (the ileum) to an opening in the abdominal wall, by passing the colon).A review of Resident #1 medical record revealed he was first admitted to the facility on [DATE]. His medical history was significant for an ileostomy. Resident #1 had multiple hospitalizations and was last readmitted to the facility on [DATE]. Review of his Minimum Data Set (MDS) revealed…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow acceptable nationally accepted infection prevention and control standards including proper use of Personal Protective Equipment (PPE) to prevent the spread of infections for 2 of 2 residents observed for direct resident care (Resident#1, #5).The findings included:On 06/24/2026 at approximately 8:42 AM, an observation was made of Resident #1's room. An Enhanced Barrier Precaution (EBP) sign was posted on the outside of the room door. While touring the room, it was noted that multiple used enteral feeding syringes were present in the room in undated bags (Photographic evidence obtained). During this observation, Staff A, Registered Nurse (RN), entered the room and donned gloves. Staff A refilled the empty hydration bag and used one of the open, undated syringes to flush Resident #1's peg tube (a flexible feeding tube which is surgically placed through the abdominal wall directly into the stomach). Staff A then reconnected the tube…

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

    Infection Control Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-04-09 · 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

    Based on observations, interviews, record reviews, policy review, and a review of the Resident Council minutes, the facility failed to uphold resident rights and dignity by not knocking and announcing staff presence before entering the rooms of two residents (Resident #23 and Resident #37). The findings include:On 04/07/2026 at 12:35 PM during observation and interview with Resident #23, Staff P, Certified Nursing Assistant entered Resident #23's room and passed the partially pulled privacy curtain by Resident #23's bed and turned and walked back out of the room. Staff P re-entered the room within a few seconds and knocked on the door and entered stating I have your lunch. On 04/07/2026 at 9:50 AM, at the suggestion of Resident #23, a telephone interview was performed with the local Long Tem Care Ombudsman. The Ombudsman revealed she visited Resident #23 last week and observed three occurrences of staff members coming into Resident #23's room without knocking or announcing themselves. The Ombudsman stated this was a concern for Resident #23, so she informed the facility's…

    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 · D2026-04-09 · tag F0552 — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to inform residents of care and treatment prior to the start of care and treatment of psychotic medication for 2 out 5 residents reviewed for general consent to treat (Resident # 12 and #37).The findings include:A record review was conducted for Resident #12. Resident #12 was readmitted to the facility following a hospital stay on 2/12/26 with the diagnoses including major depressive disorder, anxiety, bipolar disorder, and insomnia. Resident #12's medical record revealed they had a brief interview for mental status score of 15, which meant she was cognitively intact. Review of Resident #12's physician orders revealed that Resident #12 was taking Paroxetine Mesylate daily for depression, Trazodone nightly for insomnia (psychotropic), Topiramate twice a day for bipolar disorder, and Hydroxyzine three times a day for anxiety. A review of Resident #12's Minimum Data Set, dated [DATE] indicated the use of antidepressant medications being used. The care…

    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 · D2026-04-09 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to maintain required advance directive documentation for 2 of 35 sampled residents (Residents #37 and #114). The findings include: A record review was completed for Resident #37. This review revealed Resident #37 was a full code, but no advance directive education discussion sheet was available in the electronic medical record. Resident #37 had a plan of care, dated 2/10/26, which indicated she requested Full Code status. An interview was conducted with the Director of Nurses (DON) on 4/8/26 at 5:15 PM. She stated, We are unable to locate the admission documents, including [Resident #37's] consent for advance directives. During a record review of Resident #114, the electronic medical record contained no admission consent or advance directive documentation since admission on [DATE]. Requests for these documents were made to the Administrator on 4/7/26 at 10:44 AM and again during an interview with the Social Services Director on 4/7/26 at 12:57 PM.…

    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 · D2026-04-09 · 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 observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for 2 of 29 sampled occupied resident rooms. (Rooms #201 and #206) The findings include: On 4/6/26 at approximately 12:30 PM, during the initial tour, occupied room [ROOM NUMBER]'s shower was observed with black grime on the tile walls and floors. The shower drain was covered with hair and a thick white substance. (Photographic evidence obtained)An interview conducted with room [ROOM NUMBER]'s occupant, who stated he had been using the shower in his room. The resident further stated he had asked the staff multiple times to clean it. On 4/7/26 at approximately 10:30 AM, an additional observation was made. The shower still had black grime on the tile walls and floors. The shower drain was still covered with hair and thick white substance.A follow up interview was conducted with the room's occupant, who stated he wanted to take a shower but wanted it cleaned first.On 4/7/26 at approximately 12:45…

    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 · D2026-04-09 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon interview and record review, the facility failed to follow up on a grievance for 1 of 3 residents reviewed (Resident #40)The findings include: On 04/06/2026 at 12:13pm, an interview with Resident #40's sister was conducted. Resident #40's sister stated clothing items went missing in March and, when she reported it, she was informed a grievance would be completed and the facility would resolve the issue. She stated it had been about three weeks, and she has not heard the resolution.On 04/08/2026 at 2:07pm, an interview with the Social Services Assistant and the Director of Social Work was conducted. A review of the facility grievance logs from 01/28/2026 through 03/31/2026 was also conducted. There were no entries in the grievances logs regarding Resident #40. The Social Services Assistant stated she was not aware of a grievance filed by the sister of Resident #40. There was no grievance log for April 2026. The Social Services Assistant stated she still needs to make the April log. The Director of Social Work stated they could not locate a grievance form regarding Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · 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, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 2 residents sampled for indwelling urinary catheters (Residents #10 and #122) and 1 of 2 residents reviewed for falls (Resident #11).The findings include: On 4/6/26 at approximately 1:14 PM observations were made of the indwelling urinary catheters for Resident #10 and Resident #122. A review of Resident #10's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed Resident #10 had an active physician's order for a Foley catheter. The Comprehensive Care Plan failed to include a care plan focus area for the indwelling urinary catheter or catheter care interventions. Review of Resident #122's clinical record revealed they were admitted to the facility on [DATE]. Further review revealed Resident #122 had an active physician's order for a Foley catheter. The Comprehensive Care Plan failed to include a care plan focus area for the indwelling urinary…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to carry out physician orders for 2 of 20 residents reviewed. (Resident #69 and #108)Observations of Resident #69 were conducted on 04/06/2026 at 12:30 PM and 4:30 PM, 04/07/2026 at 11:30 AM, 2:30 PM, and 4:30 PM, 04/08/2026 at 8:38 AM. During each of these observations, it was noted that Resident #69 had contractures to bilateral hands. Closer observation revealed no splints or braces were in place during these observations. A record review revealed a physician order for Splint/Brace application, Encourage and assist resident to participate with donning and doffing of Bilateral palm protectors' splint/brace. Bilateral Palm protectors to be used at all times except for ADLs and skin assessment. Monitor skin surfaces under device and notify physician of abnormal findings This order was initiated on 3/31/2026. Resident #69 also had a plan of care in place for skin impairment to left palm with the goal that she will be free from any skin impairment through review date and skin will show signs of healing without…

    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 · D2026-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interviews and record reviews, the facility failed to provide treatment and services to 1 of 1 residents reviewed for pressure ulcers. (Resident #125) The findings include:A record review was conducted for Resident #125. Resident #125 was admitted to the facility on [DATE] with diagnoses including Sepsis due to EColi, Peripheral vascular disease, acquired absence of foot, and wound to right hip. Physician orders included Wound care to cleanse the right great toe with wound cleanser, paint with betadine every day shift (start date 3/13/26); Sacrum, cleanse with wound cleanser, apply barrier ointment and nystatin powder to wound bed every day shift (start date of 3/13/26); Wound Vac -apply wound care vac to right hip at 125mmhg. Cleanse area with normal saline, pat dry, apply wound vac 3 times a week and prn. every day shift on Monday, Wednesday, and Friday to right hip (start date of 3/11/26); Apply skin prep to bilateral heels as tolerated every shift for 14 days (start date of 3/7/26). A plan of care…

    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
Show the remaining 14 citations
  • Potential for harm · D2026-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to monitor weights for 1 of 3 residents reviewed for weights (Resident #9).The findings include:During an interview conducted with Resident #9 on 4/6/26 at approximately 2:06 PM, he stated he had lost some weight since being admitted to the facility.A review of Resident #9's clinical record revealed an active physician's order, dated 2/6/26, for weights 3 times a week every Monday, Wednesday, and Friday. The Comprehensive Care Plan included a care plan focus area for at risk for alteration nutrition/hydration related to history of weight loss/weight fluctuations due to Congestive Heart Failure (a chronic condition where the heart does not pump blood efficiently enough to meet the body's needs) and Edema (swelling caused by excess fluid trapped in the body's tissues) with interventions for weights as ordered. (Photographic evidence obtained.)Review of the facility's list for obtaining regular weights (dated 3/30/26) revealed Resident #9's name was omitted. (Photographic evidence obtained.)On 4/7/26 at approximately 12:30 PM,…

    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 · D2026-04-09 · tag F0698 — failed to provide proper dialysis care — isolated
    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 observations and record reviews, the facility failed to ensure ongoing communication and collaboration was maintained with the dialysis facility for 1 of 1 resident reviewed for dialysis services (Resident #52).The findings include:On 4/7/26 at 9:31 AM, Resident #52 was out of the facility for dialysis treatment. Resident #52 returned to the facility after lunch, around 2:00 PM. An observation was conducted at 4:15 PM with Resident #52. He voiced being tired due to his treatment but was okay. On 4/8/26 at 11:30 AM, during an interview with Resident #52, he stated, I don't always get the paperwork to take with me to the dialysis center.A record review revealed that Resident #52 was initially admitted to the facility on [DATE] and re-admitted to facility on 8/7/25 post hospitalization with diagnoses including end stage renal disease (ESRD), arteriovenous fistula, and dependence of dialysis. He was ordered for dialysis every Tuesday, Thursday and Saturday for his ESRD. Resident #52 had a plan of care for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on observations, staff interviews, and record reviews, the facility failed to acquire pain medication from the pharmacy in a timely manner to ensure proper continuity of care for 1 of 1 resident reviewed for pain (Resident #103).The findings include: On 4/6/26 at approximately 12:00 PM, an interview was conducted with Resident #103. Resident #103 stated he received Tramadol twice a day, but did not receive any pain medication on 4/3/26, 4/4/26 or 4/5/26. He further stated he worked out every morning despite not having his pain medication and was not going to let the pain stop him from participating in activities he enjoyed. A review of Resident #103's medical record was conducted. A review of Resident #103's diagnoses include fractured tibia, cervicalgia, and chronic pain. Further review revealed an order for Tramadol 50 mg by mouth every day at 9:00 AM and 11:00 PM. A review of the medication administration record (MAR) for April 2026 confirmed Resident #103 did not receive Tramadol on 4/3/26, 4/4/26, and 4/5/26. The documented reason indicated the medication was not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure appropriate infection control practices were followed for 3 of 3 residents reviewed for infection control (Residents #1, #10, #122). The findings include:On 4/6/26 at 1:50 PM, an observation was made of Resident #1 eating lunch. During this observation, it was noted that red biohazard bags were on the floor of Resident #1's room. An interview was conducted at the time of the observation with Staff J, Certified Nursing Assistant. Staff J stated that Resident #1 did not have a roommate because Resident #1 was on Transmission Based Precautions (TBP) for Methicillin resistant Staphylococcus aureus (MRSA) in a wound (MRSA is a drug-resistant bacteria). It was noted that no TBP signage was posted on the door of Resident #1's room. An additional observation of Resident #1's room was conducted on 4/7/26 revealed that no TBP sign was present. A review of the medical record showed that TBP had been ordered on 4/6/26. On 4/8/26, it was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0924 — isolated
    Put firmly secured handrails on each side of hallways.
    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 policy review, the facility failed to maintain handrails in a safe, secure, and functional condition for the 200 hallway.The findings include:On 4/6/26 at approximately 11:35 AM during an initial tour, the handrail on the 200 hall outside of room [ROOM NUMBER] was noted to be broken. When pressure was applied to the handrail, the handrail displaced approximately 3 inches vertically. (Photographic evidence obtained)On 4/8/26 at approximately 12:05 PM, a follow-up observation on the broken handrail was conducted with facility's Administrator and Maintenance Director. They both confirmed handrails should be secure to the wall and they confirmed this handrail needed to be repaired. A review of Facility's Maintenance Service policy (dated 12/2009) page #1 of 2 revealed: The maintenance department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner. Maintaining the building in compliance with current federal, state, and local laws,…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement care plan interventions for supervision during meals for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at approximately 9:00 AM, an observation made in Resident #6's room revealed signage above the head of bed that reads, 1. Supervised All meals. (Photographic evidence obtained).On 2/19/26 at approximately 11:10 AM, an interview was conducted with Staff A, Unit Manager (UM), who stated if a resident requires assistance or supervision with meals there is usually an order, or it will be listed on the resident's care plan. Staff A went on to state the certified nursing assistants and staff are made aware during daily shift reports.On 2/19/26 at approximately 11:45 AM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who stated if a resident requires assistance or supervision with meals, it will be located on the meal ticket for that resident. On 2/19/26 at approximately 12:45 PM, an observation was made of Resident #6's room. The door was open 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide an ordered therapeutic diet for 1 of 4 residents sampled. (Resident #6)The findings include: On 2/19/26 at approximately 9:00 AM, an observation made in Resident #6's room revealed signage above the head of bed that read, 3. Mech soft, chopped meats, thin liquids. (Photographic evidence obtained)On 2/19/26 at approximately 12:45 PM, an observation was made of Resident #6 feeding himself with no staff present. The meal tray was observed to have approximately 7 potato chips and approximately 2 saltine crackers with his meal. The meal ticket read, Regular-DYS ADV (DYS ADV is short for Dysphagia Advanced, which means a regular diet, but avoiding hard, sticky, or crunchy foods. Foods should be bite-size). (Photographic evidence obtained).On 2/19/26 at approximately 12:47 PM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA), who stated chips and crackers are not part of a mechanical soft texture diet. Staff B entered Resident #6's room and removed the chips and crackers from 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to offer the 2024 influenza vaccine to 1 of 5 sampled residents (Resident #3) and failed to document the provision of education regarding the benefits and potential side effects of the 2024 influenza vaccine and pneumonia vaccine for 5 of 5 sampled residents. (Residents #3, #37, #46, #54, and #73) The findings include: A review of Resident #3's medical record revealed the resident had not been offered an influenza vaccine since 11/10/23. No education had been documented as provided for Resident #3 regarding the influenza vaccine since 2022. A review of Resident #37's medical record revealed no education regarding the pneumonia vaccine had ever been documented. A review of Resident #46's medical record revealed no education regarding the influenza vaccine had been documented since 2021. A review of Resident #54's medical record revealed no education regarding the pneumonia vaccine had ever been documented. A review of Resident #73's medical record revealed no influenza education had been documented since…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and policy review, the facility failed to offer the 2024 COVID-19 vaccine to 4 of 5 sampled residents. (Residents #37, #46, #54, and #73) The findings include: A review of Residents #37, #46, #54, and #73's medical records revealed the residents had not been offered the COVID-19 vaccine in 2024. An interview was conducted with the Assistant Director of Nursing (ADON) on 1/9/25 at 10:53 AM. The ADON stated the last time the facility offered the COVID-19 vaccine to residents was in November 2023. She stated it should be offered annually and they just have not done so. Review of the facility policy for COVID-19 (revised 6/24/24) revealed COVID-19 vaccines are offered to residents and staff in accordance with CDC guidance. Review of the current CDC (Centers for Disease Control) recommendations for COVID-19 vaccines in the long term care setting was accessed at https://www.cdc.gov/covid/vaccines/long-term-care-residents.html on 1/10/25 at 11:10 AM. The CDC recommendations were: *Everyone ages 6 months and older should get a 2024-2025 COVID-19…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to act promptly to resolve and properly investigate grievances submitted for 2 out 2 residents sampled. (Resident #54 and #21) The findings include: On 11/17/24 Resident #54 filed a grievance. The form stated that she was only getting grits, a slice of toast and a glass of tea. She included the meal card to show what she should be getting. Resident #54's meal card for 11/17/24 stated she should receive: a double protein at breakfast, bacon, hot cereal, biscuit, jelly, margarine, juice of choice, orange juice, coffee, creamer, sausage patty, English muffin, jelly, margarine, toast, jelly, margarine. This complaint was verbally communicated to the administrator and dietary. This section was signed by the business office manager (BOM) on 11/17/24. This investigation was assigned to dietary staff and the Kitchen Manager on 11/18/24. On the Findings portion of the form, all that was written was, On the menu we have a lot of no meat days. The Plan to Resolve Complaint/Grievance section was left blank. The Expected Results 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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

    Based on record review, interviews, and policy review, the facility failed to ensure ordered medication was available to 1 of 8 residents observed for medication administration. (Resident #97) The findings included: A medication order for Resident #97 was reviewed and showed that methylprednisolone (a corticosteroid), a medication ordered to treat a flare up of muscular sclerosis (MS), was ordered for 5 days starting on 01/04/2025 but was not started until 01/08/2025. Muscular sclerosis is a disease that affects the central nervous system. An MS flare-up is an episode of new symptoms or a worsening of existing symptoms triggered by inflammation in the central nervous system for which corticosteroids are often prescribed to reduce inflammation and manage symptoms. A record review confirmed Resident #97 had a diagnosis of muscular sclerosis. The record for Resident #97 documented the medication was ordered by the Advanced Practice Nurse Practitioner (ARNP) on 1/2/2025 and confirmed on 1/3/2025 by Licensed Practical Nurse (LPN) C for methylprednisolone sodium succinate injection…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, staff interviews, and policy reviews, the facility failed to ensure staff followed appropriate infection control processes to prevent contamination during 1 of 1 observations of wound care (Resident #3) and failed to ensure staff changed PICC (peripherally inserted central catheter) dressings in accordance with the physician order and facility policy for 1 of 1 sampled residents with a PICC line (Resident #156). The findings include: Resident #3 An observation of wound care for Resident #3 was conducted on 1/8/25 at 10:30 AM with Employee A (Wound Care Registered Nurse). Employee A washed her hands, applied gloves, and removed the dressing from the left interior knee. Employee A then cleansed the wound. She then washed her hands and applied new gloves. Employee A then applied Santyl ointment, collagen powder, and CMC (carboxymethyl cellulose) fiber to the wound bed. Employee A then placed her soiled, gloved hand into her pocket to obtain her marker. She then dated a dressing with the marker and applied the dressing over the wound. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and policy reviews, the facility failed to store and prepare food in accordance with professional standards for food service safety. The findings include: On 9/17/23 at approximately 10:15 AM, an initial tour of the kitchen was conducted. During the tour, Staff A, a cook, was observed preparing food but was not wearing a hair net over his head or a beard net over his beard. On 9/17/23 at approximately 10:44 AM, the walk in cooler was observed to have a three compartment container with egg salad, macaroni salad, and lettuce, none of which were dated. On top of the container, there was an open package of peeled boiled eggs with no date on it (see photographic evidence). There were 7 plates covered with aluminum foil with no dates on them (Photographic evidence was obtained). On 9/17/23 at approximately 10:20 AM, an interview was condcuted with Staff A, who stated they ran out of hair nets and beard nets that day. The staff member stated there were nets available, but he did not have keys to get into the manager's office to get them. On 9/17/23 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record reviews, and policy reviews, the facility failed to provide infection control measures for 1 of 2 residents sampled for respiratory care. (Resident #395) The findings include: On 9/17/23 an observation was made of the Resident #395's nebulizer machine (a machine that delivers medications to the resident's lungs using a mouthpiece to help with breathing) sitting on the nightstand with the mouthpiece not bagged, covered, or stored appropriately to prevent contamination. The date on mouthpiece read 08/25/2023. On 09/18/2023, an observation was made of Resident #395's nebulizer machine sitting on the nightstand once again with the mouthpiece not bagged, covered, or stored appropriately. However, the tubing was dated 09/18/2023. On 09/19/2023 an observation was made of Resident #395's nebulizer machine sitting on the nightstand with mouthpiece not bagged, covered, or stored appropriately. (Photographic evidence obtained) A record review was conducted of Resident #395, which revealed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 2 of 52.7-0.7 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.2+0.8 vs chain
Quality measures 2 of 54.1-2.1 vs chain
The other 37 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Crescent Health And Rehabilitation CenterSarasota, FL 1 of 5Kensington Gardens Rehab And Nursing CenterClearwater, FL 1 of 5Nursing & Rehabilitation Center Of New Port RicheyNew Port Richey, FL 1 of 5Oak Haven Rehab And Nursing CenterAuburndale, FL 1 of 5Vero Beach Care CenterVero Beach, FL 2 of 5Baya Pointe Nursing And Rehabilitation CenterLake City, FL 2 of 5Capri Health And Rehabilitation CenterVenice, FL 2 of 5Creekside Health And Rehabilitation CenterSarasota, FL 2 of 5Fairway Oaks CenterTampa, FL 2 of 5Flagler Health And Rehabilitation CenterBunnell, FL 2 of 5Haines City Rehabilitation And Nursing CenterHaines City, FL 2 of 5Highlands Lake CenterLakeland, FL 2 of 5Indian River CenterWest Melbourne, FL 2 of 5North Port Rehabilitation And Nursing CenterNorth Port, FL 2 of 5Riverwood CenterJacksonville, FL 2 of 5Sandgate Gardens Rehab And Nursing CenterFort Pierce, FL 2 of 5Sea Breeze Rehab And Nursing CenterVero Beach, FL 2 of 5Tierra Pines CenterLargo, FL 2 of 5Viera Del Mar Health And Rehabilitation CenterViera, FL 2 of 5Winter Garden Rehabilitation And Nursing CenterWinter Garden, FL 3 of 5Cedarbrook Health And Rehabilitation CenterFort Myers, FL 3 of 5Coquina CenterOrmond Beach, FL 3 of 5Eagleridge Health And Rehabilitation CenterFort Myers, FL 3 of 5Fouraker Hills Rehab And Nursing CenterJacksonville, FL 3 of 5Hillside Health And Rehabilitation CenterZephyrhills, FL 3 of 5Oakpark Health And Rehabilitation CenterPalm Harbor, FL 4 of 5Bridgeview CenterOrmond Beach, FL 4 of 5Coastal Health And Rehabilitation CenterDaytona Beach, FL 4 of 5Debary Health And Rehabilitation CenterDebary, FL 4 of 5Fernandina Beach Rehabilitation And Nursing CenterFernandina Beach, FL 4 of 5Island Lake CenterLongwood, FL 4 of 5Meadowpark Health And Rehabilitation CenterDunedin, FL 4 of 5Parkside Health And Rehabilitation CenterDeland, FL 4 of 5Ruleme CenterEustis, FL 4 of 5Seaside Health And Rehabilitation CenterDaytona Beach, FL 5 of 5Bayview CenterEustis, FL 5 of 5Osprey Point Nursing CenterBushnell, FL

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PENSACOLA MEMBER LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2022
SH INDIGO CITADEL INVESTORS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST14%since 01/01/2024
ORNSTEIN, MARTONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 01/01/2024
WILDES, DONNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
DEVARAPALLI, HIMAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/14/2026
FOSTER, DANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2026
NEAL, LATISHAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/29/2025
SALTER, SADEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/28/2025
ASTON HEALTHCARE LLCOrganizationADP OF THE SNFsince 01/01/2024

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

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.7M
Net patient revenuemost recent cost report
-37.7%
Operating marginrevenue minus expenses
$2.0M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 3%Other / private 14%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$361per resident / day
operating cost
$10,974per month
≈ monthly operating cost
$262per 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 105935. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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