Pinellas Park Fl Opco, LLC
8701 49th St N, Pinellas Park, FL 33782 · For profit - Corporation · 120 certified beds · (727) 546-4661 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $46,419 in federal fines (most recent 2026-03-05)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (68%) runs well above the national median (45%)
- about 19% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | Not rated |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.7% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 0.7% | 2.0% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 6.7% | 4.6% | 6.5% | typical |
| 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 | 2.9% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.1% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.0% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.9% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.8% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.11 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.10 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
34.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.3% 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 89 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 34.0%CMS range 25.2–46.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 7.7–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 48.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 28.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.3–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
Weekend coverage: total nurse staffing is 3.05 hrs/resident/day on weekends vs 3.41 on weekdays — 11% thinner on weekends. RN hours go from 0.32 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% 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
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.
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.
26 citations, most serious first. The 15 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-03-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the residents' right to be free from neglect by failing to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.On [DATE] Resident #3 was found unresponsive and absent of vital signs by facility staff and CPR was not performed. On [DATE] Resident #3 had a meeting with the facility's Advanced Practical Registered Nurse (APRN) and expressed his Advance Care wishes. The progress note read, We had an extensive conversation concerning full code vs. (versus) DNR (Do Not Resuscitate) status. Patient verbalizes an understanding of the difference and elects/confirms full code status. On [DATE] at 5:30 a.m. Resident #3 was found unresponsive by Staff A, CNA (Certified Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2026-03-05 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F600 and F726.Findings included: Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include Type 2 diabetes, other persistent atrial fibrillation, abnormal gait, need for assistance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2026-03-05 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure nursing staff demonstrated competency in ensuring life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The facility staff's failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F600 and F678Findings included: Review of an undated facility job description titled, License Practical Nurse (LPN), revealed required qualifications included: current CPR certification.Major duties and responsibilities showed:Directs the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2023-09-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, physician interview, and facility policy review the facility failed to protect the resident's right to be free from neglect, to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses was provided care and assistance to prevent an injury from a burn during meal service times. Resident #1 suffered pain, infection of the skin and subcutaneous issue, and permanent body disfigurement related to scarring as a result of the facility's neglect to ensure this resident's safety during meal service. The facility neglected to provide care and services during a meal to a vulnerable resident with physical limitations, resulting in findings of Immediate Jeopardy on 8/16/23. The findings of Immediate Jeopardy were determined to be removed on 9/29/23 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Review of a Resident Information Record dated 09/29/23 showed Resident #1 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.
- Immediate jeopardy · Jcited before2023-09-29 · 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 review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses were free from hazards during meal service. Resident #1 is a vulnerable adult with a history of hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, and muscle weakness. On 08/16/23, during evening meal service, Resident #1 requested a bowl of soup. The facility staff provided Resident #1 with a cup of bubbling hot tomato soup that had been warmed in a microwave for approximately 3-4 minutes and was not cooled prior to serving. The soup was served in an 8-ounce disposable foam cup and was not checked for temperature before it was served to Resident #1. The resident who does not have use of her left arm reached to the hot cup with her right arm, dropped the cup of soup on herself and suffered 2nd degree burns to her left forearm and the left side of her abdomen. Resident #1 suffered…
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 before2026-06-04 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to ensure medications were stored under proper temperature controls in the two medication storage rooms (2nd and 3rd) of two facility medication storage rooms observed.Findings Included: On 6/3/26 at 8:54 a.m., during a tour of the 2nd floor medication room, the Maintenance Director (DOM) checked the ambient temperature, which measured 82.20 F.On 6/3/26 at 9:27 a.m., during a tour of the 3rd floor medication room, Regional Maintenance Director (RDOM) checked the ambient temperature, which measured 85.2 F.During an interview on 6/3/26 at 8:54 a.m. the DOM said the air conditioning unit for the 2nd floor medication rooms has been out of service for approximately one month. He stated after the facility received three repair proposals, the repairs were approved the previous week, and the work would be completed soon. During both observation tours conducted on 6/3/26 at 8:54 a.m. and 9:27 a.m., the Over the counter (OTC) medications were observed stored in both medication rooms, and the automated medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-04 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to address and respond to resident council members, related to grievances voiced in their council meetings for four months (January, February, March, and April 2026) of five months reviewed and failed to respond to grievances for one resident (#84) of one resident reviewed.Findings included: Review of resident council minutes and the facility's grievance logs dated January 2026 through May 2026 showed grievance forms were not completed for grievances voiced in resident council meetings and a response was not provided to the committee members for the four-month period reviewed.Review of the Resident Council minutes dated 1/8/26 showed the residents reported concerns regarding cold food. The minutes showed there were no nursing, therapy, housekeeping/laundry, administration/social services, and maintenance concerns listed. The committee's concern about cold food was not listed on the grievance log and the facility did not provide a grievance form or…
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 before2026-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the resident environment was free from accident hazards in one unsecured utility rooms (third floor) of two observed.Finding included: An observation on 06/01/2026 at 6:15 AM revealed the biohazard/ soiled utility room on the third floor was not locked or secured in a manner that would prevent residents on the third floor from accessing the contents of the room that could have the potential to cause injury or illness. The room was observed to contain a sharps container, a refrigerator marked with a biohazard symbol, and soiled linens. During multiple tours, residents were observed ambulating independently through the hallways on the third floor, near and around this utility room.An interview with Staff K, Registered Nurse (RN), on 06/03/2026 at 2:52 PM revealed the biohazard room should always be locked because there is a small refrigerator with biological samples in the room which need to be protected from contamination and/or tampering. Staff K said additionally, the room contains potentially hazardous items, such…
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 before2026-06-04 · 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, interviews, and record review, the facility failed to ensure sanitation requirements were met in 1 out of 1 kitchens observed.Findings included,On 06/01/2026 at 05:51 AM, a kitchen tour was conducted. During the tour, a steam table was observed to be soiled with white debris on the bottom shelf. In the dishwasher area, a metal faucet with spiraling metal was observed with brown corrosion and deformed. A stove in the kitchen was observed, with ash-like debris in various areas on the stove top. Discolored noodles were observed on the stove top near an open flame. A dish rack in the kitchen was observed soiled with debris on various dishes, such as metal pans and lids. On a wall located in the bottom left corner, a tile was observed missing. In the area, a tile was missing from, the insides of the wall were visible, including metal, various wall construction elements, and debris. A cart in the kitchen was observed with various wet and dry discolored liquids and debris.On 06/02/2026 at 04:35 PM, a kitchen tour was conducted. The kitchen stove top was observed 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 · E2026-06-04 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 maintain an effective pest control program in one kitchen (Main) out of one kitchen observed.Findings included: On 6/1/2026 at 6:02 a.m., during a tour of the kitchen, a small, slender winged, flying insect was observed in the hallway leading to the kitchen. Upon entering the kitchen, an observation was made of more of the same flying bugs in the dishwasher room, in the hallway where a locker room was located, and near the office located inside the kitchen. There were numerous flying bugs observed on the lid of a container on the ground near the dishwasher, and around a food disposal unit connected to a countertop near the dishwasher. A flying bug was observed on the handle of a cooking pot on a drying rack.During an interview on 6/2/2026 at 4:50 p.m., the Senior Certified Dietary Manager (SCDM) said he knew there were some flying bugs the day before, but he had not seen these many flying bugs previously.During an interview on 6/2/2026 at 4:44 p.m. the SCDM said the pest control company serviced the kitchen…
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 · D2026-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment in four resident rooms (235, 251, 304 and 324) of 36 rooms observed. Findings included: During an observation of room [ROOM NUMBER] with the Director of Maintenance (DOM) on 06/03/2026 at 11:15 a.m., the DOM observed and stated, he's seeing what appears to be water intrusion in to the walls from outside with the walls damaged. During an observation of room [ROOM NUMBER], the DOM stated, he was seeing that the window had failed and there was a leak in the thermal lining of the panes, there was also water intrusion into the wall with bubbling of the paint and unpainted surfaces. During an interview on 6/4/26 at 09:30 a.m. with the resident in room [ROOM NUMBER], she stated, the windows and the walls are in need of repair and has asked staff to fix, with no response. During an interview on 6/4/26 at 12:00 p.m. with the resident in room [ROOM NUMBER], he stated, the walls and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · 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 record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two residents (#1 and #85) of 4 residents reviewed for PASARRs. Findings included: 1. Review of the transfer/discharge report showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, psychosis, psychoactive substance abuse, and schizophrenia. Review of Resident #1's level I PASARR dated 1/8/26 showed qualifying diagnoses including anxiety disorder, depressive disorder, psychosis, were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 6/4/26 at 12:57 p.m. with the Director of Nursing (DON) and the Interim Social Services Director (SSD) the SSD said, I have to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
Based on record review and interviews, the facility failed to ensure dialysis residents were provided with snacks/meals consistent with professional standards of practice and the care plan for one resident (#8) of one sampled.Findings included: Record review revealed Resident #8 had medical diagnoses of dependence on renal dialysis and end stage renal disease. The order summary report for Resident #8 revealed an order to send snack with resident on dialysis days in the morning every Tuesday, Thursday, Saturday, with a start date of 04/09/2026. The care plan report for Resident #8 revealed a focus of Resident #8 is at risk for renal failure with dialysis, last revised on 01/19/2026. The intervention for that focus included to send snack/meal with Resident #8 on dialysis days, last revised on 10/22/2025. A progress note dated 05/30/2026 revealed no snacks available nor delivered by dietary staff. An interview with Staff M, Certified Nursing Assistant (CNA) on 06/03/2026 at 12:45 PM revealed it is the CNA's responsibility to ensure residents have breakfast or lunch before exiting 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 before2026-06-04 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the medication error rate was not greater than 5%. A total of 28 opportunities were observed with 2 errors constituting an error rate of 7.14%. Findings included: On 6/2/2026 at 9:26 a.m. a medication observation was conducted with Staff F, Registered Nurse (RN) for Resident# 59. Staff F, RN confirmed the tablets prior to administration. Staff F dispensed the following medication:-Methadone hydrochloride 10 MG/ML (milligrams per milliliter) Oral Solution 1ml-Amlodipine 5 MG Oral - 1 Tablet [Norvasc] this medication was held due to low blood pressure.-Folic acid 400 Mcg (microgram) Oral -1 Tablet-Tamsulosin hydrochloride 0.4 MG Oral Capsule - 1 capsule-Sertraline 50 MG Oral - 1 Tablet-Tiotropium 0.018 MG Inhalation Powder Review of Residents# 59's admission records showed she was admitted to the facility on [DATE] with a diagnosis to include: Type 2 Diabetes Mellitus, Cerebral Infarction, Atherosclerotic Heart disease, Acute Kidney…
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 · D2026-03-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews the facility failed to maintain complete and accurate medical records related to documentation of activities of daily living (ADLs) for one resident (#2) out of two residents reviewed.Findings included: A review of Resident #2's admission record revealed an admission date of 11/21/25 and a discharge date of 11/24/25, with diagnoses to include Parkinson's disease, sarcopenia, cognitive communication deficit, dementia, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits.A review of Resident #2's toileting task from 11/21/25-11/24/25 revealed there was no documentation showing Resident #2 had received incontinence care during 8 out of10 opportunities.A review of Resident #2's nutrition/eating task from 11/21/25-11/24/25 revealed there was no documentation showing Resident #2 received their meals 7 out of 9 opportunities.During attempted interviews conducted with staff on 3/4/26 and 3/5/26, they revealed they did not remember who the resident was due to the short stay and could not speak of 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.
Show the remaining 11 citations
- Potential for harm · Fcited before2025-04-24 · 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, interviews, and policy reviews, the facility failed to ensure kitchen equipment and surfaces were maintained in a clean and sanitary manner, hand washing sink was accessible with the supplies needed, and the overhead lighting was adequate in one of one kitchen. Findings included: On 4/21/25 between 9:40 a.m. and 10:45 a.m., a tour of the facility kitchen was conducted with the Certified Dietary Manager (CDM) and the Dietary Supervisor. The following were observed during the kitchen tour: - The handwashing sink located in the food preparation area was on the floor. There were three holes penetrating the wall, surrounded by wrinkled paper-like outer wall material and exposed dry, chalklike material. An uncapped white plastic accordion style drainpipe extended from the wall. The Certified Dietary Manager (CDM) said the handwashing sink fell off the wall and has been out of service for approximately two weeks. The CDM said the sink in the dishwashing area was available for staff. The sink in the dishwashing area was blocked by a dish rack cart, the paper towel…
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 before2025-04-24 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all drugs used in the facility were labeled in accordance with clinical professional standards, on two of two floors and two of six medication carts. Findings included: On [DATE] at 12:07 P.M., during observation and interview with Staff A, Registered Nurse (RN), Staff A, RN opened the top drawer of a medication cart. During an inspection of the medication cart, labeling of two translucent brown medication bottles containing eye drops had labels affixed with the following information: Notice to discard after forty-two days, with space to write the medication expiration date after the medication is first used and a yellow label with space to write the medication open date, expiration date, and staff initials. No information was written on the label. The inspection also revealed an insulin injector pen with a label to document the date opened of the medication, instructions to discard after 28 days, and an orange label 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 · E2023-12-14 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Review of the admission Record showed Resident #22 was admitted on [DATE], with diagnoses to include major depressive disorder recurrent moderate, schizoaffective disorder bipolar type and generalized anxiety. Review of the PASARR Level I, completed on 10/24/19, showed, in Section 1 Part A, anxiety as the only listed diagnosis. Section IV PASARR Screen Completion showed that a Level II PASARR was not required. Review of the electronic medical record (EMR) revealed the diagnosis of schizoaffective disorder, bipolar type was added on 5/16/23. On 5/25/23 diagnoses of major depressive disorder and generalized anxiety were added to the EMR. Review of the medical record revealed Resident #22 was not assessed for a PASARR Level II when the new diagnoses were added to resident's EMR in May of 2023. Review of Resident #22's care plan revealed diagnoses to include major depressive disorder, generalized anxiety disorder, and schizoaffective disorder bipolar type. Review of the care plan revealed: Focus, created on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-14 · 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 observation, interview, and review of the facility's policy, the facility failed to ensure opened food was labeled and dated in one of one kitchen. Findings included: On 12/11/23 at 9:30 a.m., an initial tour of the kitchen was conducted with the Assistant Dietary Manager. The following was observed in the reach in cooler: opened sliced cheese wrapped in saran wrap with no date, opened ham wrapped in saran wrap with no date, an opened bag of diced chicken with no date, and an opened bag of shredded cheese with no date. In addition, a container of liquid substance with no label or date was observed underneath the food preparation table. (Photographic Evidence Obtained) The Assistant Dietary Manager stated he wasn't sure what was in the container while smelling it. Additionally, an opened bag of biscuits with no date was observed in the walk-in freezer. All findings were confirmed by the Assistant Certified Dietary Manager during the tour. The policy provided by the facility and titled, Date Marketing for Food Safety, undated, revealed the following: Policy The facility…
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 · D2023-12-14 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to ensure the care plan for one resident (#18) out of 36 sampled residents was reviewed and revised to accurately reflect the fluid intake of the resident. Findings included: A review of Resident #18's admission Record revealed an admission date of 6/1/23 and included diagnoses not limited to hypo-osmolality and hyponatremia (sodium levels in blood are abnormally low), other specified disease of biliary tract, unspecified neuromuscular dysfunction of bladder, and presence of urogenital implants. An observation conducted on 12/14/23 at 8:25 a.m. revealed Resident #18 lying in bed, with an approximate half full large-sized bottle of commercially-produced water and a facility-provided foam cup on the over-bed table next to the resident's bed. A review of Resident #18's active care plan, initiated on 6/1/23, showed a Focus for ADL (Activities of Daily Living) related to the resident's self-care performance deficit which included an intervention, dated 8/15/23, instructing staff of NO WATER CUP AT BEDSIDE (on 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 · D2023-12-14 · 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, record review, and interviews, the facility failed to ensure one resident (#17) of one sampled resident, who was diagnosed with Post Traumatic Stress Disorder (PTSD), was provided care and services to account for experiences and preferences, nor did staff address the resident's needs by minimizing triggers and/or re-traumatization. Resident #17's direct care staff were unaware of trauma behaviors, and were not aware of what to monitor for, with relation to PTSD behaviors. Findings included: On 12/11/23 at 12:05 p.m., Resident #17 was observed in bed in her room. During an attempt to interview Resident #17, she was asked if staff were providing appropriate care to her. She yelled, No! She was then asked if she would like to explain, and she yelled I'm not telling you! A review of the admission Record showed Resident #17 was originally admitted to the facility on [DATE] with diagnoses to included bipolar disorder, current episode manic severe with psychotic features, major depressive…
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 · D2023-12-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to administer antibiotics for the duration as prescribed by the provider for one resident (#72) out of five residents sampled for unnecessary medications. Findings included: Review of Resident #72's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified obstructive and reflux uropathy and unspecified protein-calorie malnutrition. On 12/11/23 at 10:01 a.m., Resident #72's door held an isolation caddy and was posted with a sign showing Contact Precautions, the resident and roommate was not observed in the room. An interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM), on 12/11/23 at 10:07 a.m. The staff member stated Resident #72 was on contact precautions due to extended spectrum beta-lactamase (ESBL) in the urine. The staff member reported not knowing where the resident was. The staff member stated, on 12/11/23 at 10:08 a.m., the resident 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.
- Potential for harm · Dcited before2023-12-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed and seven errors were identified for three residents (#30, #77, and #64) of five residents observed. These errors constituted a 21.21% medication error rate. Findings included: 1. On 12/13/23 at 8:17 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse (LPN) was conducted with Resident #30. Staff D dispensed the following medications: - Albuterol Sulfate 90 microgram (mcg) handheld inhaler - Budesonide Formoterol 80/4.5 handheld inhaler - Vitamin C 500 milligram (mg) over-the-counter (otc) tablet - Hydrocortisone 20 mg tablet - Lisinopril 10 mg tablet - Risperidone 0.5 mg - 2 tablets - Potassium Chloride 10 milliequivalent (meq) Extended Release (ER) tablet. Staff D poured approximately 120 milliliters (mL) of nutritional supplement in a plastic cup and confirmed dispensing 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-09-30 · 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 observation, interview, and record review the facility failed to ensure 1. one newly admitted resident (#161) out of 11 new admissions sampled received physician ordered medications for pain and chronic obstructive pulmonary disease (COPD) the night of admission, and 2. failed to ensure three low air loss mattresses for residents (#90, #76 & #82) were set according to the residents' needs and manufacturer's instructions for three of four days observed of sixteen residents with air mattresses. Findings included: 1. During an interview with Resident #161 on 9/28/21 at 9:27 a.m. the resident stated on Thursday, 9/23/21 he arrived at the facility at 5:45 p.m. and did not receive any pain medication or breathing treatments for his COPD until 8:00 a.m. the next morning (9/24/21). The resident stated he had back surgery and lifted his left hand that was in a splint and stated these are the reason he had pain. Resident #161 was observed with oxygen at 3 liters and stated he needed his breathing treatments…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
Based on interview and record review the facility failed to provide care and services consisted with professional standards of practice related to the provision of hemodialysis when they failed to ensure communication with the dialysis facility regarding care and services for one resident (#5) out of seven facility residents receiving hemodialysis. Findings included: Resident #5 was interviewed on 09/29/21 at 12:09 p.m. She confirmed that she received hemodialysis treatments three times a week at an outpatient treatment center and confirmed that she had received treatment as scheduled the day before (09/28/21). Review of the medical record for Resident #5 revealed an admission Record with diagnoses including end stage renal disease, dependence on renal dialysis, and type 2 diabetes. Review of physician orders for September 2021 revealed an order for hemodialysis treatment at an outpatient provider every Tuesday, Thursday, and Saturday. Physician orders also revealed the resident received daily insulin for diabetic management. Her care plan, initiated on 11/4/19, revealed a focus…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-30 · 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 observation, interview and facility policy review, the facility failed to store a medication in a sanitary manner for one resident (#262) of eight residents sampled during the task of medication administration. Findings included: An observation of a medication administration was performed on 09/29/21 at 9:38 a.m. Staff A, Licensed Practical Nurse (LPN) brought the manufacturer's external packaging box for Spiriva Respimat from the medication cart into Resident 262's room. Staff A placed the packaging on a bedside table while she withdrew the medication to administer the dose. Staff A, LPN then placed the medication back into the box, picked it up and went into the bathroom where she placed the medication box down on top of the toilet tank to perform hand hygiene. She then picked up the box, exited the room and returned the box to the medication cart amongst the other medications. A review of the facility's policy titled, Storage of Medications, revised in November of 2020, revealed under Policy Interpretation and Implementation Section, 3. The nursing staff is responsible…
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
$46,419 in federal fines across 2 penalties.
- $26,685 — penalty dated 2026-03-05
- $19,734 — penalty dated 2023-09-29
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 |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — 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.
About 74% 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 $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105422. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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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