Vivo Healthcare Gateway
8600 Us Hwy 19 N, Pinellas Park, FL 33782 · For profit - Limited Liability company · 120 certified beds · (727) 541-7515 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 20% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.3% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 2.4% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.9% | 4.6% | 6.5% | better |
| 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 | 3.1% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.6% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.5% | 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 | 2.4% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.7% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.5% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.8% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.44 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.94 | 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.
32.3% 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 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.6% 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 74 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 32.3%CMS range 23.1–45.6 | 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 | 10.4%CMS range 7.1–14.4 | 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 | 48.6% | 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 | 56.8% | 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 | 40.5% | 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 | 97.6% | 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 | 95.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 0.8% | 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 | 6.4%CMS range 3.7–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 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 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.15 hrs/resident/day on weekends vs 3.56 on weekdays — 11% thinner on weekends. RN hours go from 0.78 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-01-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 policy review, the facility failed to perform a thorough investigation following an allegation for one resident out of three, (#1). Findings Included: During an interview on 01/07/2026 at 10:18 AM, Resident #1 stated an incident happened two weeks prior while she was being changed by a CNA (Certified Nursing Assistant). Resident #1 stated she was on her bed being pressured by an aide, while being changed. The resident stated the right and left forearms were crossed, both palms facing down and stated having asked the CNA, What are you doing. The resident stated she was on the right side of the bed. The wheelchair was facing a nightstand on the right of the bed. She stated the arms were crossed one over the other and pressed against the surface of the bed and wheelchair. Resident #1 stated having hurt wrists and bruising on her forearms. Resident #1 was observed with two- penny sized dark pink spots on both inside forearms near the wrists. The resident explained being confused about 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 · F2024-12-11 · 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 record review, the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner, and food was prepared and stored in accordance with professional standards for food safety in one out of one facility kitchen and two out of two nourishment rooms. Findings included: An observation was conducted on 12/10/24 at 2:36 p.m. in the north unit nourishment room of: -Cups and trash on the floor under the table. -The shelf above the refrigerator had dirt, dry spilled liquid, and a container with an unknown liquid. -The refrigerator and freezer contained undated, unlabeled food. -There thermometer in the refrigerator was broken and there was no thermometer in the freezer. -The seal around the refrigerator and freezer door was broken and there were icicles hanging from the freezer door and food was spilled on the shelf. -The refrigerator contained an unlabeled container of liquid that had a date of 11/19. -There was a plunger sitting on the floor next to the refrigerator. An observation was conducted on 12/10/24 at 2:45 p.m. in 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 · Fcited before2024-03-21 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility record review, the facility failed to ensure a working and properly maintained dish washing machine in the kitchen, during two of four days observed, (3/18/2024, and 3/19/2024). It was determined the low temperature chemical sanitizer dish washing machine either; 1. Was not meeting required wash and rinse temperatures, and 2. The chemical sanitizer was allocated and delivered well over acceptable ranges. Findings included: On 3/18/2024 at 9:10 a.m. an observation of the kitchen was conducted with Staff C, Dietary Manager, Staff C revealed the facility operates a low temperature dish washing machine and the expectations for wash temperatures was 125 degrees Fahrenheit (F)., and rinse temperatures was 125 degrees F. She was asked what the sanitizer level Parts Per Million (PPM) should range, and she replied, over 100 ppm. The dish washing machine was observed and the specification plate posted on the front revealed it was a low temperature chemical sanitizing machine where the wash temperature should reach 120 degrees F., the rinse…
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 · E2024-03-21 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#7, #13, #14, #20, #50, #53, #65, #80, #88 and #170) of fifteen residents sampled for PASRR review. Findings included: 1. A review of the admission Record showed Resident #65 had an original admission date of 01/19/21 with diagnoses including repeated falls, essential hypertension, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #65's annual Minimal Data Set (MDS) assessment, dated 12/31/23, revealed under Section C-Cognitive Patterns, Resident #65 had a Brief Interview for Mental Status (BIMS) of 00 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #65 had diagnoses of Non-Alzheimer's Dementia and Psychotic disorder. A review of Resident #65's Level I PASRR assessment, dated 01/19/21 revealed, under the section titled A. MI (Mental Illness) or suspected…
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 · E2024-03-21 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to have activities available and provide adequate space for activities for 52 residents residing on one of one memory care units. Findings included: The initial tour of the memory care unit was conducted on 3/18/24, the observation of the unit and resident rooms did not reveal any posted activity calendar. On 3/18/24 at approximately 10:00 a.m., Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), took approximately 6-7 memory care residents outside to a patio to play with a football. On 3/18/24 at 10:04 a.m., an observation was made of 12 residents sitting, either in a dining chair or wheelchair, in the day room on the memory care unit. The television was playing a sitcom. Staff M, Patient Care Assistant (PCA) was sitting in the corner of the room without any verbal or physical interaction with the residents. Staff K, Certified Nursing Assistant (CNA) directed an ambulatory male resident into the room then left the area. The male…
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 · E2024-03-21 · tag F0759 — failed to keep medication error rate low — patternEnsure 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%. Twenty-seven medication administration opportunities were observed and five errors were identified for five ( #57, #83, #7, #76, and #98) of eleven residents observed. These errors constituted a 18.52% medication error rate. Findings included: 1. On 3/19/24 at 11:01 a.m., an observation of medication administration with Staff N, Registered Nurse (RN) was conducted with Resident #57. The observation showed the residents electronic medication profile was colored red, showing the medications were late. The staff member dispensed the following medication: - Venlafaxine 150 milligram (mg) Extended Release (ER) capsule Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), informed the staff member Resident #57 was in the Main Dining Room. Staff Z, Interim Staff Educator, arrived, stood at the medication cart with Staff N and reported being there to help Staff N. The Director of 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.
- Potential for harm · E2024-03-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of the facility's policy titled Pest Control Program, the facility failed to maintain an effective pest control program, for two of two units and the kitchen, as evidenced by observation of pests on four (03/18/2024, 03/19/2024, 03/20/2024 and 03/21/2024) of four survey days. Findings included: 1. An observation on 03/18/24 at 10:05 a.m., revealed a corner on the secured unit near the smoking area door that had multiple flying insects on the walls. Photographic evidence obtained. An observation on 03/18/24 at 10:25 a.m., revealed a cockroach crawling around Resident room [ROOM NUMBER]'s bathroom. Photographic evidence obtained. An observation on 03/19/24 at 1:00 p.m. revealed multiple flying insects that flew around the secured unit nurses' station. During an interview on 03/19/24 at 09:40 a.m., Staff H, Pest Management (PM) stated that his company provides pest services to the facility on a weekly basis. Staff H, PM stated the company provided services that included…
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 · D2024-03-21 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #169's medical record revealed he was admitted to the facility on [DATE] with diagnosis that included Fusion of spine, and Torticollis. Review of the residents Brief Interview For Mental Status (BIMS), dated 3/1/24, revealed a score of 13 (Cognitively intact). Observation on 03/18/24 at 11:17 AM of Resident #169's name posting located on the wall outside of his room door revealed a name normally referred to a female. Observation of the resident at this time revealed the resident had facial hair consisting of a beard and goatee. Interview with Resident #169 at this time revealed that they identify as he/him/they and prefers to be referred to as an alternate name he had provided to staff. The resident reported he prefers to have his provided name posted outside of his room. Interview on 03/20/24 at 09:31 AM with Staff U, Certified Nursing Assistant (CNA) revealed she had worked with Resident #169 before. During the interview Staff U continuously referred to Resident #169 as his given name and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer three residents (Residents #5, #54 and #70) of fifteen residents reviewed for Level I Pre-admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II PASARR resident review upon a significant change in status assessment. Findings included: A review of the admission Record showed Resident #5 had an original admission date of 10/06/18 with diagnoses included but limited to anxiety disorder, unspecified, hyperthyroidism, chronic obstructive pulmonary disease and unspecified convulsions. Resident #5 was later identified with new diagnoses that included: -Other specified anxiety disorders on 08/02/22 -Other specified Depressive Episodes on 08/02/22 -Unspecified dementia, unspecified severity, with other behavioral disturbance on 10/01/22 -Major depressive disorder, recurrent, unspecified on 10/10/23 -Schizoaffective Disorder-Bipolar type 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 · Dcited before2024-03-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 (#98, #100) residents reviewed for vision and dental services. Findings included: Review of the facility policy titled Comprehensive Care Plans with an implemented date of 9/7/22 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident #98's medical record revealed she was admitted to the facility on [DATE] with diagnosis that included Type 2 Diabetes Mellitus foot ulcer, Peripheral Vascular Disease, and Basal Cell Carcinoma of skin. Review of the record revealed a Brief Interview for Mental Status (BIMS) dated 2/8/24 with a score of 14 (Cognitively intact). Interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2024-03-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to consistently provide a packaged meal for one resident (#87) out of four residents receiving dialysis. Findings included Review of Resident #87's medical record revealed that she was admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, End Stage Renal Disease. The record revealed the resident receives dialysis from a local vendor on Monday, Wednesday and Friday. The record included a Brief Interview for Mental Status (BIMS) dated 2/14/24 with a score of 14 (Cognitively intact). Interview on 03/20/24 at 09:06 AM with Resident #87 revealed her lunch has not been brought up to her yet for her 10:00 AM pick up for dialysis. She reported usually the packaged lunch comes up at 6:00 AM but sometimes they forget so her (family member) is bringing her a lunch before she leaves. Observations on 03/20/24 at 09:56 AM of Resident #87 in her room revealed her (family member) was present and that they were waiting 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.
- Potential for harm · Dcited before2024-03-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to ensure one (South #2) of four medication carts was locked while unattended, medications were secured, medications were stored per manufacturer guidelines, one (South) of two treatment carts were locked while unattended, and medications were not stored with cleaning materials. Findings included: On 3/18/24 at 9:41 a.m. while standing at an unlocked medication cart, Staff A, Registered Nurse (RN) offered to obtain a face mask for writer. The staff member left the nursing station, leaving the cart unlocked, went into the room opposite the station, returning a moment later with a box of face masks. A housekeeper was in the nursing station mopping while the cart was unlocked and unattended. The South #2 medication cart was parked in the nursing station; however the cart was parked against a half wall and within reach of residents on a memory care unit. Staff A confirmed the cart was reachable and had been unlocked. On 3/18/24 at 12:10 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to implement an appropriate infection control program related to ensuring staff were aware precaution measures for one (#80) of one residents with precautions, provide a cleanable mattress for one (#95) out of 52 residents, and to ensure adequate hand hygiene was performed for staff and residents. Findings included: 1. An interview on 3/18/24 at 9:37 a.m. was conducted with an unknown Certified Nursing Assistant (CNA) on the memory care unit. The CNA stated there was no COVID infection on the unit and Staff A, Registered Nurse (RN) confirmed this information. On 3/18/24 at 9:47 a.m., an observation was made of Resident #80's room, hanging from the door was a Personal Protective Equipment (PPE) caddy and a sign showing Droplet precautions. The caddy held gowns, N95 masks, faceshields, and gloves. During the observation, Resident #80 was observed walking out of the room. On 3/18/24 at 12:54 p.m., Resident #80 was observed walking independently in the hallway of the unit, not wearing any personal protective…
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 · D2024-03-21 · tag F0924 — isolatedPut 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 observations, interviews, and record reviews, the facility failed to ensure the handrail in one (South - Memory Care) of two units was secure and did not cause a safety issue regarding the presence of broken and/or missing components. Findings included: 1. An observation on 03/18/24 at 12:23 p.m. revealed three decorative fence posts pulled from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was loose and wobbly when touched. Photographic evidence obtained. An observation on 03/19/24 at 10:24 a.m. revealed three decorative fence posts pulled away from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was now unsecured from the wall. Photographic evidence obtained. During an interview on 03/19/24 at 10:26 a.m., Staff J, Director of Maintenance (DOM) stated, I did not know this was like this. Staff F, DOM stated the unsecured hallway handrail was certainly a safety concern and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-21 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 provide a clean and homelike environment for one resident unit (Secured Unit) out of two resident units in the facility. Finding included: 1. An observation on 03/18/24 at 10:27 a.m., revealed the secured unit dayroom had ceiling tiles that were pushed up and not flush with the ceiling. The blinds that hung in the window of the dayroom were broken and pulled apart. The walls in the secured unit dayroom were scratched and a piece of the wall near the locked storage closet was cracked. The main door of the dayroom was scratched and was missing paint. During an interview on 03/20/24 at 11:30 a.m., Staff F, Director of Maintenance (DOM) stated Staff I, Maintenance Worker (MW) just changed the blinds in the window this morning. Staff J, DOM stated staff saw Surveyor taking pictures of the blinds. Staff J, DOM was interviewed and shown the piece of wall near the locked storage closet that was cracked. Staff J, DOM stated he had extra pieces…
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 · E2021-12-16 · tag F0557 — patternHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review the facility did not ensure dignity was maintained for residents on one unit (South Unit) of two units for four days (12/13/21, 12/14/21, 12/15/21, and 12/16/21) of 4 days related to failure to provide furnishings in resident rooms to include lack of pillows, blankets, and personal effects and 2. failed to ensure fitted clothing for one resident (#306) of a total of sample of 41 residents. Findings included: 1. During a facility tour of the South Unit on 12/13/21 at 9:43 a.m., observations were made of resident rooms without personal effects. The rooms were observed without pillows or blankets on the beds. All the beds were furnished with uniform white sheets, a top sheet, and a bottom sheet. The rooms were observed without any personal memorabilia, pictures, or decorations. The rooms observed without pillows included rooms 162, 164 beds A and B,158, 160 beds A and B, 168 bed A,146 bed B and 158. During the tour on 12/13/21 at 9:43 a.m., Staff H, Registered…
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 · E2021-12-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and policy review the facility failed to ensure resident smoking materials were secured for three of four days (12/13/21, 12/14/21 and 12/15/21) on one unit (North Unit) of two units for seven residents (#39, #91, #18, #76, #74, #37, and #15) for a total sample of seven residents who smoked on the North Unit. Findings included: 1. During a facility tour on 12/14/21 at 12:12 p.m., Resident #39 was observed in her room, sitting on her bed. Resident #39 stated that she smokes whenever she likes day or night. Resident #39 stated she was an independent smoker and holds on to her cigarettes and lighter. Resident #39 stated that she holds on to a pack of cigarettes at a time. Resident #39 stated that she hides them under the seat of her wheelchair cushion. The admission Record showed Resident #39 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) for Resident # 39 Section C for Cognitive Patterns showed a Brief Interview for Mental Status score of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-16 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to immediately report an alleged allegation of neglect related to an elopement to regulatory agencies as mandated for one resident (#49) out of 41 sampled residents. Findings included: Review of Resident #49's admission Record revealed he was admitted on [DATE] from an acute care hospital with diagnoses of unspecified mood [affective] disorder, altered mental status and unspecified symptoms and sign involving cognitive functions and awareness. Further review of the admission Record revealed Resident #49 was deemed incapacitated and resided on the South Unit of the facility which is the facility's secured unit. On 12/13/21 at 10:25 a.m. an interview was conducted with Staff Z, Agency Certified Nursing Assistant (CNA) and she stated she was on a one to one with Resident #49 because he had jumped the fence. She was unsure when it happened. An interview was conducted on 12/13/21 at 10:45 a.m. with Staff Y, Social Services. He stated less than 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 · Dcited before2021-12-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure a care plan problem area with a goal and interventions was developed related to Isolation Precautions, for one resident (#156) of forty-one sampled residents Findings included: On 12/13/2021, 12/14/2021, 12/15/2021 and 12/16/2021 Resident #156's room was approached and the door was closed. Further observations revealed the front of the door had a posted sign that indicated, Attention, Droplet Precautions. The sign detailed what type of Personal Protective Equipment (PPE) one should wear upon entering the room. Also, the front of the door had hanging Personal Protective Equipment to include gowns, gloves and masks. It was determined that Resident #156 was in this room and was on Isolation Precautions. (Photographic Evidence Obtained) Resident #156 resided in the room alone. During all days observed, Resident #156 was noted in her room and in bed. An interview on 12/14/2021 at 9:00 a.m. with Staff A, Certified Nursing Assistant…
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 · D2021-12-16 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, staff interview and record review the facility failed to provide a timely discharge for one resident (#45) out of 41 sampled residents. Resident #45 had an increase in anxiety related to her discharge which resulted in an increase in her antianxiety medications. The facility was made aware on 9/9/21 that all Comprehensive Assessment and Review for Long-Term Care Services (CARES) applications must be submitted via email. The application was not resubmitted until 9/28/21. Findings included: An interview was conducted with Resident #45 on 12/13/21 at 11:00 a.m. The resident was observed walking independently, dressed in day clothes, hair and makeup done, clean and well-kept. The resident said can you please help me. I have been here for 3 months and no one will help me. The hospital made a mistake and sent me here. I live at an Assisted Living Facility (ALF), I tripped and had a compression fracture to my Spine at T12. The hospital sent me here to do therapy but I…
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 before2021-12-16 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview and record review the facility failed to ensure one of one walk in freezers was operating in a manner to be free from ice blocking and heavy frosting. It was observed that heavy ice was formed on the ceiling, motor fan housings, shelving, and various packaged food items for two days of four days observed (12/13/2021 and 12/16/2021). Findings included: On 12/13/2021 at 9:56 a.m. a facility kitchen tour was conducted with the floating kitchen manager. Upon approaching the walk in freezer, the outside digital thermometer screen was not able to be read. The screen read what appeared to not be numbers. It did not indicate what the internal temperature was. Once the door was opened and the freezer was entered, it was observed with approximately five foot shelving on either side of walls and the back wall. Above the right side shelving, was observed with a double plastic fan housing with a motor attached. Further observations revealed heavy ice build-up on the ceiling in front of the fan housing, on both fan housing cases, and very large ice chunks…
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 before2020-10-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 review of facility records, the facility failed to ensure resident rooms and other spaces in two of two units (North and South), were clean and free from disrepair during four of four days observed (10/4/20, 10/5/20, 10/6/20 and 10/7/20). Findings included: Observations on 10/4/2020 at 9:35 a.m. and 12:20 p.m., 10/5/2020 at 7:25 a.m., 10:00 a.m., and 12:55 p.m., 10/6/2020 at 8:20 a.m. and 1:00 p.m., and 10/7/2020 at 7:30 a.m. and 8:50 a.m. revealed: 1. South (Secured) unit: - The filters in the air conditioner units in resident rooms 134, 136, 137, 138, 139, 140, 141, 143, 144, and 146 were observed with a thick layer of dust and debris. - The ceiling vents in the main hallway for rooms 152 - 168 were observed during the initial tour on 10/04/2020 beginning at 9:35 a.m., to be caked with dust and debris with pieces of debris blowing down onto the floor and medication cart. - A ceiling vent, located near the nursing station, had a black substance on the ceiling tile around…
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 before2020-10-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to ensure one (#88) of 39 sampled residents had a care plan implemented related to supervision for frequent falls. Findings included: Record review of Resident #88 revealed an admission date of 08/31/2020 with a diagnosis of Dementia without behavioral disturbances. A Minimum Data Set (MDS) Assessment was completed on 09/05/2020, which identified the resident as participating in the Brief Interview for Mental Status (BIMS) but scoring a 99, indicating his answers were nonsensical. The MDS identified that he had problems with his short term memory and was moderately impaired for decision making. The MDS assessment identified the resident as needing limited assistance by two staff for bed mobility, extensive assistance by two staff for transferring, having an unsteady balance but able to stabilize on his own, able to walk in his room with limited assistance by one staff, and toileting with limited assistance by one staff . 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 · D2020-10-07 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, medical record review, and staff interviews, the facility failed to ensure one (#94) of one resident sampled for tube feeding out of 6 residents in the facility received tube feed nourishment in accordance with the physician order for two of four days observed (10/4/20 and 10/5/20). It was determined that nursing staff did not start the feeding timely, and did not provided a physician's ordered flow rate of the product. Findings included: Review of the medical record for Resident #94 an original admission date in 2018 and a readmission from the hospital in September of 2020. Review of the cumulative diagnoses sheet revealed diagnoses of Pressure Ulcer Left heel, Dementia, Gastro-esophageal reflux (GERD), Pneumonitis due to inhalation of food and vomit, and unspecified protein-calorie malnutrition. Review of the current Physician's Order Sheet (POS) dated for the month October 2020 revealed the following relevant orders: 1. Enteral Feed one time a day Jevity 1.5 at 65 ml/hr for 20 hrs (off…
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 before2020-10-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled properly and expired medications were disposed of, for two (Cart 2 South, Cart 3 North) of three medication carts observed during the medication storage task. Findings included: An observation, on 10/6/20 at 10:45 a.m., of Cart 2 South was completed with Staff Member K, Licensed Practical Nurse/Nurse Supervisor (LPN). The observation revealed a bottle of Latanoprost 0.005% ophthalmology solution, opened 8/15/20. The pharmacy label indicated the bottle of Latanoprost should be discarded after 6 weeks. The Unit Manager confirmed the medication should have been discarded on 9/26/20. An open, undated, container of Breo Ellipta 100/25 inhalation was observed. The pharmacy label attached to the Breo Ellipta indicated that it should be discarded 6 weeks after opening. An observation of the North 3 medication cart was completed, on 10/6/20 at 11:07 a.m., with Staff Member J, Licensed Practical Nurse (LPN). An Asmanex HFA inhaler was observed to be open and undated. The pharmacy label…
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.
- No harm found · C2020-10-07 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, facility file review, and staff interviews, the facility failed to post the required Nurse Staffing Information to show the census, number of licensed and unlicensed staff working for each shift and the actual hours worked was posted for review daily. Findings included: On Sunday 10/4/2020 from the time of facility entrance at 8:50 a.m. and observed again at 9:30 a.m. and 11:20 a.m., the front lobby area was observed with information sheets near the reception desk. The Daily Nurse Staffing form was posted on a cork board next to the reception desk window. There were two of these forms posted, one dated 9/17/2020 and the other dated 9/16/2020. A full tour of the facility was conducted on 10/4/20 and no evidence could be located with this information outside of the old forms found in the reception/front desk area. On 10/5/2020 at 8:35 a.m., the facility's reception area was observed to have the same Daily Nurse Staffing form posted with dates 9/16/20 and 9/17/20. Interview with the receptionist, Employee F, at the time of observation revealed she was unaware 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.
“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
No federal fines in the current CMS record.
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 77% 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 20% 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.
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 105486. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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