Nspire Healthcare Plantation
6931 W Sunrise Blvd, Plantation, FL 33313 · For profit - Corporation · 120 certified beds · (954) 583-6200 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 $35,989 in federal fines (most recent 2024-01-08)
- its payroll-based staffing rating is low (2/5)
- 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
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 | 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 3 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 | 18.1% | 8.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.8% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.1% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.7% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 2.6% | 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 | 0.0% | 2.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 22.1% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.8% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.8% | 10.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.0% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 0.0% | 9.1% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 2.51 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.92 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
41.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.9% 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 38 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | 41.6%CMS range 27.4–59.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.7–16.9 | 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 | 28.9% | 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 | 28.9% | 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 | 28.9% | 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 | 26.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the 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 | 0.0% | 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 | 5.4% | 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 | 7.4%CMS range 3.7–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 105.4 residents a day — about 88% occupied, or roughly 15 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 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.07 hrs/resident/day on weekends vs 3.34 on weekdays — 8% thinner on weekends. RN hours go from 0.59 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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 · Ecited before2024-08-22 · 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 prepare and serve food in a sanitary manner in accordance with professional standards for food safety. The findings included: 1. On 08/19/24 at 8:48 AM, during the initial kitchen tour accompanied by Staff A, Cook, the Dietary Manager and the Registered Dietitian (RD), the following were noted: a. the handles of a spoodle and three spatulas were damaged to a point that they were no longer easily cleanable. b. there was an accumulation of food residues on the blade and the mounting bracket of the table mounted manual can opener. c. there was an accumulation of dust on the air conditioning vent over the food assembly area. d. the wall over and around the door to the walk-in cooler was damaged and tiles were missing. 2. The facility's policy, titled, Handwashing / Hand Hygiene, with a reference date of August 2019, documented, in part: this facility considers hand hygiene the primary means to prevent the spread of infections. The policy did not specifically address hand hygiene in the kitchen and for food…
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 · D2024-08-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, records review, and interviews, the facility failed to ensure it timely answered call lights in response to residents' needs for 3 of 24 sampled resident, Residents #13, #38, and #55. The findings included: 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. On the most recent Minimum Date Set (MDS) assessment, the Brief Interview for Mental Status (BIMS) was documented as a score of 15 of 15, indicating the resident was alert and oriented to person, time, and place (cognitively intact). On 08/20/24 at 1:25 PM, an interview was conducted with Resident #38 who stated she had voiced multiple complaints regarding the call light response to staff. Resident #38 said at times when the call lights is activated, the Certified Nursing Assistant (CNAs) could be observed passing by the room, but they do not bother to come in the room to check. Resident #38 complained that this situation is usually worse on the weekend. In a followup interview with Resident #38 on 08/21/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the physicians' orders for wound treatment and failed to provide wound care in a timely manner for 1 of 2 sampled residents, reviewed for wound care, Resident #18. The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as a deep tissue injury (DTI), surgical wound. Review of the Physician's orders showed Resident #18 had an order for left dorsal foot and left lateral foot wound, Cleanse with Normal Saline (N/S) apply skin prep…
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 · D2024-08-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, record review, observation and interview, the facility failed to administer the correct type of Aspirin medication, as per physician's order for 1 of 5 sampled residents observed during a Medication Administration Observation, Resident #94. The findings included: Review of the facility policy and procedure on 08/19/24 at 2:30 PM, titled, Specific Medication Administration Procedures, provided by the facility's Regional Nurse, reviewed May 2022 documented, in part, in the Policy Statement: Administration Procedures for all Medications - To administer medications in a safe and effective manner. Procedures: .C. Review five (5) rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer: a. Check Medication Administration Record (MAR)/Treatment Administration Record (TAR) for order e. Prepare resident for medication administration. 2) Prior to removing the medication from the container. a. Check the label against the order on the [DATE]: After…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure accurate records related to dressing change for 1 of 2 sampled residents reviewed for wound care, Resident #18; and failed to ensure complete and adequate documentation for 1 of 1 sampled resident reviewed as deceased in the facility, Resident #99. The findings included: Review of the facility's policy titled, Documentation of Progress, dated [DATE], included the following: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. 1. Record review for Resident #18 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) 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 · D2024-08-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during medication administration for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to ensure Personal Protective Equipment (PPE) gowns were available on the 2nd floor for 8 of 11 residents who were on EBP; failed to have appropriate signage posted to indicate precautions for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to properly utilize hand hygiene and discard a used lancet after Blood Glucose check during medication administration observation for 1 of 1 sampled resident, Resident #3; and failed to ensure a sanitary environment during perineal care for 1 of 1 sampled resident reviewed for Urinary Tract Infection (UTI), Resident #56. The census at the time of the survey was 90 residents. The findings included: Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 09/01/22, included in part the following: EBP [Enhanced Barrier…
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 · D2023-10-26 · 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 record review and interview, the facility failed to follow-up on monitoring residents with a change in condition for 1 of 2 sampled residents reviewed for death in the facility, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses to include Syncope (fainting), Heart Attack, Chronic Pulmonary Edema (fluid in lungs), Diabetes, Heart Disease, and Alcohol Use. Review of the admission progress note dated [DATE] at 7:08 AM documented the resident was admitted to the facility and was receiving oxygen at 2 liters a minute via nasal canula. The progress note further documented the resident's vital signs were within normal limits, and the resident was very drowsy and lethargic, hard to arouse, and appeared confused. Review of Resident #1's physician orders revealed orders dated [DATE] revealed an order for vital signs every shift. Further review of Resident #1's records revealed the last documentation of the resident's condition / vital signs was on [DATE] at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare, store and serve food in a sanitary manner and in accordance with professional standards. The findings included: 1). During the initial kitchen tour on, 06/19/23 at 9:24 AM, accompanied by the Dietary Manager, the following were noted: a. the surface of the top of the counter mounted toaster was showing signs of wear and peeling b. there was an accumulation of food residue on the blade of the counter mounted manual can opener. At the conclusion of the initial kitchen tour, the Dietary Manager acknowledged understanding of the concerns. 2). On 06/20/23 at 9:10 AM, Resident #85 was provided lunch to take to dialysis that consisted of a sandwich that was made up of sliced deli meat and cheese, 2 containers of apple juice and graham crackers. It was noted that there was no cooling medium in the soft-sided cooler that was provided to the resident to maintain foods at safe temperatures. During an interview with Staff A, Dietary Aide,…
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 before2023-06-22 · 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 secure 3 of 6 medication carts, failed to secure 1 treatment cart, and failed to secure meds at the bedside for 1 of 19 sampled residents (Resident #143) The findings included: Review of the facility's policy titled, Storage of Medications with a revised date of January 2018 included: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1) Record review for Resident #343 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Displaced Intertrochanteric Fracture of Right Femur, Pain in Right Hip, and Anxiety Disorder. Review of the Minimum Data Set (MDS)…
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 · D2023-06-22 · 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 Based on observations, interviews, and record review the facility failed to assist residents during meals in a dignified manner for 2 of 4 residents observed for dignity (Residents #82 and #66) and the facility failed to provide privacy for 1 of 4 residents observed for dignity (Resident #90). The findings included: 1) Record review for Resident #82 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Legal Blindness, Dysphagia, Oropharyngeal Phase, and Moderate Protein-Calorie Malnutrition. Review of the Minimum Data Set (MDS) for Resident #82 dated 03/24/23 revealed the resident had a Brief Interview of Mental Status score of 15 indicating an intact cognitive response. Revealed in Section G for dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of one person assist. Review of the Care Plan for Resident #82 dated 03/27/23 with a focus on the resident has an ADL (Activity of Daily Living) self-care performance…
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 · D2023-06-22 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide residents with preferences for being out of bed for 1 of 1 residents reviewed for Preferences (Resident #47). The findings included: During tours of the facility conducted on 06/19/23 at 10:51 AM and 12:55 PM, Resident #47 was observed lying in bed. Resident #47's family member was at her bedside during the second observation. Resident #47's family member stated she had a concern about Resident #47 not being out of bed unless the family specifically requested it. When asked how long this has been going on, Resident #47's family member said approximately 6 months. She also stated she has two siblings and they each switch off coming to the facility, so one of them is at the facility with Resident #47 daily. During this interview, the surveyor observed a wheelchair in the far corner of the room. The surveyor asked Resident #47's family member if this was her wheelchair. Resident #47's family memberr confirmed that that 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 · D2023-06-22 · 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 reviews and interviews, the facility failed to act on request for Level II Pre-admission Screening and Resident Review (PASARR) for a resident determined to have 'Serious Mental Illness' for 1 of 3 residents reviewed for PASARR (Resident #11). The facility failed to have a PASARR screening completed upon admission for 2 of 3 residents reviewed for PASARR (Resident #38 and 25). The findings included: 1) Resident #11 was admitted on [DATE]. According to an admission Minimum Data Set (MDS), dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13. Resident #11's diagnoses at the time of the assessment included: Anemia, Hypertension, Hemiplegia, Seizure disorder, Malnutrition, Schizophrenia, Long-term and current drug therapy. Resident #11's care plan initiated on 05/07/23, documented, the resident uses psychotropic medications r/t Schizoaffective Disorder, Schizophrenia, Bipolar. The goals of the care plan included: The resident will be/remain free of psychotropic drug…
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 · D2023-06-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 provide showers based on shower schedule and resident preferences for Resident 2 of 4 residents reviewed for Activities of Daily Living (ADLs) (Residents #7 and 32). The facility failed to ensure proper nail care for 1 of 4 residents reviewed for ADL Care (Resident #90). The findings included: The facility's policy Bathing/Showering dated 11/30/14 and most recently revised on 04/20/22 did not address residents' refusal to be bathed/showered. 1) Resident #7 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was 'cognitively intact'. The MDS documented that the resident required: 'Limited assistance' and 'one person physical assist' for bed mobility and transfer, and required 'extensive assistance' and 'one person physical assist' for walk in corridor, toilet use, personal hygiene. The MDS…
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 · D2023-06-22 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide adequate podiatry care for 2 of 2 residents reviewed for Podiatry Care, (Residents #34 and 90). The findings included: 1) During the initial tour of the facility conducted on 06/19/23 at 10:12 AM, Resident #34 stated that he wanted to participate in physical therapy sessions but that his feet bothered him. During this interview, Resident #34 lifted his bedsheets and showed his feet to the surveyor. The surveyor observed that Resident #34's toenails were very long, thick, and overgrown. The surveyor asked Resident #34 if his toenails caused him discomfort. Resident #34 stated not really, but my feet hurt when I stand up. When asked when he was last seen by a podiatrist, Resident #34 stated I'm not sure, but I think about 2 months ago. Resident #34 was admitted to the facility on [DATE]. Resident #34 had a medical history significant for Weakness, Unsteadiness on Feet, and Chronic Pain. A Quarterly Minimum Data Set (MDS) 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 before2023-06-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide appropriate device in the form of a smoking apron to prevent injury and skin damage to 1 of 1 resident reviewed for smoking (Resident #11). The findings included: The facility's policy, 'Smoking - Supervised', dated September 2018 and most recently revised on 02/01/20, documented, The Center will provide a safe, designated smoking area for residents. Residents will be supervised during smoking. Smoking is only allowed in designated areas and oxygen is not permitted. The Center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedures: 1. Residents that smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if additional adaptive or safety equipment is needed. Resident #11 was admitted to the facility on [DATE]. According to an admission Minimum Data Set…
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 · D2023-06-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to follow the facility's Urinary Catheter Care policy, and failed to ensure the staff followed hand hygiene practices consistent with accepted standards of practice during foley/peri-care provided to 1 of 1 resident sampled for urinary catheter care review (Resident #3). The findings included: Review of the facility policy titled Catheter Care, Urinary revised on 09/05/17 documented .remove catheter securement device .reattach catheter securement device . The policy did not address the use of enhanced barrier precautions when providing urinary catheter care. Review of the Center for Disease Control and Prevention (CDC)-Hand Hygiene Guidance last reviewed on 01/30/20 documented .Healthcare Personnel should use an alcohol based hand rub or wash with soap and water for the following indications: .immediately after glove removal . Review of Resident #3's clinical record documented an admission on [DATE] with no readmissions. The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-22 · 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 record review, observations and interviews, the facility failed to monitor the resident's weight as evidenced by six (6) pounds weight loss in 12 days for 1 of 1 resident sampled for nutrition review (Resident #143). The findings included: Review of the facility's policy titled Weighing the Resident revised on 05/06/22 documented residents will be weighed unless ordered otherwise by the physician: on admission/readmission, weekly for 4 weeks, monthly thereafter, as needed .weights will be documented .in the clinical record . Review of Resident #143's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Fracture of Right Femur, Rheumatoid Arthritis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Chronic Kidney Disease, Depression, Gastro-Esophageal Reflux Disease (GERD), Irritable Bowel Syndrome and Long Term Use of Systemic Steroids. Review of Resident #143's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief…
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 · D2023-06-22 · 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, interviews, and record reviews, the facility failed to ensure tube feeding tubing was changed in a timely manner and failed to ensure tube feeding was administered per physician orders for 4 of 4 residents reviewed for Tube Feeding (Resident #47, 67, 20, and 40). The findings included: Review of the facility policy titled Enteral Feeding-Enteral Nutrition Pump, revision date 11/12/18 revealed the following: Closed System Enteral Feeding Containers and tubing can hang safely for up to 48 hours. Use only 1 feeding set per container. 1) During the tour of the facility conducted on 06/19/23 at 10:51 AM, the surveyor observed that Resident #47 was lying in bed with eyes closed. Upon closer observation, Resident #47 had a bottle of Jevity 1.5 (formulary type) tube feeding that was labeled as started on 06/18/23 but was untimed and was infusing at 50 milliliters/hour (mL/hr). Further observation revealed the water flush bag was dated 06/17/23 at 2:00 PM. The tube feeding was at the 350mL mark out…
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 · D2023-06-22 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 administer scheduled medications in a timely manner for 1 resident reviewed for pain management (Resident #60) and for 1 resident reviewed for insulin (Resident #3). Medications are administered within (60 minutes) of scheduled time. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. The findings included: Review of the facility's policy titled, Medication Administration - General Guidelines with a revised date of December 2019 included: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Fracture of Sacrum, Fracture of Pubis, Displaced Fracture of Base of Neck of Right…
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 before2022-02-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: 1. During the initial tour of the kitchen conducted on 02/13/22 at 8:48 AM, accompanied by the Food Service Director (FSD), the following were noted: a. At the request of the surveyor, the FSD checked the chemical concentration of the sanitation bucket located near the 3 compartment sink using the facility's test strips. The concentration was recorded between 0-150 parts per million (ppm). The FSD stated that the chemical concentration should have been around 200 ppm and that he had not had any issues with the sanitizer before. He then emptied and refilled the bucket with sanitizing solution and re-checked the chemical concentration. The concentration was still recorded between 0-150 ppm. b. At the request of the surveyor, the FSD checked 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 · D2022-02-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately code discharge assessments for 1 of 3 sampled closed records reviewed, Resident #85. The findings included: Record review for Resident # 85 revealed the resident was admitted on [DATE] with a readmission on [DATE] and was discharged to home on [DATE]. The diagnoses included Rhabdomyolysis, Alcohol Abuse, Anxiety and Schizoaffective Disorder. The discharge (d/c) documented the return was not anticipated. Further reivew of the Minimum Data Set (MDS) dated [DATE] revealed in Section A that the d/c status was to ans acute hospital, and Section C revealed a brief interview for mental status (BIMS) of 15 indicating intact cognitive response. Record review for Resident #85 revealed a social worker progress note, dated 12/06/21. The note documented that Social Services spoke with patient to see how the patient was doing; the Patient stated that she is doing good, and that she is looking forward to being discharged home. Resident #85 also…
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 before2022-02-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to conduct quarterly fall risk assessments for 1 of 3 sampled residents reviewed for accidents, Resident #54. The findings included: Review of the facility's policy, titled, Clinical Guideline - Fall Management, revised on 03/01/20, documented the following: Residents to be evaluated for fall risk on admission / re-admission, quarterly, significant change, and following a fall. Review of the record showed that Resident #54 was re-admitted to the facility on [DATE] with diagnoses that included: Unspecified Fall, History of Falling, Blindness in One Eye, Unsteadiness on Feet, and Muscle Weakness. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #54 had a Brief Interview for Mental Status score of 14, which indicated that she was cognitively intact. Review of Section J of the MDS, dated [DATE], documented that Resident #54 had one fall since admission / prior assessment. Review of the Care Plan, dated…
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 before2022-02-16 · 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 During observations, interviews and record reviews, the facility failed to secure 1of 6 medication carts observed; and failed to secure medications that were observed at the bedside for 3 of 78 sampled residents observed during the initial screening process, Residents #5, #43, and #81. The findings included: Review of policy, titled, Medication Storage in the Facility, dated April 2018, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure B) only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of policy, titled, Self-Administration 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 · D2022-02-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the influenza vaccine to a resident who consented to receive the influenza vaccine for 1 of 5 sampled residents reviewed for influenza and pneumonia vaccinations, Resident #4. The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included COVID-19, Hypertension and Cellulitis. A review of the medical record for Resident #4 revealed a signed Informed Consent for the Influenza vaccine, dated 11/06/21. An interview was conducted with the Director of Nursing (DON) on 02/15/22 at 3:00 PM regarding the status of the influenza vaccine for Resident #4 that the resident consented for. The DON stated that she will look into it because the immunization is not in the resident's chart. On 02/15/22 at 3:20 PM, the DON stated Resident #4 had not received the influenza vaccine and acknowledged that he should have received it when he consented to it.
- No harm found · C2023-06-22 · 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 and interviews, the facility failed to ensure accurate posting of nursing staffing at 2 of 2 nursing stations on 06/19/23 and 06/20/23. The findings included: During the initial tour of the facility conducted on 06/19/23 at 9:35 AM, the surveyor noted the posted nurse staffing located at both nursing stations was dated 04/19/23. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 06/19/23 at 9:38 AM. The surveyor asked the ADON if this nurse staffing sheet was posted that day. The ADON stated she did not know. The surveyor told the ADON that the date on the posting was 2 months old. The ADON stated that must be a mistake and said she would replace it. A tour of the facility was conducted on 06/20/23 at 6:21 AM. During this tour, the surveyor noted the posted nurse staffing located at both nursing stations was still dated 04/19/23. Photographic evidence obtained. An interview was conducted with the facility's ADON on 06/20/23 at 9:08 AM. The surveyor showed the ADON that the posted nurse staffing still had the date of 04/19/23.…
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 · B2022-02-16 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to conduct a review of the Facility Assessment Tool annually and with all of the necessary participants. The findings included: During a review of the Facility Assessment Tool, on 02/15/22 at approximately 3:00 PM, it was noted that the Tool documented the last date of assessment as 'August 31, 2020 Updated'. It was noted that the Tool documented that the last time it was reviewed by QA/QAPI Committee was 'September 2020'. The Tool documented in the section for 'Persons (names/titles) involved in completing the assessment, participation by: * The Director of Nursing, with a hire date of 09/13/21 * The Social Services Director, with a hire date of 10/25/21 * The MDS Coordinator, with a hire date of 07/27/21 * The Food Service Manager, with a hire date of 10/25/21 * Activities, with a hire date of 01/31/22. During an interview with the Administrator, on 02/16/22 at 8:43 AM, when the concerns regarding the timing and participants documented in the facility assessment were brought to her attention, the Administrator stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$35,989 in federal fines across 8 penalties.
- $4,938 — penalty dated 2024-01-08
- $4,587 — penalty dated 2024-01-02
- $11,645 — penalty dated 2023-12-11
- $3,176 — penalty dated 2023-11-20
- $2,823 — penalty dated 2023-11-13
- $2,470 — penalty dated 2023-11-06
- $2,117 — penalty dated 2023-10-30
- $4,233 — penalty dated 2023-10-10
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 3.5 | -1.5 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MLNM MASTER TENANT, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| FC INVESTORS XXI LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| LAVIE HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2021 |
| LV INVESTMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR CARE CENTERS, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR OPERATIONS I, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR OPERATIONS II, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| LEE, BRADLEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 04/22/2026 |
| NSPRMC, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2018 |
| PORTNOVA, REGINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2025 |
| TATE, SAMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/11/2023 |
CMS files one row per role, so the 17 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $502K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 105519. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-22, 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 →
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