Charlotte Bay Rehab And Care Center

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

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.

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.

38.7% 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 158 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 47.5% 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 198 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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.

Staffing

How full it usually is: this home is certified for 164 beds and averages 155.3 residents a day — about 95% occupied, or roughly 9 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.38 hrs/resident/day on weekends vs 3.72 on weekdays — 9% thinner on weekends. RN hours go from 0.81 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 15 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · J2025-03-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interviews and record review, the facility failed to protect residents' rights to be free from neglect. The facility failed to appropriately monitor the urinary output after insertion of an indwelling urinary catheter and failed to monitor the resident's change of condition for 1 (Resident #1) of 5 residents with urinary catheter reviewed. Resident #1 was admitted to the facility on [DATE] with diagnoses including prostatic hyperplasia (enlarged prostate). Resident #1 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). On 1/28/25 at approximately 5:30 a.m., Resident #1's urinary catheter was changed. There was no documentation Resident #1 was monitored to ensure the catheter was properly inserted and draining urine. On 1/28/25 at approximately 4:30 p.m., Resident #1 had no urinary output. The urinary catheter was removed. Resident #1 experienced copious amount of bleeding and clots. There was no documentation the facility monitored Resident #1's status,…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-03-22 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility's policies and procedures, and staff interviews the facility failed to ensure Licensed Nurses had the skills set to safely care for residents with indwelling urinary catheters, including inserting the catheters, monitor residents, recognize significant changes in condition and complications from urinary catheters requiring immediate physician notification and interventions to prevent further deterioration. On 1/28/25 at approximately 5:30 a.m., Licensed Practical Nurse (LPN) Staff B changed Resident #1's urinary catheter and did not ensure free flow of urine to verify the tip of the catheter was in the appropriate location in the bladder. On 1/28/25, Unit Manager LPN Staff D did not monitor Resident #1 from 7:00 a.m., to 2:00 p.m. to ensure the urinary catheter was functioning and draining urine. On 1/28/25 at approximately 5:00 p.m., LPN Staff A received a practitioner's order to monitor Resident #1 and send him to the hospital when the urinary catheter was removed 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-03-22 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility's Administration failed to utilize resources effectively to ensure nursing staff were trained, knowledgeable and competent to prevent the neglect of residents with urinary diagnoses, including insertion of urinary catheters and monitoring for complications from the urinary catheters. Resident #1 was an [AGE] year-old-male admitted to the facility with a diagnosis of prostatic hyperplasia (enlarged prostate). Resident #1 had an indwelling urinary catheter (catheter inserted in the bladder to drain urine). On 1/28/25 at 5:30 a.m., nursing staff changed Resident #1's urinary catheter and failed to ensure the catheter was properly inserted and draining. Nursing staff neglected to notify the physician until 1/28/25 at approximately 4:30 p.m. that Resident #1 had no urinary output since the catheter was inserted. On 1/28/25 at approximately 4:30 p.m., Resident #1 experienced a copious amount of bleeding and blood clots when the catheter was removed. 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide 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 observation, interview and record review, the facility failed to ensure a resident admitted with a urinary catheter was assessed for removal of the catheter as soon as possible, received services to prevent urinary tract infections, and had the proper securing device to prevent friction and movement at the insertion site for 1 (Resident #305) of 2 residents reviewed for urinary catheters. The findings included: Review of the facility Policy for Urinary Catheter Care revised 2/21/23 included instructions for infection control: Be sure the catheter tubing and drainage bag are kept off the floor. Catheter changing instructions included: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.) Review of the clinical record for Resident #305 revealed an admission date of 1/14/25 for rehabilitation after pacemaker surgery. Diagnoses included vascular implant infection, diabetes,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 clinical record review, review of facility's policies and procedures, and staff interviews, the facility failed to ensure staff followed safety precautions in the care plan while providing care to prevent avoidable fall and fall related fracture for 1 (Resident #50) of 3 residents reviewed for accidents. The findings included: Review of the facility's policy for Falls and Fall Risk-Managing with effective date of 4/1/2022 revealed, Based on previous evaluations and current data, the staff should identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Review of the clinical record for Resident #50 revealed an admission date of 3/6/23. Diagnoses included Chronic Kidney Disease, and anemia. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 12/2/24 noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. The assessment noted…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-17 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, review of facility's policy and procedure and staff interviews, the facility failed to ensure the safe storage of medications to prevent unauthorized use for 1 (Resident #875) of 3 residents' rooms observed. The findings included:Review of the facility policy and procedure Clinical Medication Administration (revised 12/10/25) revealed, .Residents who are deemed appropriate to self-administer and wish to keep their medication at bedside, will be provided with a locked container or drawer to house the medication when not in use.On 3/16/2026 at 9:53 a.m., observation of Resident #875's room revealed a Dulera inhaler (medication used to reduce airway inflammation) and four vials of Ipratropium-Albuterol solution (bronchodilator) nebulizer solution stored unsecured and unattended on the resident's bedside table. Resident #875 was not in the room at the time of the observation. Photographic evidence obtained.Review of Resident #875's Medication Administration Record (MAR) for March 2026 revealed she received the Dulera inhaler twice a day and the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to implement procedures to identify risk for elopement and adequately monitor 1 (Resident #1) of 1 cognitively impaired resident reviewed who left the facility without staff knowledge. The findings included: Review of the facility's policy titled, Nursing - missing resident/elopement with a revision date of 2/20/23 indicated: 1. Residents of the facility shall be maintained in a safe and secure environment. Residents may be considered missing and or to have eloped if they: d. leave the facility without authorization. 3. Locating the resident. D. Documentation regarding the elopement should be done in the interdisciplinary progress notes. E. An accident/incident form should be completed by a nurse including statements from all involved staff. F. At the next scheduled morning report, safety committee meeting, and QAPI (Quality Assurance and Performance Improvement) meeting the incident should be discussed and root cause analysis of elopement should be identified. 4. An event report should be completed and available for review…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and procedure and resident and staff interviews, the facility failed to maintain urinary catheters in a sanitary manner for 4 (Residents #61, # 249, #252, and #305) of 4 residents observed with urinary catheters. The facility also failed to ensure intravenous (IV) access devices were dated and secured properly for 2 (Resident #252, and #305) of 3 residents reviewed. The findings included: The facility policy Nursing- Catheter Care- Urinary. The purpose of this procedure is to prevent catheter associated urinary tract infections (UTI's). Infection Control) . Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag . Be sure the catheter tubing and drainage bag are kept off the floor. Review of the clinical record revealed Resident #61 had a readmission date of 12/15/24 with diagnoses including obstructive, reflux uropathy and urinary tract infection. Record Review documented the resident's labs results were…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide 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 observations, review of the clinical record, resident and staff interviews and review of facility policy and procedures, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents #252 and #61) of 3 residents reviewed for activities of daily living (ADL's). The findings included: Review of the facility's policy, Activities of Daily Living effective 4/1/22 documented Purpose: To ensure all residents needs are met in a manner that promotes their quality of life and preferences . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good . grooming, and personal and oral hygiene . Review of the clinical record revealed Resident #252 had an initial admission date of 1/3/25 with readmissions on 1/11/25 and 1/23/25 following hospitalization. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a target date of 1/11/25 documented…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility policy and procedures, resident and staff interviews, and review of the clinical record, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion (ROM) for 1 (Resident #61) of 1 resident reviewed for limitation in ROM. The findings included: The facility policy Nursing-Mobility and Range of Motion with an effective date of 4/1/2022 documented, Residents with limited ROM should receive treatment and services to increase and or prevent a further decrease in ROM. As part of the resident's comprehensive assessment the nurse should identify the resident's.limitations in movement or mobility. The nurse should also identify conditions that place the resident at risk for complications related to ROM. including.contractures. The care plan should include specific interventions, exercises and therapies to maintain, prevent avoidable decline…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide 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, review of the clinical record, resident, resident representative and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #999, #900, and #899) of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: The facility policy, Nursing-Activities of Daily Living (ADL's) documented, The facility shall ensure a resident is given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . 1. Review of the clinical record revealed Resident #999 was 82 had an admission date of 1/11/24, with diagnoses including Parkinson's disease, sepsis, muscle weakness and need for assistance with personal care. The admission Minimum Data Set (MDS) (standardized assessment tool 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-07 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, resident, resident representative and staff interviews, the facility failed to ensure 3 (Residents #899, #799 and #75) of 4 sampled residents at risk for compromised nutrition received dietary supplements as ordered to maintain acceptable parameters of nutrition. The findings included: 1. On 2/6/24 at 9:00 a.m., in an interview Resident #900 said the facility runs out of food often and they have no salt packets right now. They are out of health shakes. The resident said her roommate (Resident #899) is supposed to get a health shake (dietary supplement) and had not received the shake with her meals for a few weeks now. Review of the clinical record for Resident #900 revealed an admission Minimum Data Set (MDS) assessment with a target date of 12/5/23. The Assessment noted Resident #900's cognitive abilities for daily decision making were intact with a Brief Interview for Mental Status score of 15. 2. Review of the clinical record for Resident #899 revealed a physician's order dated 12/5/23 for health shakes with meals. Review of Resident #899's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-07 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, review of manufacturer recommendations, staff and resident interviews, the facility failed to maintain 1 of 2 sit to stand lifts used to transfer residents in safe operating condition. The findings included: The [brand name] Instruction for Use Manual of the sit to stand lift specified Periodic testing to be carried out at weekly intervals . Adjustable width chassis function: Open and close the chassis legs to check for full and efficient movement. The manual specified the transfer shall be performed with the chassis legs closed, as this will be easier when maneuvering. On 2/6/24 at 9:00 a.m., in an interview Resident #900 said the [brand name] sit to stand Lift was not working, the legs do not close, and I am afraid the staff will drop me. I was dropped at another facility and fractured my back. The Lift remote is broken too, it has been broken for several weeks. On 2/6/24 at 9:15 a.m., CNA Staff A was observed pushing a sit to stand lift down the halls from Unit A to Unit B with the legs of the lift in open position. CNA Staff A said the legs of the lift did…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-08-16 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and staff interviews, the facility failed to ensure insulin vials and pens were properly labeled and dated when opened, in medication carts for 1 (C wing) of 3 wings reviewed. Without an open date on the insulin there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: On 8/16/23 at 9:00 a.m., during an observation of medication cart #3 on the C wing with Registered Nurse (RN) Staff A the following was observed: 1. One open bottle of Glargine insulin for Resident #950 without a date of when it was opened. The pharmacy label documented to discard after 28 days. Photographic evidence obtained. 2. One open bottle of Glargine Insulin in the medication with no resident identification label and no open date. Photographic evidence obtained. 3. One open bottle of Aspart insulin for Resident #800 without a date of when it was opened. The findings were verified by RN Staff A. 4. One Aspart insulin pen for Resident #850 without a date of when it was…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-12-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure 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 observation, record review, review of the facility's policies, staff, and resident interview the facility failed to have documentation of analysis of falls to implement appropriate interventions to prevent avoidable falls and fall related injuries for 3 residents (#17, #48, #76) of 4 residents reviewed who sustained falls at the facility. The findings included: A review of the facility policy and procedure, Falls Policy, revised 7/29/2022 stated, The intent of this policy is to ensure the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls. The policy further states, all residents will have a comprehensive fall risk assessment on admission, quarterly, annually and with significant change in condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$274,053 in federal fines across 2 penalties.

• $8,788 — penalty dated 2025-01-30
• $265,265 — penalty dated 2025-01-30

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 EXCELSIOR CARE GROUP — 33 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 →

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

2 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 $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL