Savannas Park Health And Rehabilitation Center
1655 SE Walton Road, Port Saint Lucie, FL 34952 · For profit - Limited Liability company · 120 certified beds · (772) 337-1333 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)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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 | 11.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.3% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 14.3% | 4.6% | 6.5% | worse |
| 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 | 0.6% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.9% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.7% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 97.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.0% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.19 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.96 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.0% 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 413 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.2% 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 141 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 37% 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 | 54.0%CMS range 47.5–59.0 | 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 | 13.1%CMS range 10.9–15.4 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 70.2% | 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 | 69.5% | 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 | 55.3% | 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 | 94.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.6% | 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 | 7.8%CMS range 5.5–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 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 114.9 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 4.38 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.83 is at or above 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 4.04 hrs/resident/day on weekends vs 4.51 on weekdays — 10% thinner on weekends. RN hours go from 0.41 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2025-08-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 policy review, record review, and interview, the facility failed to ensure resident rights for 1of 3 sampled residents, as evidenced by the failure to assess Resident #20 for self-administration of medications.The findings included:Review of the policy titled, Resident Rights, implemented 11/2020 and revised on 01/2023, documented in part, 1. The right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. Record review revealed Resident #20 was admitted to the facility on [DATE] with a recent readmission date of 05/06/25. Review of the current Minimum Data Set (MDS) assessment documented Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale, indicating the resident had moderate cognitive impairment. Further review of the record revealed Resident #20's diagnosis documented in part, Pleural Effusion, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · 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 review, the facility failed to respond to a resident's request to remove food allergies from the meal ticket for 1 of 8 sampled residents reviewed regarding choices, Resident #34. The findings included: Record review revealed Resident #34 was admitted to the facility on [DATE] and 07/09/25 with a diagnosis of Anemia. An review of the care plans, revised on 07/29/25, showed that Resident #34 was at risk for altered nutrition and lab values.On 08/25/25 at 9:19 AM, Resident #34 was interviewed. She voiced her meal ticket recorded that she had allergies to shellfish and shrimp, but she did not have these allergies. She expressed frustration about her attempts to have the facility correct this information, saying, It's like talking to a brick wall.On 08/27/25 at 8:09 AM, the resident was observed lying in bed and her breakfast tray on the table. She reiterated that she does not have allergies to shellfish and shrimp. On 08/27/25 at 1:14 PM, the resident was again observed…
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 before2025-08-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to provide a safe, clean comfortable homelike environment for 3 of 4 units. The findings included: A tour of the facility was completed on 08/27/25 at 1:45 PM with the Maintenance Director and the Director of Housekeeping. The following was observed, and they acknowledged these findings: a. room [ROOM NUMBER] - there was white caulking patches on the wall, the tile in the bathroom below the sink was cracked, there was a metal bar above the toilet that was moved and the holes from the screws remained and the rust stains not repaired, the floor in the bathroom was dirty with black stains on beige tile and floor caulking was black, and the door trim outside the door had come off the wall. b. room [ROOM NUMBER] - Resident #30 stopped the surveyor and Maintenance Director during the tour on 08/27/25 at 2:45 PM and stated that his left brake on his wheelchair did not lock. c. room [ROOM NUMBER]-A - A water stain was noted on the ceiling tile above…
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 · D2025-08-28 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 interviews, the facility failed to ensure a PRN (as needed) antipsychotic medication was addressed in a timely manner for 2 of 7 sampled residents, as evidenced by the Lorazepam (antipsychotic) prescribed to Resident #96 and Resident #85 did not have a discontinue date or documented rationale by the doctor to extend the order.1.Review of the record revealed Resident #96 was admitted to the facility on [DATE]. The annual comprehensive assessment dated [DATE], documented that the resident had a Brief Interview for Mental Status Score of 10 on a 0 to15 scale, indicating moderate cognitive impairment. The resident had a documented medical diagnosis history of anxiety disorder and mood disorder. Review of the record revealed an order dated 07/07/25 for Resident #96 to administer Lorazepam 0.5 milligrams (mg) 1 tablet every four hours as needed f[PRN] or anxiety with no date to discontinue or documented rationale by the doctor to extend the medication. A second order dated 05/31/24…
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 · D2025-08-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure timely and appropriate care and services for 5 of 34 sampled residents as evidenced by the failure to clarify multiple physician orders and appropriately treat a rash for Resident #8; failure to ensure timely initiation of an antibiotic for Resident #96, who had an infected wound; failure to ensure medications were not provided by mouth for Resident #3, who had orders for nothing by mouth; failure to ensure treatment for a skin cancer wound for Resident #61; and failure to follow physician ordered blood pressure medication parameters for Resident #6.The findings included:1. Record review revealed Resident #8 was admitted to the facility 03/04/23, with the most recent readmission on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMS) of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 facility policy, observations, record reviews, and interviews, the facility failed to provide care and services to prevent further decrease in range of motion for 1 of 3 sampled residents as evidenced by not applying the splints on Resident #25. The findings included: Review of the policy titled Restorative Nursing Program revised 05/2022 documented in part . It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Compliance Guidelines: 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services include: a. Passive or active range of motion. b. Splint or brace assistance. Record review revealed Resident #25 was admitted to the facility on [DATE]. Review of the annual comprehensive Minimum Data Set (MDS) 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 · Dcited before2025-08-28 · 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 observation, interview, record review, and policy review, the facility failed to follow physician orders for nutritional support via a feeding tube for 2 of 2 sampled residents, Residents #3 and #5.The findings included:Review of the policy Care and Treatment of Feeding Tubes reviewed 11/27/23, documented in part, 1. Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: . e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders.1. Record review revealed Resident #3 was admitted to the facility on [DATE]. The current Minimum Data Set (MDS) assessment lacked a cognitive rating as the resident was rarely or never understood. This MDS also documented the resident was dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen orders and cleanliness of oxygen equipment for 1 of 3 sampled residents, Resident #5, who lacked any order for oxygen, failure of staff to change an oxygen nasal cannula that had been on the floor, and failure to ensure a clean oxygen canister filter.The findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses to include Respiratory Failure and dependence upon supplemental oxygen. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS also documented the resident was receiving supplemental oxygen.Review of the current physician orders lacked any order for the administration of the oxygen with an ordered rate of administration. The orders did document to clean the oxygen filter every night shift on Sundays.A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 2 of 4 sampled residents, as evidenced by a medication error rate of 14.81% with 27 opportunities due to failure to ensure that Resident #22 received medications prescribed to him and was available for him, failure to ensure Resident #86 received medications prescribed to him and was available and failure to follow physician orders for a narcotic prescribed to Resident #86.The findings included:1. An observation of medication administration pass was conducted on 08/27/25 at 5:05 PM with Staff J, Licensed Practical Nurse (LPN), who prepared medications for Resident #22. She prepared Acetaminophen 325mg 2 tablets, Vitamin C 500mg 1 tablet, Atorvastatin 40mg 1 tablet, Methocarbamol 500mg 1 tablet. After preparing the medications, Staff J was asked how many pills she had in the medicine cup and she stated, 5 pills. Staff J crushed the medications all together and added applesauce to the cup. Staff J was observed administering the 5 medications to 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 · D2025-08-28 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 interview and record review, the facility failed to ensure that the laboratory test was completed as ordered for 1 of 5 sampled resident records reviewed, Resident #5. The findings included: Record review revealed Resident #5 was re-admitted to the facility on [DATE], with diagnoses that included Diabetes and cancer. Review of the care plan, revised on 08/04/25, noted that Resident #5 was at risk for nutritional problems due to type 2 Diabetes, altered nutrition-related lab values, Dysphagia (difficulty swallowing), and dependence on enteral nutrition. The intervention outlined in the care plan included reviewing labs as indicated.Review of physician orders dated 08/22/25 revealed that a blood laboratory test for A1C (a test that measures the average blood glucose levels over the past two to three months) was ordered. There was no evidence that the A1C test was completed, as the test result could not be found in the records. There was no documentation revealing that the test was refused. On 08/28/25 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.
Show the remaining 15 citations
- Potential for harm · D2025-08-28 · 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 observation, interview, and record review the facility failed to ensure infection control standards for 4 of X34 sampled residents as evidenced by the failure to ensure timely contact precautions for Resident #33 who had symptoms of C-diff (Clostridium difficile, a highly contagious infection characterized by diarrhea); failure to collect a stool sample timely to ensure timely treatment for C-diff for Resident #51; failure to follow contact precautions during the medication pass observation for Residents #51 and #22; and failure to follow Enhanced Barrier Precautions (EBP) for Resident #129. The findings included:1. Record review revealed Resident #33 was admitted to the facility on [DATE]. A stool sample was collected on 07/13/25 with reports of C-diff positive results reported to the facility on [DATE] at 11:16 AM. This result was reviewed by facility staff on 07/16/25 at 8:08 PM. Review of progress notes revealed Resident #33 had frequent loose stools as of 07/13/25 and an order to collect the stool…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to store, prepare and serve foods in a sanitary manner in accordance with professional standards for food safety. The census at the time of the survey was 117 residents. The findings included: The facility's policy, titled, Use and Storage of Food Brought in by Family or Visitors, with a reference date of 11/03/20 and a revision date of 03/20/23, documented, in part: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so. On their own. The facility's policy, titled, General Food Preparation and Handling, with a reference date of 2005, documented, in part: Food items shall be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. Procedure: 2. 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 · E2024-05-01 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow the approved menu for meals, for French Dip on a Roll, that was to be served for lunch on 04/30/24 from the Main Kitchen and the satellite kitchen on the Oasis Unit (400 unit). This regular menu could potentially affect 113 residents, including residents receiving the puree diet, of the 117 residents in the facility. The findings included: Review of the approved menu documented that residents were to be served 'French Dip on a Roll' for lunch on 04/30/24. The recipe for the 'French Dip on a Roll' was as follows: 6. slice each roll into bottom and top halves. 7. Assemble each sandwich by portioning 2.5 oz of meat on bottom roll of half roll using tongs. Top with second half. 8. Standard portion: Serve one assembled sandwich or serve per menu/tray card. Place 1 fl. Oz. (Fluid ounce) of Au jus in a souffle cup using a ladle and serve on the side with the sandwich. During the follow up kitchen tour, on 04/30/24 at 10:56 AM, the Food Service Director was observed using tongs to place the sliced meat directly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · 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 interview and record review, the facility failed to provide care and services per residents' request and choice for 2 of 2 sampled residents, as evidenced by failure to ensure showers as per preference and schedule for Resident #56, and failed to provide meals in the dining room per residents' request for Resident #56 and #78. The findings included: 1. Review of the record revealed Resident #56 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) assessment for Admission/Medicare Part A Stay dated 01/29/24 revealed the Brief Interview for Mental Status (BIMS) score was 15, indicating cognition was intact. This MDS also documented the resident was Substantial / Maximal Assistance for showers. Review of the current care plan for Activities of Daily Living (ADL) self-care performance deficit related to paraplegia, and other clinical history, documented provide sponge bath when a full bath or shower cannot be tolerated. Review of the shower schedule revealed Resident #56 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 before2024-05-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure it provided a safe, clean comfortable homelike environment, as evidenced by damaged and dirty equipment, peeling paint, bathroom issues, and stained walls and doors. The findings included: Review of the Preventive Maintenance for wheelchairs, dated 11/03/20 with a revision date of 06/07/23, documented, in part; It is the practice of the facility to develop and implement a preventive maintenance program to ensure wheelchairs are maintained in a safe and operable manner. 2. All staff have the responsibility to ensure that wheelchairs in need of repair are not used and are reported for repairs. 3. The Maintenance Director is responsible for developing and maintaining a schedule of preventative maintenance services to ensure that equipment is maintained in a safe and operable manner. e. Check seats, backs, arm rests and cushions for tears, cracks or missing screws-replace or repair if present. 5. If the wheelchair fails any element of the preventative…
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 · D2024-05-01 · 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, policy and record reviews, the facility failed to follow policies and procedures to ensure a safe smoking environment for residents that choose to smoke for 3 of 3 residents reviewed for smoking, Residents #60, 110 and 112. The findings included: The facility's policy, titled, Smoking Policy, (no reference date), documented, in part: This facility will establish and maintain safe resident smoking practices for all residents. To assure maximized safety, all residents who choose to smoke will be supervised smokers. Policy Interpretation and Implementation: 2e. All smokers will be supervised during smoking without exception. 4. Th designated smoking area will be staff-supervised at times posted at the entrance to the smoking area. Those who wish to smoke outside designated times designated time blocks will request assistance from staff who will provide supervision at the earliest convenience. 15. All smoking materials will be kept in a lock box at the adjacent nurse's station.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · 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 provide nutrition via enteral means as ordered by physicians for 1 of 1 sampled resident, Resident #108, reviewed for tube feeding. The findings included: Record review revealed Resident #108 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an admission Minimum Data Set (MDS), dated [DATE], documented Resident #108 had a Brief Interview for Mental Status (BIMS) score of 06, indicating the resident had severe cognitive impairment. Resident #108's dietary orders included: a. On 04/19/24, CCHO (Controlled Carbohydrate) diet, Mechanical Soft texture, Thin consistency. b. On 04/19/24, Enteral Feed - in the afternoon for NUTRITION OFF AT 10AM - ON 2PM Glucerna 1.5 at 40 milliliters per hour (ml/hr). Resident #108's care plan for tube feeding dated 04/28/24, documented, Resident requires an enteral feeding tube to meet nutrition and hydration needs related to: Cerebrovascular Accident) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-01 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations interviews and record reviews, the facility failed have nurse staffing information posted daily and failed to update the nursing staff information, including names of staff providing care to the residents and residents' census on 2 of 3 units. The findings included: 1. Upon entering the facility, on 04/28/24 at 8:30 AM, it was noted that the nurse staffing hours were not able to be located by members of the survey team. During a tour of the facility, on 04/28/24, beginning at 9:26 AM, the staffing data was again not able to be located. On 04/28/24 at approximately 10:30 AM, the staffing data was on the reception desk in the Main Lobby, where the information was not available during the previous observations. 2. During a unit by unit tour of the facility, on 04/28/24 at 9:26 AM, the following were noted: a. On the Reflections Unit, 200 unit and rooms 309-316, the white board that was used to list the names of the nursing staff providing care to the residents was dated Friday, 04/26/24. b. On the Oasis Unit (400 unit), the white board that was used to list 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 · D2024-05-01 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare and provide meals in a manner to conserve the nutritive value of pureed vegetables. The findings included: The facility's policy, titled, General Food Preparation and Handling, with a reference date of 2005, documented, in part: 15. Food items shall be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. Procedure: 15. Leftovers must be cooled to <40 degrees F within 4 hours (or cooled to 70 degrees F within 2 hours and then down to 40 degrees F within another 4 hours) .Leftovers are not to be used for as pureed food. The facility's approved recipe for Pureed Buttered Broccoli Florets (no reference date) frozen broccoli pieces lightly seasoned with margarine then pureed to a pudding texture was as follows: 2. Prepare Broccoli according to the attached/printed sub recipe (referring to the recipe for broccoli to be steamed from frozen florets). 3. drain vegetables and place in food processor, add margarine, then puree. During 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 · D2024-05-01 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 foods per residents' religious preferences for 1 of 4 sampled residents reviewed for food concerns, Resident #108. The findings included: Record review revealed Resident #108 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an admission Minimum Data Set (MDS), dated [DATE], documented Resident #108 had a Brief Interview for Mental Status (BIMS) score of 06, indicating that the resident had severe cognitive impairment. Resident #108's dietary orders included: a. CCHO (Controlled Carbohydrate) diet, mechanical Soft texture, thin consistency - dated 04/19/24. Review of Resident #108's electronic health record (EHR) showed that the resident was allergic to pork. During an interview, on 04/29/24 at 7:40 AM, with Resident #108, when asked about the food served in the facility, Resident #108 replied, the food is terrible. They keep serving me food that I don't like. I don't like pork…
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 · D2024-05-01 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 assistive devices to enable residents to improve or maintain their ability to eat or drink independently for 1 of 28 sampled residents, Resident #267. The findings included: Record review revealed Resident #267 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an admission Minimum Data Set (MDS), dated [DATE], documented Resident #267 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #267's diagnoses at the time of the MDS included: Arthritis, Malnutrition, Rhabdomyolysis, Dysarthria following non-traumatic intracerebral hemorrhage, altered mental status, Muscle weakness, Dysphagia, and Cognitive communication deficit. Review of Resident #267's physician orders included: a. NAS (No Added Salt) diet regular texture, thin consistency, lip plate with meals for diet - dated 04/19/24. During an observation of lunch being…
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 · D2023-08-03 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review, and interview, the facility failed to provide evidence that adequate pain management was provided for 1 of 3 sampled residents reviewed for pain management, Resident # 5, as evidenced by failure to provide evidence of providing appopriate pain management when the patient voiced complaints of pain; failure to provide evidence of performing the appropriate pain assessment associated with the administration of pain medication and failure to accurately document the administration of pain medications. The findings included: Review of the clinical record for Resident # 5 revealed the resident was admitted to the facility on [DATE] for Aftercare following joint replacement surgery. Review of the progress note dated 04/20/23 at 2:19 PM documented that staff report resident complained of left hip pain. The staff member followed up with the resident, who stated about 9:00 PM last night wanted to use bathroom and asked staff to help me with the left leg and since then my…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-23 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observation, interviews and record reviews, the facility failed to ensure staff limited the use of cell phones while on duty and providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); staff did not communicate in a foreign language while providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); and four of 22 sampled residents (Resident #204, #92, #47, #58) were treated in a dignified manner related to dining in 1 of 3 dining rooms (200 unit). The findings included: The facility's policy on Dignity (2001, Revised [DATE]) stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility's Employee Handbook stated: The use of cellular telephones on [the facility's] premises is permitted only in your parked car in the parking lot or in the event of an emergency. While on duty, cell phones may be carried on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-23 · 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, interview, record review and policy review, the facility failed to ensure reasonable accommodation of needs for 2 of 21 sampled residents, as evidenced by: Resident #24 lacked a call bell system that she could physically utilize to get staff assistance; and Resident #80 lacked an appropriately sized bed. The findings included: Review of the policy, Equipment - General Use for All Residents, revised August 2026, documented, Our facility shall provide routine equipment for the general use of the resident population. 3. Request or the need for special equipment should be referred to the Social Services Department. 1. On 02/22/23 at 8:37 AM, while in a resident room speaking with Resident #75, the roommate on the other side of a drawn curtain, Resident #24 called out nurse nurse please help me . help me with my elbow. The surveyor explained she was unable to assist, but asked the resident to push her call bell for assistance. Resident #24 stated, I can't . it's not here. Observation revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-23 · 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 observation, interview, and record review, the facility failed to provide requested beautician services to 1 of 1 sampled resident (Resident #7). The findings included: During an interview on 02/20/23 at 10:26 AM, Resident #7 stated she would like a haircut, as she pulled her long pony-tail up to show the surveyor. When asked if she had requested a haircut with the facility's beautician, the resident stated she had asked but they say nothing. Review of the record revealed Resident #7 was admitted to the facility on [DATE], and had transferred to her current room on 02/22/21. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating she was alert and oriented with minimal confusion. This same MDS documented the resident needed extensive to total assistance for all Activities of Daily Living (ADLs) except for eating. During an interview on 02/23/23 at 10:44 AM, the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ROBERT SCHOENFELD — 8 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 | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 4 of 5 | 3.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 7 homes this chain runs (chain average 3.4★, 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 | Share | Since |
|---|---|---|---|---|
| PORT ST LUCIE HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/11/2023 |
| SCHOENFELD, ROBERT | Individual | CORPORATE OFFICER | — | since 08/11/2023 |
1 organizational owner 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105579. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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