Abbey Rehabilitation And Nursing Center
7101 Dr Martin Luther King Jr St N, Saint Petersburg, FL 33702 · Non profit - Corporation · 132 certified beds · (727) 527-7231 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has abuse, neglect, or exploitation citations (F0600, F0609, F0610) — most recent Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $139,355 in federal fines (most recent 2024-12-12)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.5% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.1% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.3% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 8.3% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.2% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 14.8% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 37.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.7% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.04 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.8% 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 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 66 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 | 38.8%CMS range 28.9–53.8 | 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 | 11.2%CMS range 8.0–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 30.3% | 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 | 19.7% | 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 | 96.7% | 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 | 95.0% | 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 | 3.3% | 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 | 7.2%CMS range 3.9–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 132 beds and averages 115.2 residents a day — about 87% occupied, or roughly 17 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 3.04 hrs/resident/day on weekends vs 3.29 on weekdays — 7% thinner on weekends. RN hours go from 0.70 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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 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.
33 citations, most serious first. The 16 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-01-24 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review the facility failed to protect residents' right to be free from neglect related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not performing laboratory tests and not following up on critical lab results for two residents (#11 and #13) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. These failures created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death to Residents #1, #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Kcited before2024-01-24 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review the facility failed to ensure an allegations of neglect were reported related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: On [DATE] at 2:14 p.m. after multiple requests for the facility to provide a list of incidents that had been reported in [DATE], the DON confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2024-01-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review facility failed to ensure an allegations of neglect were investigated related to not ensuring cardiopulmonary resuscitation (CPR) was provided according to policy and procedure for one resident (#1) out of three reviewed for the CPR process; not following up on critical lab results for one resident (#11) out of three reviewed for lab testing and not ensuring treatment and care was in place for one resident (#11) out of three reviewed for an immune deficiency syndrome. This failure created a situation that resulted in a worsened condition and/or the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: An interview was conducted on [DATE] at 2:46 p.m. with the DON. The DON said she did not hear there were any problems with the code for Resident #1 on [DATE]. She said no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2024-01-24 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed according to professional standards on one resident (#1) out of three reviewed for CPR, the facility failed to ensure three out of five emergency carts were stocked correctly and ready to be utilized in a code blue, and failed to ensure six out of thirty-two nurses had hands-on and in person skills assessment training with their CPR certification. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Findings included: 1. Not ensuring cardiopulmonary resuscitation (CPR) was provided: Staff M, Nurse was interviewed at 3:00 pm on [DATE] and stated Staff L, Nurse was performing CPR on Resident #1 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.
- Immediate jeopardy · K2024-01-24 · tag F0773 — patternProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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, interview, and policy review the facility failed to perform ordered laboratory (lab) testing, failed to inform the provider of critical lab results and/or failed to carry out provider orders in response to critical lab results for two resident (#11 and #13) out of three residents reviewed for labs. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #11, and #13 and resulted in the determination of Immediate Jeopardy which began on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E. Finding included: 1. Resident #11 Review of the admission records showed Resident #11 was initially admitted on [DATE] after a hospital stay for pneumonia and with diagnoses including pneumonia, immune deficiency syndrome, thrombocytopenia, and cirrhosis of liver and was re-admitted on [DATE], after a hospitalization for a gastrointestinal bleed.…
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.
- Actual harm · Gcited before2024-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #3's Hospital record revealed Resident #3 was hospitalized from [DATE] to 8/15/2024. The History of Present Illness (HPI) section revealed the following: Patient (Resident #3) is a [AGE] year old male with a past medical history of hypertension, alcohol use, tobacco use, and history of open reduction internal fixation, who presents to the ER (Emergency Room) with complaints of worsening right wrist pain. He was recently admitted on [DATE], due to a right wrist abscess, which was MRSA positive osteomyelitis for which he underwent irrigation/debridement. He required 6 weeks of IV Vancomycin as per ID recommendations for which he received a total of 10 days of antibiotics before leaving AMA on July 26th. Today (8/1/2024), the patient arrived at ER due to progressive worsening pain and swelling of the right wrist. Review of Resident #3's admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including primary osteoarthritis right wrist, arthritis due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-25 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to report an elopement (an unauthorized exit from a secure unit) in accordance with State law through established procedures for one resident (#1) out of three residents sampled.Findings Included:During a phone interview on 06/25/2026 at 11:43 a.m., the Resident Representative (RR) for Resident #1 stated, I received a call from the facility letting me know [Resident #1] had escaped from the secure unit. I spoke to the police who told me they found Resident #1 quite a ways away from the facility. The facility told me he left during a fire drill. [Resident #1] was placed at the facility on the secure unit because of the history of exit seeking and attempting to leave from another facility.Review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE] and discharged from the facility on 01/21/2026. Resident #1 was admitted to the facility with diagnoses to include; lack of coordination, unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-02 · 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, staff interview and record review, the facility failed to 1. Ensure planned meals were held at and below required temperatures and were ready to serve to residents for consumption during one of three meal service observations, (on 4/1/2026). It was found several of the planned cold food times were held over 41 degrees F.; 2. The facility kitchen staff failed to conduct and promote good hand hygiene practices when handling food. Findings included:1.On 4/1/2026 at 10:00 a.m. the meal menu board posted in the main 100 hallway outside the kitchen revealed the following menu food items to be served: (1. Turkey Croissant, 2. Macaroni Salad, 3. Relish Salad, Pudding, and with an alternate menu item of Beef Stew).It was determined the primary meal to be served for lunch meal service were cold items and with beef stew to be the hot item as an alternate. The menu further revealed residents could order choice items to include grilled cheese, hot turkey sandwiches, etc.On 4/1/2026 at 11:00 a.m. the kitchen was entered and met with the Dietary Manager (DM). The DM stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-02 · 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 observations, record review and interviews, the facility failed to promote and maintain dignity for residents during activities, during meal services, and while in their rooms for six residents (#87, #8, #34, #101, #52, and #51) out of sixty-one sampled residents.Findings included: 1. On 3/30/2026 at 10:39 a.m. Resident #87 was observed lying in bed with the call light cord/button was on the floor, out from her reach. Resident was noted with what appeared to be a dark color saliva from her mouth. Resident #87 was attempted interview, but she did not want to answer. The resident was lying on brown colored saliva with brown matter all over her upper buttock area, the surface of the mattress, the side of the mattress, the bed frame, and trash can on the side of the bed. On 3/30/2026 at 12:04 p.m. just before the lunch meal service, Resident #87 was still observed in her room and lying in bed in the same position with heavy saliva coming from her mouth to a white with brown stained towel, and all over her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations interviews and review of the facility policy, the facility failed to provide a homelike environment in15 resident rooms (#1 through #15) out of 15 rooms located on the secured unit (300 Hall).Findings Included: During multiple facility tours of the secured unit (300 Hall) conducted from 03/30/3026 through 04/02/2026, observations revealed a plain halls layout with minimal decor, and no personal touches or affects throughout the physical environment. The resident rooms were observed to be bare with no personal effects and the overall atmosphere lacking warmth, comfort and familiar features. The Common areas appeared sparce, with little decoration and non-inviting seating which failed to promote a comfortable living environment for the residents. Attempts to interview the residents of the secured unit were unsuccessful due to noted severe cognitive impairments.During an interview on 03/31/2026 at 11:50 a.m., a family representative stated, This place could use some personal touches. It is not very home like.During an interview on 04/01/2026 at 4:45 p.m., 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 · E2026-04-02 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 interview the facility failed to ensure adequate staffing related to 1.) administering medications within their scheduled time frames or two residents (#100 and #94) out of two residents reviewed; 2.) answering call lights in a timely manner as reported by all residents in the Resident council meeting.Findings included: 1. On 3/30/2026 at 9:26 a.m., an interview was conducted with Resident #100 in his room. The resident stated over the weekend the nursing staff were low. The resident stated normally there are three nurses each with a cart on his hallway (100) but stated yesterday there were two nurses on the evening shift. The resident stated yesterday, the nurse [Staff Y] was running around and trying his best during his medication administration but the resident was not sure if he got his mediation on time. Resident #100 stated Staff Y, Licensed Practical Nurse (LPN) stated he had close to 40 residents to give all their medications to. Resident #100 stated he seemed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-02 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to follow standards of care for infection control related to; 1. offering hand hygiene to residents before meals for three of three meal observations; 2. Failed to follow hand hygiene practices during meal services; 3. Failed to use personal protection equipment (PPE) in one room (room [ROOM NUMBER]) of 3 rooms with transmission-based precautions.Findings included: 1. During an observation on 03/30/2026 at 11:44 a.m., multiple residents on the secure unit (300 hall) were observed sitting in the dining room at tables. Staff began passing meal trays without offering hand hygiene to residents. During an observation on 03/30/2026 at 1:18 p.m. of multiple rooms on the 300 unit revealed no paper towel holders in multiple resident rooms. During an observation on 04/01/2026 at 12:04 p.m., multiple residents on the secure unit (300 hall) were observed sitting in the dining room at tables. Staff began passing meal trays without offering hand hygiene…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of the facility policy, the facility failed to ensure implementation of their abuse policy related to an allegation of physical abuse and failure to immediately remove the resident from the alleged perpetrator, for one resident (#80) out of one resident sampled. Findings included: On 3/30/26 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director (AD) was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering the front of his dark colored shirt and the top of his dark colored pants. Resident #80 said Staff F, CNA slapped him. Staff F, CNA said he did not slap the resident, but that Resident #80 slapped himself. Staff F stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for three residents (#10, #34, #62) of seven residents sampled.Findings included: 1. A review of Resident #10's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses to include; schizoaffective disorder, bipolar type, depressive disorder, Epilepsy, mood disorder, psychoactive substance abuse, antisocial personality disorder, generalized anxiety disorder, and alcohol use, Review of Resident #10's records revealed the resident did not have a level one PASARR completed prior to admission. The review further showed a level II PASARR was not submitted for consideration following qualifying diagnoses. 2.Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to implement care plan interventions related to 1. Positioning of adaptive eating equipment and 2.Ensuring call light bell/cords are within reach for two residents (#87 and #114) of sixty-one sampled residents, during four days (3/30/2026, 3/31/2026, 4/1/2026, and 4/2/2026) of four days observed. Findings included: 1. On 3/30/2026 at 12:29 p.m. the main dining room was observed for the lunch meal service. There were nine residents including Resident #114 seated at various tables and being served and assisted by staff with their meals. Resident #114 had already received his plate of food, observed with adaptive eating assistive equipment including a high scoop plate. Resident #114 was noted with his left hand and arm positioned on his lap while he used his right hand to grip the eating utensil. Resident #114 used the eating utensil and began to scoop food inward towards him as the high side of the scoop plate was positioned outwards and away…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure a care plan was revised in a timely manner related to behaviors for one resident (#80) out of seven residents reviewed. Findings included: On 3/30/26 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director (AD) was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering the front of his dark colored shirt and the top of his dark colored pants. Resident #80 said Staff F, CNA slapped him. Staff F, CNA said he did not slap the resident, but that Resident #80 slapped himself. Staff F stated the resident was care planned for accusing staff of hitting him. The Activities Director was observed asking…
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 17 citations
- Potential for harm · D2026-04-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to provided assistance with meals for two residents ( #34 and #61) out of two residents reviewed for activities of daily living (ADL).Findings Included:1.During an observation on 03/30/2026 at 11:56 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit). Resident #34 was observed attempting to scoop food off of his plate and dropping it onto the table.During an observation on 04/02/2026 at 11:46 a.m., Resident #34 was observed sitting at a table in the dining room of the secure unit (300 unit), scooping food off of his plate, and feeding himself.Review of Resident #34's admission record revealed an admission date of 02/24/2026. Resident #34 was admitted to the facility with diagnosis to include unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified protein-calorie malnutrition, other lack of coordination,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a notification of change was completed for one resident (#129) out of one resident reviewed who was severely cognitively impaired.Findings included: A review of Resident #129's admission record revealed an initial admission date of 3/5/26, and a re-entry date of 3/26/26 with diagnoses to include unspecified intracranial injury with loss of consciousness of unspecified, duration, subsequent encounter, unspecified sequelae of unspecified cerebrovascular disease, acute and chronic respiratory failure with hypoxia, encephalopathy, unspecified, and tracheostomy status. The admission record, under contacts, revealed Resident #129 was documented as the responsible party and two family members were listed as emergency contacts #1 and #3.A review of Resident #129's minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0.0. indicating severe cognitive impact. A BIMS evaluation dated 3/30/26 showed severe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility did not ensure ongoing monitoring for changes in condition related to catheter use for one resident (#126) out of two resident sampled.Findings included: An observation on 03/20/2026 at 2:23 PM revealed Resident #126 had a catheter bag that contained dark red and cloudy urine. An observation was made on 04/01/2026 at 1:28 PM with Staff O, Licensed Practical Nurse, (LPN) of Resident #126 having red and amber urine in the catheter bags. Staff O stated the physician should be notified if changes are observed in the residents output or color.Review of Resident #126's admission record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage and obstructive and reflux uropathy.Review of physician orders active as of 04/02/2026 revealed: Nephrostomy catheter, drain nephrostomy catheter bag every shift and PRN (as needed) every shift.Review of the care plan report for Resident #126 revealed a focus of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · 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 record review and interview, the facility did not ensure oxygen therapy was provided per physician orders for one resident (#126) out of one resident sampled.Findings included: On 03/30/2026 at 2:21 PM, an observation revealed Resident #126's oxygen concentrator was set to 9 liters per minute (LMP).Review of physician orders for Resident #126 active as of 04/02/2026 revealed: Humidified oxygen per trach continuously, 7 liters every shift for shortness of breath, effective 03/26/2026.Review of Resident #126's admission record revealed Resident #126 was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. Review of the care plan report for Resident #126 revealed a focus initiated on 03/13/2026, Revised 3/27/2026, Oxygen - Resident #126 has oxygen therapy related to O2 (oxygen) via tracheostomy, O2 dependent. The goals revealed; Will experience minimal to no shortness of breath (SOB), will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0741 — failed to have staff trained for behavioral health — isolatedEnsure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health 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 observation, record review and interviews, the facility failed to ensure nursing staff were competent, related to residents with behavioral health needs, as evidenced by the following: 1) accurately documenting behavior monitoring for three residents (#8, #62, and #80) out of three residents reviewed for behaviors; 2) supervising residents on the 300 (secured) unit for two residents (#61, and #34) out of two residents observed during dining; and 3) sufficient staffing to meet the needs of residents on the secured unit. Findings included: 1. On 3/30/2026 at 9:46 a.m., an observation of the closed door of the shower room in the 300 (secured) unit revealed elevated voices, the sound of a loud smack, and a male voice stated, Ow, he slapped me. The Activities Director was observed walking to the closed shower room door; she asked who was in there and Staff F, Certified Nursing Assistant (CNA) opened the door. Staff F, CNA was behind Resident #80 who was observed in a wheelchair with a pink substance covering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility did not ensure pharmacy recommendations related to labs were completed for one resident (#13) out of five residents reviewed. Findings include:A record review of Resident #13's Medication Regimen Review (MMR) from 01/01/2026 - 01/08/2026 showed the following recommendation for the Nursing staff: The resident is no longer receiving drug therapy requiring lab monitoring. Please consider discontinuing the following lab orders: RECOMMEND DC [discontinue] LITHIUM LEVELS (MED DC'D) [medication discontinued] dated 01/08/2026. A further review of the documentation showed a column to the right labeled Follow-Through. The recommendation showed a hand-written note Done. A record review of Resident #13's MMR (Nursing Recommendations) dated 3/01/2026-3/05/2026 showed the following recommendation for the nursing staff: This resident is no longer receiving drug therapy requiring lab monitoring. Please consider discontinuing the following lab orders: RECOMMED TO DC LITHIUM LEVELS (MED DC'D) dated 3/05/2026.A record review of Resident #13's lab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0840 — isolatedEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility did not ensure outside physician appointments were arranged/scheduled in a timely manner for one resident (#5) out of two residents reviewed.Findings included:On 3/31/2026 at 9:30 a.m., an interview was conducted with Resident #5 in his room. Resident #5 stated he had missed an outpatient appointment for an ophthalmologist. Resident #5 pointed to his right eye and stated he needs to be seen by his eye doctor for his vision. An observation was made of the resident's appointment card scheduled for 01/16/2026 at 12:10 p.m. for an ophthalmologist appointment. Resident #5 stated he also missed his monthly urologist appointment for the month of March. Resident #5 stated he had a suprapubic catheter in which he sees the urologist monthly.On 3/31/2026 at 2:39 p.m., an interview was conducted with Staff T, Registered Nurse/Unit Manager (RN/UM)for the 100 hallways. Staff T, RN/UM stated she is new to the role of unit manager and was not familiar with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement an effective Infection Control and Prevention program by 1.) failing to ensure staff donned appropriate personal protective equipment (PPE) while caring for a resident under Enhanced Barrier Precautions for one resident (Resident #5) of two residents sampled for Infection Control precautions, and 2.) failing to ensure staff donned appropriate PPE while in the room of a resident under Transmission Based Precautions for one resident (Resident #4) of two residents sampled for Infection Control precautions. Findings included: A review of Resident #5's admission Record showed Resident #5 was admitted on [DATE] and was readmitted on [DATE]. Review of the admission Record also showed diagnoses including but not limited to cachexia, obstructive and reflux uropathy, gastrostomy status, neuropathic bladder. Review of Resident #5's Order Summary Report, active as of 12/12/2024, showed an order dated 6/24/2024 for Enhanced Barrier…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, facility policy review and medical record review, the facility failed to facilitate a prompt response to a grievance of one of 4 sampled residents, the facility did not document, or communicate a resolution or outcome with Resident #3. Findings include: During an interview on 1/17/2024 at 8:45 a.m. with Resident #3 in her room, she stated she had $200 dollars cash missing in the last couple months at the nursing home. States she had $100 dollars go missing in early November and another $100 dollars went missing a little over a month later in early December. She said the second time (December) her roommate had given her $100 dollars as she had damaged her iPad. She kept it in her purse and took her purse with her everywhere, except to bingo activity. She discovered it was missing at dialysis when she went to pay for a snack and all $100 dollars was missing. She remembers seeing money in her purse 1-1.5 weeks prior and was unable to pinpoint exact date. She reported it to the DON (Director of Nurses) and was provided a locked drawer on her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure clean and sanitary equipment in the one of one kitchen related to 1) the dishwashing machine not reaching optimum wash and rinse temperatures, and 2) the sanitizer solution not reaching the dishwashing machine by way of pump and tubing properly. Findings included: On 10/9/2023 at 9:30 a.m. a general tour of the kitchen was conducted with the Dietary Manager (DM) and the Registered Dietician (RD). The DM stated the kitchen had a Low temperature dish washing machine. He stated the staff run the machine three times a day, once after the breakfast meal, once after the lunch meal, and once after the dinner meal. He stated the machine has been running appropriately and has not had any recent repairs, other than routine maintenance provided by an outside contract company. The dish machine log was reviewed for 10/2023 and revealed daily wash and rinse temperatures as well as sanitizer Parts Per Million (PPM) logged each day with each meal service. The log revealed temperatures ranging over 120 degrees…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 observations, record reviews, and interviews the facility failed to ensure the urinary drainage bag for one resident (#66) was maintained in a manner that allowed for urine to drain via gravity into the drainage bag and failed to store the urinary catheter tubing and drainage bag in a sanitary manner for one resident (#102) out of four residents with urinary catheters. Findings included: 1. On 10/9/23 at 8:04 a.m. Resident #66 was observed sitting in a wheelchair. The resident's urinary catheter tubing was observed leaving the left leg hole of above-the-knee green shorts. The tubing hung down and then back up to a drainage bag attached to a metal plate located approximately 2 below the wheelchair's armrest. The resident's urine appeared to be thin consistency, milky-colored. On 10/9/23 at 10:41 a.m. Resident #66 was observed sitting in a wheelchair with the urinary drainage bag hanging from the metal plate below the left armrest of the wheelchair, approximately level with the resident's bladder.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the Quarterly Minimum Data Set (MDS) accurately reflected the status of one resident (#11) of thirty four residents sampled. Findings included: Review of the admission Record for Resident #11 revealed he was admitted to the facility on [DATE] from an acute care hospital. admission diagnoses included paranoid schizophrenia, unspecified protein-calorie malnutrition, anemia, and anorexia. Review of the Quarterly MDS, dated [DATE], revealed in Section E - Behavior Resident #11 had no physical behaviors directed towards other (e.g. such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually), verbal behaviors directed towards others (e.g. threatening others, screaming at others, cursing at others), or other behavioral symptoms not directed toward others such as hitting or scratching self, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Further review showed…
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 before2023-10-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to revise the individual comprehensive care plans for two residents (#77 and #11) out of 34 sampled residents. Findings included: 1. Review of Resident #77's admission Record showed Resident #77 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes without complications. A review of the active October 2023 physician orders for Resident #77 showed a physician order dated 07/13/23 as, Insulin Lispro Solution 100 UNIT/[milliliter] ML inject 5 unit subcutaneously before meals for diabetes mellitus. A second physician order dated 08/11/23 showed, Accu-check per order related to diabetic monitoring of Hypo/Hyperglycemia activity. as needed for hyper/hypoglycemia. A review of the comprehensive care plan showed a focus of DIABETES MELLITUS: [Resident #77] has diabetes Mellitus as evidence by: Type 2 Diabetes. The goals showed, Minimize effects of Hypoglycemia and Hyperglycemia and monitor for diabetic complications. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · 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 observations, interviews and record review the facility failed to provide care and treatment services in accordance with professional standards of practice as evidenced by not ensuring an acute skin condition was assessed for one resident (#9) of four residents sampled. Findings included: During an interview on 10/9/2023 at 10:00 a.m. Resident #9 said she has been telling her CNAs (certified nursing assistants) and nurses since last week that she has been having pain on her left side near her abdomen and no one has addressed her about it to stop the pain. She said they just continue to ignore her and yell at her when she asks them for assistance. On 10/10/2023 at 10:37 a.m. Resident #9 stated she has been complaining about a sore on her side that has been very painful. On 10/10/2023 at 4:00 p.m. Resident #9 was observed laying down in her bed and she stated she was still having pain on her left side. Review of the admission Record revealed Resident #9 was admitted to the facility on [DATE], 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 before2023-10-12 · 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 observations, interviews, and record reviews the facility failed to maintain one resident's (#102) tracheotomy in a clean, sanitary manner of one sampled resident with a tracheotomy. Findings included: On 10/10/23 at 10:00 a.m. an observation of Resident #102's tracheostomy's (trach) revealed the inner cannula had a dried brown/tan colored substance around the entire rim of it, the oxygen trach mask was located toward the resident's shoulder and had brown/tan colored smudges, the green elastic mask tie had the same colored dried substance on it, and the padded trach collar was discolored with a tan and darkish brown substance on it. The resident's skin around the whitish colored split gauze under the trach appeared to be reddened. The suction canister, located on the nearby dresser had approximately 2 of an opaque white watery liquid in it. The Assistant Director of Nursing (ADON) viewed the resident, attempted to move the trach mask, and the resident began swinging their arms. The ADON confirmed 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 · D2023-10-12 · 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 reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and two errors were identified for two residents (#59 and #14) of six residents observed. These errors constituted a 7.14% medication error rate. Findings included: 1. On 10/10/23 at 8:15 a.m., an observation of medication administration with Staff K, Licensed Practical Nurse (LPN) was conducted with Resident #59. Staff K dispensed the following medications: - Metformin 1000 milligram (mg) tablet - Buspirone 10 mg tablet - Fludrocortisone 0.1 mg tablet - Lisinopril 20 mg tablet - Celecoxib 100 mg capsule - Potassium Chloride Extended Release 20 milliequivalent tablet - Zoloft 50 mg tablet. Immediately following the dispensing of the medications and prior to entering the resident room to administer them Staff K confirmed seven tablets/capsules had been dispensed. A review of Resident #59's Medication Administration Record (MAR) for October 2023 identified the resident was to receive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to ensure one resident (#92) of thirty four sampled residents received a breakfast meal tray as ordered to meet nutritional needs during one meal (10/10/2023) of three meals observed. Findings included: Resident #92 resides in the dementia unit of the facility and requires continual supervision. On 10/10/2023 at 8:00 a.m. Resident #92 was observed in her room, seated in a chair, and had just received her breakfast meal tray from Staff D, Certified Nursing Assistant (CNA). Staff D placed the tray on the over the bed table and set it up for Resident #92 to start eating. Staff D, CNA sat down next to the resident and attempted to assist with her meal. Resident #92 got up and began to ambulate around the room. Staff D attempted to coerce Resident #92 to sit and eat but the resident continued to walk away. An interview was conducted with Staff D, CNA on 10/10/2023 at 8:00 a.m. Staff D provided the meal ticket for review which and 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.
“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
$139,355 in federal fines across 2 penalties.
- $53,625 — penalty dated 2024-12-12
- $85,730 — penalty dated 2024-01-24
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 FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 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 | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
The other 16 homes this chain runs (chain average 2.2★, 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 |
|---|---|---|---|---|
| FI-THE ABBEY, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/03/2003 |
| FLORIDA INSTITUTE FOR LONG TERM CARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 04/16/2025 |
| OMEGA HEALTHCARE INVESTORS, INC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 07/01/2003 |
| JAFFE, HOWARD | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| KATZ-HALL, KATHY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| MULLARKEY, JAMES | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| RICHMOND, PENNY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| AEGIR HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/16/2025 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/16/2025 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/24/2025 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/24/2025 |
| CLOUD, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/16/2015 |
| MAXWELL, TASHAUN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/29/2022 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 22 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $201K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 105749. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-02, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.