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Alhambra Healthcare & Rehabilitation Center

7501 38th Ave N, Saint Petersburg, FL 33710 · For profit - Limited Liability company · 60 certified beds · (727) 345-9307 Medicare & Medicaid certified

Call the home — (727) 345-9307 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7655 38th Ave N, Ste 101 · (727) 345-1332 · Call to confirm hours
Pharmacy
3994 Tyrone Blvd N · (727) 343-2221 · Call to confirm hours
Grocery
7835 38th Ave N · (727) 344-8591 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
4001 74th St N · (727) 343-3321

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.8%8.7%15.4%better
Long-stay residents who lose too much weight5.5%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms14.2%4.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%2.5%3.3%better
Long-stay residents whose ability to walk worsened6.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.7%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.5%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control7.1%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 table3.3%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine86.5%94.7%79.4%typical
Short-stay residents rehospitalized after admission26.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit19.4%9.1%12.0%worse

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.

38.7% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.7%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
62.5%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 62.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF38.7%CMS range 26.4–51.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.3–15.410.7%Oct 2022–Sep 2024no 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 discharge62.5%56.6%Oct 2024–Sep 2025CMS 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 discharge67.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge57.5%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS 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

0.32
RN hours/ resident / day
1.08
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.64
Total nurse hours/ resident / day
0.21
RN hoursweekends
55.2%
Total nursing turnover
83.3%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 54.7 residents a day — about 91% occupied, or roughly 5 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 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 3.39 hrs/resident/day on weekends vs 3.73 on weekdays — 9% thinner on weekends. RN hours go from 0.36 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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

6
deficiencies at the latest standard inspection (2025-03-26)
6
at the previous standard inspection (2023-01-05)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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 · F2026-03-03 · tag F0726 — failed to have competent, trained nursing staff — widespread
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure Licensed Practical Nurses (LPN) were board certified to administer intravenous (IV) infusion of medications for three residents (#1, #3, and #4) out of five residents sampled for medication administration. Findings included: https://www.fha.org/common/Uploaded%20files/FHA/Health%20Care%20Issues/Growing%20the%20Health%20Care%20Workforce/Issue%20Brief%20on%20Licensed%20Practical%20Nurse%20Scope%20of%20Practice.pdf showed the following:Approved Programs for IV CertificationsThe Board of Nursing (Board) specifies the requirements for LPNs to practice infusion therapy (IVs), pursuant to the Rule 64B9-12.005, Florida Administrative Code, Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy. The Board recognizes that after appropriate education and training, an LPN may perform intravenous therapy under the direction of a registered professional nurse and is approved by the facility to expand the LPNs scope of practice based on the completion of the program.Appropriate…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed: 1) to ensure proper PPE (personal protective equipment) was utilized for one resident (#5) on Enhanced Barrier Isolation, 2) to properly store a nebulizer for one resident (#3) receiving respiratory treatments, 3) to provide timely dressing changes for a Peripherally Inserted Central Catheter (PICC) for one resident (#3), and 4) to properly dispose of potentially contaminated personal protective equipment and linen for two residents (#3 and 5) out of five sampled residents for infection control. Findings included: On 3/02/2026 at 9:55 a.m., an observation was made in Resident #5's room of one small trash receptacle without a disposable liner. An observation was made of another small trash receptable in the resident's bathroom without a disposable liner. The trash receptacle in the room had gloves, gown and garbage inside. A sign for Enhanced Barrier Precautions was observed outside taped to the door. A record review of physician orders for Resident #5 showed an order for Enhanced Barrier Precautions-right…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide necessary treatment and services for pressure ulcers in a timely manner for one resident (#5) out of two residents sampled.Findings included: On 3/02/2026 at 9:55 a.m., an interview was conducted with Resident #5 in his room. Resident #5 stated he was admitted on [DATE] from the hospital. Resident #5 stated he had sores to his bottom. Resident #5 stated he had not received a bath/shower and could not recall if his wounds were addressed. A record review of Resident #5's 3008 Section T. Skin Care-Stage & Assessment Pressure Ulcers (indicate stage and location(s) of lesions using corresponding number showed pressure areas for coccyx, bilateral buttocks and bilateral thighs. A record review of Resident #5's initial admission skin assessment, dated 02/27/2026, showed:Sacrum 9 x 7Left buttock 6 x 3Right buttock 5 x 2Left gluteal fold 2 x 2Right gluteal fold 2 x 3All were noted as pressure wounds. A record review of Resident #5's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure adequate provision of care and services for activities of daily living, toileting services for two residents (#14 and #10) of sixteen sampled residents. Findings included: 1.On 12/03/2025 at 12:48 p.m. an observation of Resident #14 was conducted. The resident was in bed, covered up to neck, alert, and agreed to an interview. She stated she could now transfer herself out of bed. When asked if she needed assistance with the bathroom use, she stated when I got here, I did. I came in the evening before Thanksgiving. When asked about call bell light response, if it was timely. She stated, the waits happen mostly at night. I was upset one night; I could not transfer myself out of bed to go to the bathroom. I had to lay in my feces and urine for hours. I told the medical records girl. I do not know her name. She said she would speak to people and see it did not happen again. I could not walk. I had an arterial bypass in my leg; had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure pharmacy services for timely procurement of pain medication for one (#14) resident and failed to ensure a system of accurate accounting of dispensed controlled substances for one (#14) resident of three residents reviewed for pain medications.Findings included: 1. On 12/03/2025 at 12:48 p.m., an observation of Resident #14, in bed, covers up to neck, alert, agreed to an interview. She stated upon admission to the facility, I could not walk. I had an arterial bypass in my leg; had incision; the pain was excruciating. When I first came, it took me until Monday, 12/01 to get medications. I was upset. They did not have hydrocodone. They could not find the order. The doctor was out.A review of Resident #14's admission Record showed an admission date of 11/26/2025. Her diagnosis information included but not limited to atherosclerosis of native arteries of extremities with claudication, peripheral vascular disease, and chronic obstructive pulmonary disease.A review of Resident #14's admission Nursing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 a safe, sanitary, and comfortable homelike environment for 6 resident rooms (105, 110, 112, 205, 212, and 109) out of 16 rooms observed related to absent caulking around commodes, discoloration on commodes, unclean resident room and bathroom flooring, and discoloration on privacy curtain. Findings include: On 12/03/2025, at 9:10 a.m., a tour of the facility was conducted. room [ROOM NUMBER], the resident's bathroom, the commode had no caulking present. The flooring around the commode was darker than the rest of the flooring and presented as unclean.room [ROOM NUMBER], two areas of orange-colored semi-dried sticky puddles, approximately 4-5 inches in circular size were observed on the resident's floor. The floor had clear glistening splotches visible which presented to be sticky.room [ROOM NUMBER], the resident's bathroom, the caulking around the base of the commode had an orangish brown color, the flooring around the commode extending out…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an effective pest control program to maintain a pest free environment for two residents (#15 and #10) of sixteen sampled residents. Findings included: On 12/03/2025, at 9:10 a.m., a tour of the facility was conducted. At 9:35 a.m., Resident #15's room was observed. A line of tiny ants was observed crawling on the floor next to Resident #15's nightstand. The floor was observed to have food debris present. Resident #15 was present and stated he had seen a couple of ants on his bed.At 11:56 a.m. Resident #10 was interviewed in his room. He stated he had seen ants in his bathroom by the window. He said he told them about them a long time ago. An observation of the bathroom was conducted at this time; the windowsill had a line of tiny ants crawling just below the sill.On 12/03/2025 at 3:00 p.m., an interview was conducted with the Maintenance Director. He stated the pest control company comes every other Friday and every time 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-10-15 · tag F0559 — pattern
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to document room change notifications for three residents (#2, #3, and #4) of three residents sampled.Findings included: 1.) Review of Resident #2's census revealed Resident #2 changed rooms on 9/29/2025, 9/19/2025 and 9/15/2025. Review of Resident #2's progress notes revealed no documentation of notification of the room changes were located for 9/19/2025 and 9/15/2025. 2.) Review of Resident #3's census revealed Resident #3 changed rooms on 09/24/2025 and 09/19/2025. Review of Resident #3's progress notes revealed no documentation of notification of the room changes for 09/24/2025 and 09/19/2025. 3.) Review of Resident #4's census revealed Resident #4 changed rooms on 09/30/2025. Review of Resident #4's progress notes revealed no documentation of notification of the room changes for 09/30/2025. During an interview on 10/15/2025 at 12:46 P. M., the Director of Nursing (DON) stated the Social Services Director (SSD) was out of the building and was not reachable. The DON stated the SSD notifies the family of any room changes…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-21 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interviews and policy review, the facility did not ensure medications were stored and labeled appropriately in three medication carts (Split back, East front and [NAME] front) of three medication carts observed. Findings included: 1. An observation on 7/21/2025 at 2:25 P.M. of the Split Back Cart Medication Cart revealed an undated used bottle of Latanoprost eye drops, two undated Breo Inhalers and an undated Combivent inhaler. The boxes containing the Breo inhalers were labeled expires six weeks after opening and the Combivent inhaler was labeled expires three months after opening. The boxes did not show an opening date.An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 7/21/2025 at 2:32 P.M. She stated if she found medications that were not labeled in the medication cart, she would discuss it with the shift supervisor. She stated she never discards medications from the medication cart without speaking to a supervisor. The nurse placed all the undated medications back into the medication cart. Staff B, LPN stated it was her second day…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-26 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review, the facility did not ensure up-to-date staffing information was posted on one day (3/24/25) of three days observed. Findings included: Upon entering the facility on 3/24/25 at 9:00 AM, an observation was made of a posting titled, Daily Staffing Projection, dated 3/22/25 with census of 60. On 3/24/25 at 10:12 AM, the staffing posting was still not updated. Review of the facility's policy and procedure dated 11/19/2019 titled Nursing Services - Nurse Staffing Information showed: INTENT: It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time. POLICY: 1. The facility will post the following information on a daily basis: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses or licensed vocational nurses (as defined under State law). iii. Certified nurse aides.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Fcited before2025-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility did not follow professional standards for food service safety as evidenced by food not maintained for safe consumption and improper labeling and dating of food items in the main kitchen and dining room. Findings included: On 3/24/25 at 9:56 a.m., an initial tour of the facility's kitchen was conducted with the facility's Certified Dietary Manager (CDM). An observation of the dish machine area, that was in use by Staff E, Cook, revealed pliers with a red handle on the machine's base. Further observations on the top area of the dish machine revealed light brown colored crumbs and other food particles. An observation of the dish machine hood revealed multiple dark brown and black spots along the top and sides. The multiple spots observed appeared to be signs of rust. On 3/24/25 at 10:03 a.m., an observation of the walk-in cooler, conducted with the CDM, revealed strips of bacon in a clear storage bag with an open date of 3/17/25, but no use by date. The CDM identified the food as, Vegan bacon, and stated the staff should have kept 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-26 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of policy and procedures, and interviews, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) screening was completed for five residents (#48, #29, #6, #13, and #2) of 15 residents sampled. Findings included: 1. A review of Resident #48's admission Record showed an admit date of 8/21/2023 with diagnoses of Post-Traumatic Stress Disorder (PTSD), unspecified dementia, alcohol abuse, and cocaine abuse. The diagnosis of major depressive disorder was added on 9/26/2024. A review of Resident #48's Level I PASRR screen completed on 11/13/2024 showed in Section A. Mental Illness (MI) or suspected MI, depressive disorder, substance abuse, and PTSD were checked. Section II showed, Question #5: Does the individual have a primary diagnosis of Dementia? The response was checked Yes. Section II: Other Indications for PASRR Screen Decision-Making also showed, A Level II PASRR evaluation must be completed if the individual has a primary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment in two resident rooms (#201 and #214) of 32 rooms in the facility. Findings included: During an observation and interview on 3/24/25 at 10:45 AM and 3/26/25 at 12:15 PM, in room [ROOM NUMBER], the resident stated the dark brown armoire's drawer is broken and will not open. The resident who resided in the room stated the furniture has not worked for a while and would like to be able to use the space. The face of the top drawer of the dark brown armoire was observed separated from the rest of the drawer on the left side facing the drawer. During an observation and interview on 3/24/25 at 11:00 AM and 3/26/205 at 9:00 AM, in room [ROOM NUMBER], the toilet base was not secured to the floor. Both residents of the room stated they utilized the toilet. During an interview on 3/25/25 at 10:45 AM, Staff D, Certified Nursing Assistant (CNA), stated both residents in room [ROOM NUMBER] utilized 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observations, record review, and interviews, the facility failed to develop an individualized plan of care to include goals and interventions for two residents (#11 and #9) of forty two residents sampled. Findings included: 1. On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's admission Record revealed an original admission date of [DATE] and a re-admission date of [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review of Resident #11's psychiatry notes, dated [DATE], [DATE], 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 identify specific triggers related to post traumatic stress disorder (PTSD) and develop an individualized plan of care to prevent re-traumatization for one resident (#11) of one residents reviewed for PTSD. Findings included: On [DATE] at 11:09 a.m., Resident #11 was observed reading a book while sitting in a wheelchair. An interview was attempted, however, she did not respond and continued to read her book. Her roommate stated Resident #11 is, Always reading, hard of hearing, and doesn't wear her hearing aids. A review of Resident #11's admission Record revealed an original admission date of [DATE] and a re-admission date of [DATE]. Further review of the admission record revealed the following diagnoses to include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, generalized anxiety, and post-traumatic stress disorder. A review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-01-05 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy reviews, the facility failed to properly store and secure medications in two of three medication carts, one medication stock room, one of three medication refrigerators, and for one (Resident #208) of one resident reviewed. Findings include: An observation was made on 1/4/23 at 4:11 p.m. of an unlocked medication cart on the [NAME] Back Unit. Two nurses were standing five feet away from the medication cart. At 4:15 p.m. both nurses had walked out of the hall and the cart remained unlocked. There were no nurses in sight of the cart and the medication cart was sitting in one of the main resident hallways. After four minutes had passed, a nurse on the opposite hall asked if there was a problem. She was notified the medication cart was unlocked. She stated she would call the nurse who was using the cart. At 4:20 p.m., Staff Q, Licensed Practical Nurse (LPN) walked to the unlocked medication cart. Staff Q stated she walked away from the cart because she had to go put…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment to include one of one main hall through ways (East unit), and one of one main dining rooms, during three of three days observed (1/3/2023, 1/4/2023, and 1/5/2023). Findings included: 1. On 01/03/2023 at 10:00 a.m., the main throughway/hallway in the East 100 hall was observed with a section of flooring in disrepair with raised edges and sunken areas. The floor in disrepair was between resident rooms 104/106 and 103/105. The plastic/vinyl flooring was a different size and color as the original, not matching the rest of the floor, and were not glued down appropriately, causing trip hazards and feet scuffing risks. Observations on 01/03/2023 at 11:10 a.m., revealed an employee scuffed her feet while passing over the floor. She was observed to scuff over the raised sections of the plastic/vinyl flooring. Photographic evidence was taken. 01/03/2023 at 11:45 a.m., Staff A, Certified Nursing…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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, record review, and interviews, the facility failed to ensure care planning with problem areas, goals, and interventions was developed for three (Residents #108, #3, and #10), of twenty residents related to contracture management, splint/bracing management, and PTSD/Trauma behavior management. Findings included: 1. On 12/3/2023 at 10:20 p.m. and 1:45 p.m., Resident #108 was observed in his room and seated in a wheelchair next to his bed. The call light was placed within his reach and he was dressed for the day. He appeared pleasant and had no immediate concerns. He was not presenting with any behaviors, pain or discomfort at the time of the visit and agreed to be interviewed. He was observed with a hard plastic splint on his left forearm up to his elbow that was held on with two expanding stretch fabric strips. He indicated he was right handed and had a contracture in his left arm due to a stroke in the past, and used the splint to manage his contracture. He said he put the splint 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure activities of daily living (ADLs) related to showers and hair care were provided for one (Resident #17) of three residents reviewed. Findings included: During a facility tour on 01/04/23 at 12:22 p.m., an interview was conducted with Resident #17. She stated she felt neglected. The resident said, look at my hair, it's like a lump of a nest. They haven't tried to assist me, no one has attempted to comb or brush my hair since I have been here. Resident #17 stated her hair was matted because they left her hair uncombed for a long time. The resident stated she had one shower that she could remember. She stated one of the CNAs told her she should cut her hair. Resident #17 said, I said No, they can take the time to comb it. It is not fair to me. I am dependent on staff for care. The resident stated she had not refused to shower. She stated there was one incident, the only one time she received a shower. The CNA was not comfortable 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-05 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 did not ensure follow through on services related to a power wheelchair were conducted in a timely manner for one (Resident #3) of two sampled residents. Findings included: An interview was conducted with Resident #3 on 01/03/2023 at 9:24 a.m The resident was observed dressed for the day in plain clothes with a blanket over her lap and positioned by the nursing station. Resident #3 stated she had returned from a radiation appointment that morning and when transported back to the facility she was placed by the nurse's station. Resident #3 stated that she would kill for a cup of coffee and that she had asked for a cup and was told by an aide that there was some in her room. Resident #3 stated that she was unable to wheel herself to her room and was waiting for a staff member to assist her. Resident #3 stated she had asked an aide to move her to her room but at the time the aide needed to provide assistance to a different resident. Resident #3…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 reviews, the facility failed to ensure behavior monitoring was in place for one (Resident #10) of five residents on psychotropic medication reviewed for unnecessary medication. Findings included: A review of the admission records for Resident #10 indicated he was initially admitted on [DATE] and a re-admitted on [DATE] with diagnoses including recurrent depressive disorders. A review of physician orders revealed the following: Duloxetine HCL Dr sprinkle 40 mg. One time a day for depression. Date 11/29/22 A care plan review showed a care plan in place for the potential for adverse side effects related to the use of psychotropic medication. The interventions included observe for effectiveness of psychotropic medications, observe for adverse side effects related to psychotropic medication use, and observe for changes in mood/behavior. A review of Resident #10's electronic Medication Administration Record (eMAR) did not show any behavior or side effect monitoring in place for the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-07-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 observation, interview, and record review the facility failed to ensure sanitizer solution used to clean food and non-food contact surfaces in the kitchen, which serviced two of two hallways, was at manufacturing concentration levels of 200-400 parts per million (ppm) to ensure equipment was sanitized prior to storage. Findings included: During a comprehensive kitchen tour on 07/15/21 at 10:00 a.m., with the Kitchen Manager and the Certified Dietary Manager (CDM), Staff H, [NAME] was observed standing at the 3-compartment sink in the process of cleaning dishes. The Kitchen Manager revealed the food-contact sanitizing solution used in the 3-compartment sink was quaternary ammonia. The process for the 3-compartment sink was to have the far-right hand compartment filled with soap, the middle compartment filled with water, and the left-hand compartment filled with the sanitizer solution. After the dishes have been placed in the sanitizer solution, the dishes are placed on the left-hand side storage area. An observation on 07/15/21 at 10:00 a.m. revealed food-contact equipment…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-07-15 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    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, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the annual survey conducted 7/15/2021 regarding cleanliness and food safety in the kitchen. Findings included: 1. On 7/15/2021 during a recertification survey deficient practice was identified in the kitchen and cited at F812 scope and severity of F. The findings were: During a comprehensive kitchen tour on 07/15/21 at 10:00 a.m., with the Kitchen Manager and the Certified Dietary Manager (CDM), Staff H, [NAME] was observed standing at the 3-compartment sink in the process of cleaning dishes. The Kitchen Manager revealed the food-contact sanitizing solution used in the 3-compartment sink was quaternary ammonia. The process for the 3-compartment sink was to have the far-right hand compartment filled with soap, 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-07-15 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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, interview, and record review the facility failed to ensure resident areas were maintained in safe, clean, comfortable and homelike conditions related to wall bumpers at the base of the walls were not maintained in good repair and, a light fixture inside a resident's room directly over the head of the bed was not secured against the wall on two of two units. Findings included: 1. During a facility tour on 07/13/21 at 10:00 a.m. multiple wall bumpers located just above the baseboards were observed to be in disrepair, with metal edges exposed that residents could catch their feet or legs on while walking or self propelling in a wheel chair. The observations included: (photographic evidence obtained) 1. The wall bumper, attached to the base of the wall approximately a foot from the floor was observed outside of the conference room across from the 100-hallway nursing station detached from the wall by approximately half an inch, exposing the internal metal piece securing the bumper to the wall.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to respond to a request for room change in a timely manner for one of two residents reviewed (Resident #31). Findings included: A review of Resident #31's face sheet in the electronic medical record (EMR) revealed an original admission date of 12/07/19 and readmission on [DATE] with diagnoses that included cognitive communication deficit, post traumatic disorder (PTSD), generalized anxiety disorder, bipolar disorder, current episode manic without psychotic disorder, unspecified psychosis, insomnia, anxiety, vascular dementia, and cerebral infarction. A review Resident 31's quarterly MDS (minimum data set) dated 06/16/21 revealed a BIMS (Brief interview for mental status) score of 08, indicating moderate cognitive impairment. Section D, an assessment of mood indicated that Resident #31 did not report little interest or pleasure in doing things. Resident #31 reported feeling down, 7 out of 11 days of the month. Resident did not report…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to GOLD FL TRUST II — 36 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 →

RatingThis homeChain avg
Overall 1 of 53.4-2.4 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 4 of 54.7-0.7 vs chain
The other 35 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Lady Lake Specialty Care Center and RehabLady Lake, FL 2 of 5Cypress Care CenterWildwood, FL 2 of 5Lehigh Acres Healthcare & Rehab CenterLehigh Acres, FL 2 of 5North Beach Healthcare And Rehabilitation CenterNorth Miami Beach, FL 2 of 5Park Meadows Healthcare & Rehabilitation CenterGainesville, FL 2 of 5Rockledge Healthcare & Rehabilitation CenterRockledge, FL 2 of 5Sunset Lake Healthcare And Rehabilitation CenterVenice, FL 2 of 5Village Place Healthcare And Rehabilitation CenterPort Charlotte, FL 2 of 5Villages Healthcare And Rehabilitation Center, TheLady Lake, FL 3 of 5Apollo Healthcare & Rehabilitation CenterSaint Petersburg, FL 3 of 5Club Healthcare And Rehabilitation Center At The VThe Villages, FL 3 of 5Greenbriar Healthcare Rehabilitation And Nursing CBradenton, FL 3 of 5Grove Healthcare And Rehabilitation Center And RehHernando, FL 3 of 5Lexington Healthcare And Rehabilitation CenterSaint Petersburg, FL 3 of 5Shore Acres Care Center And RehabSaint Petersburg, FL 3 of 5South Campus Care Center And RehabLeesburg, FL 3 of 5The Club At Lake GibsonLakeland, FL 3 of 5Viera Healthcare And Rehabilitation CenterViera, FL 4 of 5Advanced Care CenterClearwater, FL 4 of 5Lakes Of Clermont Health And Rehabilitation CenterClermont, FL 4 of 5North Healthcare And Rehabilitation CenterSaint Petersburg, FL 4 of 5North Lake Care Center And RehabLake Park, FL 4 of 5Ridgecrest Healthcare And Rehabilitation CenterDeland, FL 4 of 5The Lodge Healthcare And Rehabilitation CenterOcala, FL 4 of 5Wilton Manors Healthcare & Rehabilitation CenterWilton Manors, FL 5 of 5Carlton Shores Healthcare And Rehabilitation CenteDaytona Beach, FL 5 of 5Gardens Healthcare & Rehabilitation CenterDaytona Beach, FL 5 of 5Isle Healthcare & Rehabilitation CenterOrange Park, FL 5 of 5Kendall Lakes Healthcare And Rehab CenterMiami, FL 5 of 5Plaza Health And RehabGainesville, FL 5 of 5Ponce Therapy Care Center And Rehab, TheSaint Augustine, FL 5 of 5Terrace Healthcare & Rehabilitation CenterGainesville, FL 5 of 5Unity Healthcare And Rehabilitation CenterMiami, FL 5 of 5Villa Healthcare & Rehabilitation CenterDeland, FL 5 of 5Woodland Grove Healthcare & Rehabilitation CenterJacksonville, FL

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 / managerTypeRoleShareSince
ALHAMBRA SNF HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/23/2022
FL MASTER OPCO HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST90%since 12/20/2022
KATZ, AHARONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER10%since 12/20/2022
WILEY, LAURAIndividualW-2 MANAGING EMPLOYEEsince 03/11/2024

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.5M
Net patient revenuemost recent cost report
-16.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 59%Medicare 7%Other / private 34%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$374per resident / day
operating cost
$11,376per month
≈ monthly operating cost
$320per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

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 105712. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, 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.

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