Alpine Health And Rehabilitation Center
3456 21st Ave S, Saint Petersburg, FL 33711 · Non profit - Corporation · 57 certified beds · (727) 327-1988 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- 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 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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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.
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 | 14.1% | 8.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.7% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 0.3% | 0.9% | worse 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 | 1.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 8.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.4% | 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 | 11.4% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 2.2% | 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 | 9.6% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.6% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.8% | 9.1% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 4.01 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.23 | 1.15 | 1.80 | worse |
* 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.
Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 59% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.1–14.6 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 96.3% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.4% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.14 | 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 57 beds and averages 50.8 residents a day — about 89% occupied, or roughly 6 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.09 hrs/resident/day on weekends vs 3.30 on weekdays — 6% thinner on weekends. RN hours go from 0.57 to 0.43 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%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2026-05-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure accurate skin evaluations were completed in a timely manner for one resident (#1) out of three residents reviewed. Resident #1 was diagnosed with a Stage IV pressure ulcer to the sacrum and osteomyelitis and sent to a higher level of care for treatment. Findings included: A record review of Resident #1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 3/11/2026 at 7:29 a.m., showed a new pressure ulcer with the primary physician and family notified. A record review of Resident #1's admission Record showed an original admit date of 6/06/2013 with the following diagnoses: Traumatic subarachnoid hemorrhage without loss of consciousness, Type 2 Diabetes Mellitus without complications (DMII), Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side, and other comorbidities. Resident #1 was discharged on 4/20/2026 to the hospital due to the pressure ulcer and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-08 · tag F0645 — widespreadPASARR 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 and interviews, the facility did not complete and/or update the level I pre-admission screening and resident reviews (PASSARs) for residents with qualifying medical diagnoses for six (#4, #5, #9, #13, #18 and #36) out of 18 residents reviewed for PASSARsFindings Included: 1. A review of Resident #9's admission record revealed an original admission date of 11/4/24, and a re-admission date of 11/2/25, with diagnoses to include but not limited to; other recurrent depressive disorders, post-traumatic stress disorder, chronic, anxiety disorder unspecified, and alcohol abuse with intoxication, unspecified. A review of Resident #9's annual minimum data set (MDS) for medications, dated 11/7/25, revealed the following under high-risk drug classes: antidepressant usage. A review of Resident #9's care plan revealed the following focus areas to include: - Trauma Informed Care-PTSD [post-traumatic stress disorder] and major depression. - PSYCHOTROPIC MED [medication]: The resident uses psychotropic medication r/t [related to] Antianxiety to manage: anxiety Antidepressant…
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 · F2026-01-08 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program by failing to 1.) ensure hand hygiene was offered for eight ( 20A, 21B ,22B, 23A,24A 24B, 25A, 26A, 26B, 28B) of the eight rooms observed prior to meals. (2) The facility failed to ensure staff wore appropriate personal protective equipment (PPE) while handling laundry for the facility in one of one laundry rooms. 3.) The facility failed to follow infection control practices related to respiratory equipment for one (#2) of two residents samples with oxygen. Findings Included: On 01/05/2026 at 10:40 a.m., observed Resident #2 sitting up in bed with the tray table in front of them. The resident was fully dressed and observed using oxygen with a nasal cannula in place. The resident stated they used oxygen during the day. Resident #2 said the staff have not changed the nasal cannula. Observed the nasal cannula tubing was labeled 11/10. Review of Resident #2'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.
- Potential for harm · Ecited before2026-01-08 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure resident council meetings were documented as required for six of six months of resident council minutes requested. The facility could not demonstrate that they acted upon grievances voiced during resident council meetings.Findings Included: A review of the grievance log from June 2025 to December 2025 did not reveal any entries from Resident Council. During the Resident Council (RC) meeting on 1/7/2026 at 1:26 p.m. The RC members said they are not sure who the Grievance Official. The Grievance Official changes frequently, and they are not informed when the changes occur. The RC members said the staff never discuss the rationale behind unresolved issues, but We [the facility] will look into it is the answer received without resolution. On 1/7/26 at 5:12 p.m., an interview with the Nursing Home Administrator (NHA) was conducted. The NHA said the activities director had no documentation of the resident council minutes. The NHA said the expectation is the activities director should document what occurred in the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain a safe, clean, comfortable homelike environment related to rusted equipment, unpainted, damaged and uncleanable surfaces in the laundry room and 13 (2,6,10,11,14,16,19,20,21,23,26,28 and 29) of 28 resident rooms toured and one of one laundry room toured Findings included: 1. On 1/5/26 at 10:30 a.m., an observation of room [ROOM NUMBER] revealed the dresser drawers, to the left of the bed closest to the window, were coming off the tracks and slanted. The wall closest to the door had a linear groove, the length of the resident's bed, where paint was peeling and scraped off. Observations of the bathroom shared by room [ROOM NUMBER] and 17 had towels wrapped around the toilet which were brown-stained. The plunger on the floor next to the toilet had no bag over it. On 1/5/26 at 11:13 a.m., an observation of room [ROOM NUMBER] revealed the top drawer of the dresser was missing. Observations of the bathroom shared by room [ROOM…
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 · E2026-01-08 · tag F0585 — failed to handle grievances — patternHonor 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 record review and interview, the facility failed to implement its grievance process. The facility did not ensure resident's grievances from Resident Council were received, investigated, and a resolution provided or discussed for six of six months of resident council meeting minutes reviewed. Findings Included: Resident #9 said the residents are not sure who the Grievance Official is currently. The Grievance Official changes, and they must look at the paper on one of the office doors to find out the current person. The staff never discuss the rationale behind unresolved issues. We will look into it is the answer the residents receive all the time without any resolution. On 1/7/26 at 5:12 p.m., an interview with the NHA was conducted. She said the activities director had no documentation of the resident council minutes. She said the expectation is the activities director should document what occurred in the resident council meetings on the minutes. She then said the activities director has some notes and would provide copies of what documentation was completed. On 1/08/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review, the facility did not ensure the appropriate staff member referred one (#7) with serious mental disorder(s)/diagnoses to the State's Mental Health authority for Level II Preadmission Screening and Resident Review (PASRR) out of 18 residents sampled. A record review of Resident #7's admission Record showed an original admit date of 11/27/2025 with diagnoses to include but not limited to:Epilepsy, unspecified, not intractable , without status epilepticusAnxiety disorder, unspecifiedLatent syphilis, unspecified as early or lateBipolar disorder, current episode mixed, severe, with psychotic featuresMajor depressive disorder, recurrent, unspecifiedAlcohol abuse with intoxication, unspecifiedA record review of Resident #7's PASSR dated 01/27/2025 showed in Section A. MI or suspected MI (mental illness) (check all that apply) showed Substance Abuse as the only MI. On 01/08/2026 at 1:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility currently does not have a designated individual to screen,…
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 · D2026-01-08 · 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, record reviews, and interviews, the facility did not 1. Ensure a care plan was initiated for one (#4) of two residents reviewed for mental health diagnoses; and 2. did not ensure care plans were initiated and/or implemented for two (#34 and #23) of three residents reviewed for smoking.Findings include: 1. A review of Resident #4's admission record revealed an admission date of 04/04/2025, with diagnosis to include but not limited to, major depressive disorder, recurrent, unspecified. A review of Resident #4's annual minimum data set (MDS),for medications, dated 12/22/2025, revealed the following under high- risk drug classes: antidepressants usage. A review of Resident #4's physician's orders dated January 2026 revealed the following to include: -Setraline Hydrochloride (HCS) Oral Tablet 50 milligrams (mg), give 50 mg by mouth in the afternoon for depression. A review of Resident #4's care plan revealed no documentation of interventions or focus area related to major depression diagnosis.…
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 · D2026-01-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure activities of daily living, specifically nail care was provided for three (#5, 21, and 43) of six residents reviewed who required assistance with personal hygiene. Findings included: On 01/05/2026 at 9:30 a.m., observed Resident #21 sitting up in bed. Observed the resident had soiled, long fingernails. Observed scratches on their right upper arm. Resident #21 stated the wounds on their legs are due to lymphedema. The bandage on the right leg had a date of 01/02. On 1/7/2026 at 11:40 a.m., observed Resident #21 sitting in his bed. Resident #21 stated the facility does not cut his nails but wished the facility would. Observed several of the long nails had broken and were hanging on the nail bed. Review of admission Records showed Resident #21 was admitted to the facility on [DATE] with diagnoses including but are not limited to chronic obstructive pulmonary disease, muscle wasting and atrophy, and type 2 diabetes mellitus without…
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 before2026-01-08 · 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 reviews, the facility did not ensure weekly skin sweep evaluation were done for three (13, 36, and 5) out of three residents.Findings included: A record review of weekly skin sweeps for Residents #5, 13 & and 36 showed the following: Resident #5 had weekly skin sweeps on 12/06/2025, 12/18/2025 and 01/07/2026 with 12/18/2025 showed a skin impairment under right eye for discoloration.Resident #13 had weekly skin sweeps on 12/06/2025 and no further skin sweeps documented.Resident #36 had weekly skin sweeps on 12/06/2025 and no further skin sweeps documented. During an interview on 01/05/2026 at 9:20 a.m., Resident #13 stated her bottom is sore. Resident #13 said sitting in her wheelchair for an extended time as well feels her bottom hits the springs of the bed under the mattress. On 01/08/2026 at 9:33 a.m., an observation occurred with Staff D, Registered Nurse/Unit Manager (RN/UM) and Staff M, Certified Nursing Assistant (CNA) for skin sweep assessments for Residents…
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 before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility did not ensure residents were free from accident hazards for two (#34 and #23) of three residents reviewed for smoking as evidenced by residents not being evaluated, care plan interventions were not developed and implemented, and the smoking procedure/policy was not followed.Findings included: 1.On 1/7/26 at 11:27 a.m., an observation of Resident #34 revealed he was self-propelling in the wheelchair from the hall to the smoking area for the resident's designated smoking time. Further observations of the designated smoke time revealed Resident #34 took a cigarette that was on his lap and Staff E, Certified Nursing Assistant (CNA) proceeded to light his cigarette. Staff E, CNA was not observed providing him a cigarette from the facility's designated box where residents smoking materials are kept. An observation of Resident #34 revealed the bottom of a white and green cigarette box was seen coming out underneath his shirt. A review of Resident #34'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.
Show the remaining 14 citations
- Potential for harm · D2026-01-08 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record review the facility did not ensure narcotic medications were provided in a timely manner for three (#5, 10, and 18) out of three residents reviewed.Findings included: On 01/05/2026 at 10:15 a.m., an observation and interview was conducted with Resident #18. Resident #18 had stated her pain was a 9 out of 10 and she had not received her pain medication this morning or throughout the night. Resident #18 stated she was told the nurses are waiting for a prescription. On 01/05/2026 at 10:40 a.m., an interview was conducted with Staff K, Licensed Practical Nurse (LPN) assigned to Resident #18. Staff K, LPN stated the physician will be coming in sometime today to write a new prescription. Staff K, LPN acknowledged Resident #18 had not had her pain medication since last night and stated she gave the resident two Tylenol tablets and a Flexeril tablet. Staff K, LPN stated there was nothing else she could do but wait until the doctor comes in sometime today to re-prescribe the pain medication. On 01/05/2026 at 11:00 a.m., an observation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0925 — failed to control pests — isolatedMake 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 observations, staff and resident interviews, and record reviews, the facility failed to maintain an effective pest control management system in one (East Wing) of two Wings and in one (room [ROOM NUMBER]) of twenty-eight rooms.Findings Included: During an interview on 01/07/2026 at 11:14 AM, Resident #8 stated, The rooms have pests and we need someone to help us keep the bathrooms and rooms clean. During an interview on 01/08/2026 at 1:52 PM with Staff J, Certified Nursing Assistant (CNA) stated, If I see bugs, I will tell the Nursing Home Administrator (NHA) or the Director of Nursing (DON), however I don't use the bug book to report pest sightings. During an interview on 01/07/2026 at 1:24 PM the Regional Maintenance Director (RMD) stated, The gap in the pest control plan is that our pest log is not being utilized as it should be, and the company I believe is performing their tasks, but I still find live bugs throughout the building. We do not do any type of room round audit but were supposed to do…
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 before2023-12-14 · 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
On 12/13/2023 at 11:45 a.m. an ice chest on the [NAME] Hallway was observed to have brown and pink bio growth around the upper edge of the chest, the ice scoop was sitting in a tray with water and pink bio growth was observed in the corners. (Photographic Evidence Obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 12/13/2023 at 11:53 a.m. The ADON confirmed the ice chest had pink and brown bio growth around edges as well as in the ice scoop tray. The ADON stated, I thought they cleaned this yesterday with the ice machine, but I guess they did not. The ice chest and scoop should not be left like this. Review of the facility's policy titled, Cleaning and Sanitation, dated September 2021, showed, The facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. [sic] walls, floors, ceiling, equipment and utensils are clean, sanitized and in good working order. Based on observation and interviews the facility failed…
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 before2023-12-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to provide a clean and home-like environment for three resident shared bathrooms (Rooms 25/27, 12/13, and 14/15) out of 17 bathrooms sampled for environmental services. Findings included: 1. During an interview on 12/11/23 at 8:45 a.m. the resident in room [ROOM NUMBER] stated he had cleaned himself up today, so he washed his shorts out and hung them to dry in bathroom. An observation on 12/11/23 at 8:45 a.m. revealed a strong odor of feces. A pair of shorts soiled with a wet brown stain hung on the handrail in the shower of the bathroom shared between rooms [ROOM NUMBERS]. An additional observation showed a brown substance was smeared on the shower wall. (Photographic Evidence Obtained) During an interview on 12/11/23 at 9:00 a.m. Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated those shorts should not be hanging there. Staff A, LPN/UM was observed holding her nose and stated, that is a strong smell. An observation on 12/12/23 at 1:45 p.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.
- Potential for harm · Ecited before2023-12-14 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for 10 residents (4, 7, 15, 19, 22, 28, 31, 40, 42, 44) of 33 sampled residents. Findings included: 1. Review of Resident #4's admission Record revealed she was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and psychosis. Review of Resident #4's PASARR, dated 8/7/23, revealed qualifying mental health diagnoses of anxiety disorder and depressive disorder, and no PASARR Level II was required. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], Section I Active Diagnoses, revealed a diagnosis of anxiety disorder. Review of the Annual MDS, dated [DATE], and a Quarterly MDS, dated [DATE], Section I Active Diagnoses, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-14 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain accurate medical records related to insulin documentation for two residents (#28 and #27) out of four residents reviewed for medication administration. Findings included: 1. Review of Resident #28's admission Record revealed she was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus and diabetes mellitus due to underlying condition with hyperglycemia. Review of Resident #28's December 2023 Medication Administration Record (MAR) revealed a physician's order, with an order date of 9/11/23 and no end date, for insulin glargine subcutaneous solution. Inject 32 units subcutaneously at bedtime for antidiabetics. Review of Resident #28's December MAR revealed on 12/1/23, 12/2/23, 12/3/23, 12/5/23, 12/7/23, and 12/11/23 the medication was documented as NS. Review of Resident #28's November 2023 MAR revealed the same medication was documented as NS on 11/1/23, 11/3/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and record review the facility failed to ensure one resident (#27) out of 3 residents observed for insulin medication administration received care in accordance with professional standards of practice related to the time of administration of short acting insulin, in relation to the time the resident received her lunch meal. Findings included: Review of Resident #27's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include type 2 diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and lack of coordination. Review of Resident #27's physician's order revealed an order, with a start date of 2/23/23 and no end date, for Novolog Injection Solution 100unit/ml [Milliliters] inject per sliding scale: If 0-149= 0 Less than 60 call MD [Medical Doctor]; 150-200=2 [units] 201-250= 4; 251-300= 6; 301-350= 8; 351-400= 10 Greater that [sic] 401 given [sic] 12…
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 before2023-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure one resident (#35) out of four residents reviewed had a smoking evaluation completed to ensure safety during smoking. Findings included: During an interview on 12/11/23 at 7:44 a.m. Resident #35 stated the facility was supposed to let residents smoke at certain times but they make us wait and are about 15 to 20 late. Resident #35 stated, then once we get out there to smoke, we are then rushed to get done to come back in. An observation on 12/11/23 at 9:00 a.m. showed residents were exiting the door to the smoking designated area to smoke. Review of the facility's scheduled smoke times showed: 7:00 a.m. 9:00 a.m. 11:00 a.m. 1:30 p.m. 3:00 p.m. 5:00 p.m. 7:00 p.m. 9:00 p.m. An observation on 12/11/23 at 11:05 a.m. showed Resident #35 was outside smoking on the designated smoking area with supervision. Review of the admission Record showed Resident #35 was admitted to the facility with diagnoses including but not limited to chronic obstructive…
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 · D2023-12-14 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide intravenous (IV) care according to standards of practice for one resident (#40) out of one resident reviewed. Findings included: Review of Resident #40's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses not limited to Alzheimer's Disease, dementia, and pressure ulcer of unspecified site, unstageable. Review of Resident #40's physician orders revealed an order, with a start date of 12/11/23 and an end date of 12/16/23, for Cefepime intravenous solution 1gram/50ml [milliliters] .use 1 gram intravenously every 8 hours for wound infection for 5 days obtain midline for IV infusion. An intravenous medication administration observation with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), was conducted on 12/13/23 at 2:26 p.m. for Resident #40. Staff A, LPN/UM primed the IV tubing with cefepime 1 gram for 5-6 seconds, removed the IV tubing cap, cleaned the IV cap,…
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 · D2023-12-14 · 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 review the facility failed to ensure respiratory care and services was consistent with professional standards of practice for one resident (#4) out of 33 sampled residents. Findings included: Review of Resident #4's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease, morbid obesity, need for assistance with personal care, nasal congestion, and obstructive sleep apnea. Review of Resident #4's physician orders revealed an order with a start date of 12/2/23 and no end date for Oxygen at 2LPM [liters per minute] Via NC [nasal cannula] PRN [as needed] for shortness of breath. An observation was conducted on 12/11/23 at 9:17a.m. of Resident #4 receiving 2.5LPM of oxygen via a nasal cannula. (Photographic Evidence Obtained) An observation and interview were conducted on 12/12/23 at 10:48 a.m. as Resident #4 was observed to be in bed with her nasal cannula on.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-10-06 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that resident council meetings were facilitated and failed to provide and train a designated staff person to assist with providing for the council meeting process for July 2021, August 2021, and September 2021. Due to this failure, there was no resident council activity for those months. Findings Included: The Nursing Home Administrator (NHA) was interviewed about the resident council during the survey entrance conference conducted on 10/04/21 at 9:32 a.m. He confirmed there was a council and identified the president as Resident # 35. On 10/04/21 at 4:46 p.m., the NHA was asked to provide the minutes from the past 3 months of resident council meetings (July 2021, August 2021, September 2021) after gaining permission from the council president. On 10/05/21 at 11:41 a.m., a follow up interview was conducted with the NHA to provide the requested minutes. He explained that there were no minutes for the months requested because there had been 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.
- Potential for harm · Ecited before2021-10-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that resident food was stored under sanitary conditions in one of one refrigerator/freezer designated for resident food storage The facility failed to ensure that foods were labeled properly and discarded for food safety, failed to ensure no staff food was stored with resident food items, and failed to monitor the refrigerator/freezer for safe food storage temperatures. A tour of the facility resident nourishment pantry areas was conducted on 10/5/21 at 12:00 p.m. with Staff C, Registered Nurse (RN), Unit Manager (UM). She confirmed that there was only one refrigerator/freezer in the facility used for storage of resident's personal food, including food brought in by visitors and family. She revealed the refrigerator/freezer was located in the main dining room. Observation of the refrigerator/freezer revealed a typed sign posted on the freezer compartment that read STAFF ONLY. Staff C immediately removed the sign during the observation but replaced it upon request for photographic evidence to be…
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 · D2021-10-06 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 reviews, the facility failed to implement an ongoing resident centered activities program that incorporated the residents' interests for two (Resident #16 and Resident #24) of two sampled residents investigated for activities. Findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses of acute kidney failure, dysphagia, urinary tract infection, adult failure to thrive, neuromuscular dysfunction of bladder, hypertension, hydrocephalus, neoplasm of bladder, convulsions, anxiety, and major depressive disorder. On 10/4/21 at 11:17 a.m., Resident #16 was observed seated in a wheelchair in his room. The resident indicated he had been at the facility for several months due to the unavailability in the Veterans Administration long term care facilities. He was watching a small television in his room. Resident #16 stated that there were not a lot of activities to get involved in at the facility. He stated he would like to get access to books and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-10-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 record review and interview, the facility failed to ensure that behavior and side effects monitoring was recorded for two (Residents # 50 and #28) of five sample residents who were reviewed for unnecessary medications. Findings included: 1. Resident #50 was originally admitted to the facility on [DATE] with the primary diagnosis of end stage renal disease. Other pertinent diagnoses included but were not limited to anxiety disorder, major depressive disorder, unspecified convulsions, and bipolar disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE], section C (Cognitive Patterns) reflected a Brief Interview for Mental Status (BIMS) of 15 indicating that Resident # 50's cognition was intact. A review of the active physician orders dated 10/04/21 for Resident # 50 included the psychotropic medications Risperidone tablet 1 mg (milligrams) by mouth one time a day for mood disorder. There was no physician order for the monitoring of behaviors or for the monitoring of side effects related 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SENIOR HEALTH SOUTH — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 1.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 3 of 5 | 3.8 | -0.8 vs chain |
The other 7 homes this chain runs (chain average 1.9★, 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 |
|---|---|---|---|---|
| SENIOR HEALTH PROPERTIES SOUTH, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/23/2002 |
| SENIOR HEALTH SOUTH EX LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/26/2025 |
| DEPIANO, RICH | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| JAFFE, HOWARD | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| MULLEN, ANN | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| RICHMOND, PENNY | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2025 |
| ELEUS HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/07/2025 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/26/2025 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| MADZVIMBO, NOREST | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/13/2019 |
| MCFARLANE, MARCEA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| OMEGA HEALTHCARE INVESTORS, INC | Organization | ADP OF THE SNF | — | since 07/01/2003 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 21 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 $246K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105713. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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