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Balanced Healthcare

4250 66th St N, Saint Petersburg, FL 33709 · For profit - Limited Liability company · 299 certified beds · (727) 546-2405 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 2024Behavioral-health or dementia-care citation — no harm found (F0758)3 immediate-jeopardy citations$98,540 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $98,540 in federal fines (most recent 2024-02-14)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • about 20% of its spending goes to commonly-owned related companies

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) 4 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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
3900 66th St N · (727) 343-9265 · Call to confirm hours
Pharmacy
4404 66th St N · (727) 513-1107 · Call to confirm hours
Grocery
Save A Lot<0.1 mi
4380 66th St N · (727) 544-6820 · Call to confirm hours
Park
6201 40th Ave N · (727) 723-4906 · Typically dawn to dusk
Place of worship

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 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased9.4%8.7%15.4%better
Long-stay residents who lose too much weight4.8%5.5%5.4%better
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 symptoms0.9%4.6%6.5%better
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 injury5.0%2.5%3.3%worse
Long-stay residents whose ability to walk worsened8.8%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication27.2%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.9%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control14.4%10.5%21.2%worse than state — see note marked double-dagger below the table
Short-stay residents who newly got an antipsychotic medication8.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine91.3%94.7%79.4%better
Short-stay residents rehospitalized after admission34.5%26.1%22.6%worse
Short-stay residents with an outpatient ER visit13.5%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.252.131.67worse
Long-stay outpatient ER visits per 1,000 resident days2.921.151.80worse

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.

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.

21.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

21.4%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
63.0%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 63.0% 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 119 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF21.4%CMS range 13.8–31.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.0–15.310.7%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 discharge63.0%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 discharge49.6%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 discharge49.6%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 identified98.0%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 setting98.8%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 stay2.9%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 worsened3.9%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 hospitalization10.5%CMS range 6.9–14.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.351.02Oct 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

0.36
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.85
Total nurse hours/ resident / day
0.24
RN hoursweekends
34.3%
Total nursing turnover
39.1%
RN turnover

How full it usually is: this home is certified for 299 beds and averages 259.7 residents a day — about 87% occupied, or roughly 39 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 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.62 hrs/resident/day on weekends vs 3.94 on weekdays — 8% thinner on weekends. RN hours go from 0.41 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

7
deficiencies at the latest standard inspection (2024-11-07)
12
at the previous standard inspection (2022-06-30)

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

Inspection deficiencies

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

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.

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

  • Immediate jeopardy · J2024-02-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse to one (Resident #1) of three residents reviewed, by failing to provide medication and supervision to an unsafe resident. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. Resident #2 required two psychiatric medication changes in the first five days of his stay in the facility and four days later he assaulted Resident #1. Resident #2's admission medication was not correctly transcribed and of the two medication changes made only one was administered, and that one, only once. This failure created a situation that…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-02-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to ensure adequate supervision to prevent physical and psychosocial harm to one (Resident #1) of three residents reviewed. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA…

    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
  • Immediate jeopardy · Jcited before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policies and procedures review, interviews with facility staff, Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA), Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Medical Director (MD), the facility failed to provide supervision during meal service to prevent choking for a vulnerable resident (#1), who was on a puree diet and had previously attempted to gain access to foods not on his prescribed diet, out of 12 sampled residents for dietary needs. On 08/13/2023 Resident #1, who was on a puree diet for a diagnosis of dysphagia, accessed a roommate's food tray. On 08/13/2023 during the dinner meal service, Resident #1 was observed attempting to access food trays from the tray cart when the cart was delivered to the floor and was redirected by staff. Resident #1 was witnessed by staff attempting to access trays from the tray cart again after the meal and was redirected back to his room. In his room, Resident #1 accessed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to provide adequate supervision to two (#4 and #5) of two residents which resulted in an physical altercation perpetrated by one resident (#4).Findings included:Review of the facility's reported incident log showed a resident - resident physical abuse incident had occurred on 3/8/26 between Resident #4 and Resident #5.On 3/26/26 at 10:37 a.m. Resident #5 was observed in room lying on bed with eyes closed.Review of Resident #5s progress notes showed a note dated 3/8/26 at 10:11 p.m. The note referred to a linked incident: Resident to Resident 3/8/26 at 4:20 p.m. go to incident. The note revealed Staff C, Licensed Practical Nurse (LPN) was sitting at desk charting with staff members then writer looked up and see (Resident #5) get hit on the right side of the face by another resident. CNA and writer got up and redirected resident to room, (Resident #5) stayed in his chair till we came to check on him, (Resident #5) has no complaints of pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · 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 observations and interviews, the facility did not ensure a clean, sanitary, and homelike environment for three (1 [NAME] [also known as the secured unit], 1East, and Lifestyle 2) out of six Wings. Findings included: On 11/4/24 at 10:13 a.m., a tour of the 1 East wing was conducted. Observations of room [ROOM NUMBER] revealed the privacy curtains between bed A and B with stains and dirty. Further observations of room [ROOM NUMBER] revealed paint was peeled from the ceiling above the window. An observation of the bathroom shared by rooms [ROOM NUMBERS] revealed a detached shower head, white washcloth, and a light cover fixture on the shower seat. Further observations of the floor of the shower revealed multiple unknown particles and debris that were black and white colored. Further observations of the bathroom revealed multiple brown stains on the seat of the toilet. On 11/4/24 at 10:27 a.m., an observation of room [ROOM NUMBER] revealed two dresser knobs were separated from the drawer. An observation of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-07 · 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 observation, record review and interview, the facility did not ensure Enhanced Barrier Precautions (EBP) were initiated for three (#163, #138, and #237) of four residents sampled. Findings included: 1. On 11/04/2024 at 9:25 a.m., an observation was made of Residents #237. Resident #237 was in his room with a 1:1 sitter. Resident #237's room had a sign on his door for EBP. The signage was unclear on which resident was on EBP. Staff F, Registered Nurse, stated Resident in bed A was on EBP secondary to a wound. Resident #237 did not have an order for Enhanced Barrier Precautions. A review of Resident #237's physician orders showed the following: Sacrum: Cleanse with normal saline, apply collagen with calcium alginate to wound bed, cover with border foam gauze daily every day shift for pressure ulcer, dated 10/31/2024. 2. On 11/04/2024 at 10:00 a.m., an observation was made of Resident #163. Resident #163 had an intravenous (IV) medication infusion into a venous access catheter to his left arm. Outside Resident #163's room there was no signage for EBP or any personal protective…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · 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 observation, record review and interview the facility did not implement a comprehensive person-centered care plan consistent with resident rights for one resident (#51) out of eight residents sampled. Findings included: On 11/04/2024 at 10:30 a.m., an observation and interview were conducted with Resident #51 in her room. Resident #51 stated she did not consistently get her bath twice a week and had not had her hair washed in over two months. Resident #51 stated she would like to have a bath consistently at least twice a week and would like to have her hair washed. Resident #51 stated she had asked for this but stated she did not get this offered to her. Resident #51 preferred to stay in bed and have a bed bath and stated she did not know how they would wash her hair. A review of Resident #51's admission Record showed diagnoses: Bipolar disorder Type 2 diabetes mellitus Depression Essential hypertension Post-traumatic stress disorder, chronic Paranoid schizophrenia Muscle weakness, general Morbid…

    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 · D2024-11-07 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not honor the wishes for Activities of Daily Living (ADL) related to bathing of body and hair for two residents (#51 and #100) out of eight residents sampled. Findings included: 1. On 11/04/2024 at 9:30 a.m., observations and interviews were conducted with Resident #51 and #100. Resident #51 stated she had not consistently received her baths in weeks and her hair had not been washed in over a month. Resident #51 stated she preferred bed baths and stated baths were scheduled three times a week but could not state the days. Resident #100 stated she did not get her baths three times a week and her hair had not been washed in over a month. Resident #100 stated she preferred to have bed baths. A review of the facility's 30-day bathing task showed Resident #51 had three baths in 30 days. Resident #51's bathing schedule on the bathing task showed shower/bath every Monday, Wednesday and Friday during the 3-11 shift. A review of Resident #51's Minimum Data Set (MDS)…

    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 before2024-11-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on observations, interviews, and record reviews, the facility failed to provide quality care and services related to wound care management and treatment for two (#377 and #378) out of three sampled residents. Findings included: 1. Review of Resident #378's admission Record revealed he was admitted to the facility with medical diagnoses of congestive heart failure, dementia with behavioral disturbances, unsteadiness on feet, cellulitis of other sites, mood affective disorder, and anxiety disorder. An observation was conducted on 11/04/24 at 10:30 AM. Resident #378 was observed sitting in the hallway in a recliner chair. He was observed to have bandages on his bilateral upper arms. He said he got the injuries from slipping and falling at home. He said he was not sure how often they changed the bandages. His left upper arm bandage was dated 11/4 and was clean and intact. The right upper arm bandage was intact and clean but dated 10-31. An observation was conducted on 11/4/24 at 3:39 PM. Resident #378 was observed self-propelling in his wheelchair down the hallway. His right upper…

    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 before2024-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure smoking adaptive equipment was provided for one (#42) of 11 residents sampled. Findings included: During an observation made on 11/4/2024 at 10:15 a.m. and 11/6/2024 at 2:20 p.m., Resident #42 was observed outside smoking without using a smoking adaptor. Resident #42 said he did not use smoking adaptive equipment while smoking. Review of an admission Record dated 11/ 7/2024, showed Resident #42 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinsonism, unspecified, Type 2 Diabetes, Aute Respiratory Failure, and Paranoid Schizophrenia. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Review of Resident # 42's care plan revised on 9/13/2024, showed the resident was at risk for smoking injuries to self - related to use of cigarettes. The care plan goals showed Resident #42 will…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide enteral nutrition according to standards of practice related to expired nutritional formula for one resident (#246) out of one resident sampled. Findings included: On [DATE] at 12:11 p.m., an observation of Resident #246 revealed he was laying down in bed, with a family member at the bedside. On the left side of the bed, there was a pole and enteral feeding pump observed. An observation of the pole and enteral feeding pump revealed there was no tube feeding bag or container hanging. Further observation revealed the pump was off. An observation of the small dresser, to the left of Resident #246's bed, revealed three, 8-ounce bottles of TwoCal HN [high nutrient] 2.0 formula with a date observed at the top which indicated the following, 1 SEP 2024. A review of Resident #246's admission Record revealed an original admission date of [DATE] and a re-admission date of [DATE]. Further review of the admission Record revealed diagnoses to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-30 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and the Ombudsman for five residents (#24, #161, #188, #221, and #95) of five residents sampled for hospitalization. Findings included: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was re-admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease, Diabetes Mellitus, Malnutrition, and Hypertension. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer…

    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 · E2022-06-30 · tag F0625 — pattern
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 reviews the facility failed to provide written notification of Bed Hold Policy to Resident/Resident Representatives for five residents (#188, #24, #221, #161, and #95) of five residents sampled for hospitalization. Findings include: On 6/28/22 at 10:44 a.m. Resident #24 was observed lying in the bed in his room. The resident was able to answer simple questions. The resident was observed with a hospital armband on and denied being hospitalized recently. A review of the medical record revealed Resident #24 was re-admitted to the facility on [DATE] with diagnoses including but not limited to Parkinson's Disease, Diabetes Mellitus, Malnutrition, and Hypertension. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. A review of the nursing progress notes revealed the following entry: 6/4/22 8:47 p.m. At approximately 4 pm staff notified writer that resident had loose…

    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
Show the remaining 15 citations
  • Potential for harm · Ecited before2022-06-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, the facility failed to 1. Adequately supervise thirty-two sampled residents to include resident (#193 and #10); and who reside in one of six units (LS1 [NAME] Secured) unit, during two of four days observed, on (6/27/2022, and 6/28/2022). It was determined Resident #193 was standing and walking out in the main hallways disrobed and not wearing any clothing on her lower part of her body, and with no staff supervision for long periods of time; 2. Failed to assure fall floor mats were placed while residents #721, #670, and #184 were in bed. Findings included: 1. On 6/27/2022 at 9:30 a.m. an interview with the Nursing Home Administrator and the Director of Nursing (DON) revealed the LS1 [NAME] unit is a Secured Unit, that houses thirty-two residents who either have diagnosis of Dementia and or Alzheimer's. The Administrator and DON further indicated the residents in that unit are in need of continual supervision and many who walk and wander throughout 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-06-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, staff interview, and record review, the facility failed to ensure the kitchen and kitchen equipment were sanitary and maintained during four of four days observed (6/27/2022, 6/28/2022, 6/29/2022, and 6/30/2022). The kitchen was observed with peeling and chipped paint on equipment over the food preparation tables, rusted pipes and ducts that were over food preparation areas, food not stored appropriately in the walk-in refrigerator, pools of raw meat blood on the floor of the walk-in refrigerator, and refrigerator motor housing dripping rust color liquid on a vented bag of onions. Findings included: On 6/27/2022 at 10:00 a.m., 6/28/2022 at 11:00 a.m., 6/29/2022 at 11:00 a.m., and 6/30/2022 at 9:30 a.m., kitchen tours were conducted with the Dietary Manager. During the tours of the kitchen, the following was observed: 1. The overhead metal duct work directly above the table where clean dishes come out from the dish washing machine was observed heavily peeling and chipping. There were pieces of the chipped and peeling paint on the top surface of the actual dish…

    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 · Dcited before2022-06-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one resident (#193) out of eleven sampled residents who had intellectual and or developmental disabilities, was dressed in a dignified manner during two days (6/27/22 and 6/28/22) of four days observed while in the LS1 [NAME] Secured unit. It was observed staff did not intervene to assist Resident #193 who disrobed and was standing out in the hallways for long periods of time. Findings included: On 6/27/2022 at 9:30 a.m. an interview with the Nursing Home Administrator and the Director of Nursing (DON) revealed the LS1 [NAME] unit is a Secured Unit, that houses thirty-two residents who either have diagnosis of Dementia and or Alzheimer's. The Administrator and DON further indicated the residents in that unit are in need of continual supervision and many who walk and wander throughout the unit and with some going in and out from other resident rooms. On 6/27/2022 at 11:30a.m. the LS1 [NAME] secured unit was entered for tour…

    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 · D2022-06-30 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 one resident (#143) was free from the use of restraints out of one sampled resident for restraint usage. Findings included: On 6/27/22 at 12:02 p.m., Resident #143 was observed in her room sitting in a high back wheelchair with a black thigh belt across her thighs. When an attempt to interview the resident was conducted Resident #143 would not speak. On 6/28/22 at 10:00 a.m., Resident #143 was observed in her room sitting in the high back wheelchair with a black thigh belt across her thighs. A review of the admission Record indicated Resident #143 was readmitted into the facility on 6/10/22 with a primary diagnosis of Huntington's Disease and other diagnoses included but were not limited to schizophrenia, abnormal posture, bipolar disease, mood disorder, and history of falling. A review of Section C: Cognitive Patterns of the Annual Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely/never understood. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0679 — failed to provide activities — isolated
    Provide 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 observations, interviews, and record review the facility failed to provide an activities program based on the comprehensive assessment and care plan for one resident (#212) of one sampled for activities. Findings included: Multiple observations were made of Resident #212. On 6/27/22 the resident was observed throughout the morning and at 2:10 p.m. in a specialized chair placed in a semi-reclined position with a foot plate positioned in the hallway against the wall outside of his room. He was awake and alert. On 6/27/22 at 2:14 p.m. Resident #212 gestured upon approach and said bed. He was asked if he wanted to go to bed and he nodded. On 6/27/22 at 2:17 p.m. the resident was observed gesturing to a Certified Nursing Assistant (CNA) who was walking in the hallway and saying bed. The CNA continued walking down the hallway. On 6/27/22 at 2:41 p.m. the resident was observed still in the hallway, awake and alert. On 6/28/22 at 10:05 a.m. Resident #212 was observed in his room in bed, he was awake and alert,…

    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 before2022-06-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on observation, interviews, and medical record review the facility failed to provide care and services four wound care of ulcers to one resident (#211) out of one sampled for wound care. Findings Included On 6/27/22 at 10:18 a.m. Resident #211 was observed sitting in the hallway with both of his feet wrapped with a thick white kerlix dressing. The dressing to his left foot contained bright yellow moist drainage noted to be the size of a soft ball. The yellow drainage was surrounded by a dark brown color dried drainage. The resident had no socks or shoes covering the dressing and both of his feet rested on floor surface. On 06/28/22 at 9:55 a.m. Resident #211 was observed in the hallway speaking with Staff M, Physical Therapist. She said Resident #211 had just finished his therapy session and she was going to transport him back to his bedroom. Resident #211's bilateral feet appeared as the same soiled dressing from the day prior. Staff M confirmed the dressing to his feet contained the date of 6/26/22. Resident #211 was alert and stated, the dressing are not changed daily. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure orders were followed related to catheter care for three residents (Resident #207, #188, and #218) out of the sampled five residents. Findings included: 1. On 06/27/22 at 11:52 a.m., Resident #207 was observed in bed in his room. There was a very offensive urine odor in the room. The resident had a catheter, and the tubing was observed with thick gray sediment. On 06/28/22 at 9:53 a.m., Resident #207 was observed in bed in his room. There was a strong urine odor in the room. The catheter tubing appeared unclean, with thick grey sediment. On 06/30/22 at 10:25 a.m., Resident #207 was observed in bed in his room. The catheter tubing was observed with thick gray sediment and tan clots and there was a very strong urine odor in the room. A review of the admission Record indicated Resident #207 was initially admitted into the facility on [DATE] with diagnoses that included but were not limited to cerebral palsy, disorder of urea cycle…

    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 before2022-06-30 · 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 observations, interviews, and record reviews the facility failed to ensure behavioral and side effect monitoring was conducted with the use of psychotropic medications for one resident (#188) of five resident sampled for unnecessary medications. Findings included: 6/27/22 at 12:30 p.m. Resident #188 was observed seated quietly in a wheelchair by the nurse's station. He was unable to answer questions related to care and services. Resident #188 was admitted to the facility on [DATE] with a diagnosis of dementia, anxiety, mood disorders, major depressive disorder, bipolar, insomnia, and psychosis. A review of the Order Summary Report dated 6/29/22 revealed Resident #188 was prescribed the following medications: -Divalproex Sodium tablet delayed release 250 mg (milligrams) give one tablet by mouth two times a day for anxiety. -Lorazepam tablet 1 mg give one by mouth three times a day for anxiety. -Melatonin tablet 3 mg give two tablets by mouth at bedtime for insomnia. -Paroxetine Hydrochloride tablet 10 mg…

    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 · D2022-06-30 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy reviews facility failed to 1) properly secure one of twelve medication carts, two of six narcotics boxes, and prescription medication for three residents (#14, # 47, and # 49) and one unknown resident and 2) ensure one of six refrigerators was at a proper temperature for medication storage. Findings include: On 6/27/2022 at 10:50 a.m. the 1 [NAME] (Secured Unit) was entered for a tour. The nurses' station area was observed with six residents standing up and ambulating in the hallways. There were four additional residents seated in various chairs across from the nurse station as well. Residents in this unit are monitored and supervised routinely and have cognitive inabilities where they cannot speak to their medical care and daily routines. At 11:00 a.m. the nurse station area was still observed with approximately 6-8 residents either standing at and near the station or seated in chairs across from the station. There were no staff in the immediate area. Further…

    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 · D2022-06-30 · tag F0885 — failed to notify residents/families about COVID-19 — isolated
    Report COVID19 data to residents and families.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, medical record review, and facility policy review the facility failed to notify two resident representatives (# 79 and 105) by 5:00 p.m. on the calendar day once a COVID-19 positive case was confirmed by the facility out of three residents sampled for notifications. Findings Included: On 6/30/2022 at 3:15 p.m. an interview was conducted with the Director of Nursing (DON) who verbalized the last three residents that had tested positive for COVID-19 at the facility. A review of Resident #79's medical record contained a copy of a Lab Results Report which revealed a positive result of COVID-19 dated 6/22/2022. A review of Nursing Progress Notes dated 6/22/2022 at 11:46 p.m. read the resident was transferred to the isolation unit. The medical record did not reflect documentation of the emergency contact being notified of the change in condition. A medical record review for Resident #105 contained a copy of laboratory results which revealed a positive test for COVID-19 on 6/22/2022. A review of Nursing Progress notes dated 6/22/2022 indicated the resident had a 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to treat residents with respect and dignity for two (Residents #167 and #102) of sixty one sampled residents related to the lack of privacy for Resident #167 that was left in bed unclothed and Resident #102 that did not have a privacy cover on his urinary drainage bag. Findings included: 1. On 03/02/21 at 1:01 p.m., Resident #167 was observed in bed completely nude without anything covering him. Resident #167's roommate was in the room in his bed at this time. The resident could be seen unclothed with his entire body exposed from the hallway. Staff N, Certified Nursing Assistant (CNA), stated, That's what he likes to do. Staff N, CNA, did not attempt to cover the resident. A privacy curtain was not observed in the room. On 03/04/21 at 2:23 p.m., Resident #167 was observed in bed unclothed from the hallway. A privacy curtain was not observed in the room. Staff O, Housekeeping, was outside of the room at this time and stated, He is like…

    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 · D2021-03-05 · tag F0573 — isolated
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    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 resident interviews, staff interviews, and policy review, the facility failed to honor a request for one (Resident #553) of two sampled residents to obtain copies of their medical record. Findings include: A medical record review was conducted for resident #553 and revealed that the resident had been admitted to the facility on [DATE] with a discharge date of 6/22/2020. During a telephone interview with Resident #553, she reported that at various times she had requested a copy of her medical records. Resident #553 reported that she had made a request for her medical records at the time of her discharge and during several follow up calls. The facility had not responded to her requests as of 03/05/21. On 03/05/21 at 10:00 a.m., an interview was conducted with the Social Service Director who confirmed that the resident had called her several times requesting a copy of her medical records, however, she did not work in medical records, so she would transfer the calls to medical records department. 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · 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

    Based on observations, policy review, and staff interview, the facility failed to ensure a safe, clean, comfortable and homelike environment as evidence by, chipped paint, broken cabinet doors, a missing cabinet drawer, and dusty ceiling vents at the entrance to the kitchen and in nourishment rooms on three (1 East, 2 East, and Lifestyle 2) of five occupied units. Findings included: On 03/02/21 starting at 9:51 a.m., a tour of the kitchen and the nourishment rooms was conducted with the Certified Dietary Manager (CDM). Chipped paint was observed around the ceiling vent above the entry door to the kitchen. The CDM stated that the chipped paint was probably from condensation. The 1 East nourishment room was observed with broken cabinet doors and a dusty ceiling vent. The Lifestyle 2 nourishment room was observed with a missing cabinet drawer. The 2 East nourishment room was observed with an excessive amount of dust on the ceiling vent (photographic evidence obtained). Observations were confirmed by the CDM. The policy Preventative Maintenance Program undated revealed the following: 2.…

    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 · Dcited before2021-03-05 · 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 observation, interview, and record review, the facility failed to implement a care plan for three (Residents #102, #152, and #52) of 61 sampled residents related to 1). A urine catheter for Resident #102, 2). A wander alarm for Resident #152, and 3). Nutritional behaviors for Resident #52. Findings included: 1. On 03/04/21 at 2:06 p.m., an observation of Resident #102 revealed that he had an indwelling urine catheter. Review of the clinical record for Resident #102 showed an admission date of 03/29/2019 and diagnoses that included, Dementia, Parkinson's Disease and Neuromuscular Dysfunction of Bladder, as per the admission face sheet. The 5-day Minimum Data Set (MDS) dated [DATE], revealed under Section H the resident had an indwelling urinary catheter; and under Section I had a diagnosis of Neurogenic Bladder. Further review of the clinical record revealed no documentation of the indwelling urine catheter on the Care Plan, as well as no interventions or goals for the catheter and care. Review of 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-03-05 · 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 observation, interview, and record review, the facility failed to ensure behavioral monitoring for psychotropic medications was performed for one (Resident #82) of five residents reviewed. Findings included: Record review for Resident #82 revealed an admission date of 12/24/2020 and diagnoses that included dementia, mood disorder and anxiety as per the admission face sheet. The admission Minimum Data Set (MDS) dated [DATE] showed under Section C a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment; Section E, delusions [yes]; Section I, diagnosis of Anxiety; and Section N, antipsychotics and antidepressants were received during 6 of the past 7 days. Review of the Care Plan revealed foci that included: 1) [Resident] has a mood problem, with interventions that included administer medications as ordered, monitor/document and report increased anger, labile mood or agitation, feelings of being threatened by others, thoughts of harming someone; and, 2) Psychotropic…

    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

“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

$98,540 in federal fines across 1 penalty.

  • $98,540 — penalty dated 2024-02-14

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$24.0M
Net patient revenuemost recent cost report
+0.7%
Operating marginrevenue minus expenses
$4.8M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 11%Other / private 6%

About 84% 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 $4.8M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$270per resident / day
operating cost
$8,217per month
≈ monthly operating cost
$272per 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 105390. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-07, 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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