Lexington Healthcare And Rehabilitation Center
6300 46th Ave N, Saint Petersburg, FL 33709 · For profit - Limited Liability company · 159 certified beds · (727) 544-1444 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,345 in federal fines (most recent 2025-07-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 2.2% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.3% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 4.4% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.1% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 5.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.6% | 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 | 3.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.3% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.7% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.61 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.40 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.8% 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 177 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 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 46.4%CMS range 36.5–53.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.5–13.8 | 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 | 58.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 53.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 46.9% | 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 | 100.0% | 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 | 0.8% | 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 | 0.0% | 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 | 9.0%CMS range 4.9–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.15 | 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 159 beds and averages 141.4 residents a day — about 89% occupied, or roughly 18 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.23 hrs/resident/day on weekends vs 3.55 on weekdays — 9% thinner on weekends. RN hours go from 0.40 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2025-07-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement interventions and provide supervision to prevent accidents/injuries to residents related to: 1) failure to prevent a fall with injuries for one resident (#56) out of four residents reviewed for falls; and 2) failure to ensure a safe environment for residents to smoke for two residents (#21, #41) out of two residents who required the use of a wheelchair. Residents were expected to sign a leave of absence (LOA) form and then navigate off facility grounds, unassisted, through the parking lot approximately 350 feet, over a large speed bump, and across large potholes, despite being assessed to require supervision during ambulation or requiring the use of a wheelchair. Findings included: 1. A review of the medical record for Resident #56 revealed a progress note dated 07/02/2025 at 6:35 a.m. “Resident attempted to get oob (out of bed) without assistance, found with left leg stuck inside rail and face on the floor, noted moderate…
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 · F2025-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner in one kitchen (Main) of one kitchens observed during survey.Findings included:During the initial tour of the kitchen conducted with the Certified Dietary Manager (CDM) on 07/14/2025 from 9:59 a.m. to 10:25 a.m., concerns were identified related to the following:The filter in the juice machine was observed with dirt and debris. An immediate interview with the CDM revealed she did not know how the filters can be cleaned. She stated they would have to order new filters and the vendor would install.The juice machine equipment was observed with brown - coloring and stains on the surface of the stainless-steel surfaces. The CDM stated the surfaces are rusted and there was no way to clean them.The ceiling filters were observed with stains, dust and dirt, located above food prep and food service areas.The light by the food prep area was observed with brown stains and bio-growth.An observation was made of water leaking close to the light fixture above the food service…
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 · E2025-07-17 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) for five residents (#107, #86, #18, #43 and #102) of seven residents sampled.Findings included: 1. On 07/16/2025 at 9:13 a.m. Resident #107 was observed with long fingernails and hair on her chin. She stated she would like to be assisted with trimming her nails and shaving her face. She stated she preferred her nails short and clean. She stated the Certified Nursing Assistants (CNA’s) say they will help, but then they do not. Review of the admission record for Resident #107 revealed she was admitted to the facility on [DATE] with diagnoses to include dementia. Review of Resident #107’s quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment. Section GG - showed the resident required partial/moderate assistance (Helper does…
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 · E2025-07-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide incontinence care and prevent a Urinary Tract Infection (UTI) for one resident (#150) out of three residents sampled.Findings Included: During a phone interview on 07/15/2025 at 5:15 p.m., Resident #150 Family Member (FM) stated Resident #150 has been in and out of the hospital related to UTI's, multiple times. When she picks up Resident #150's laundry it is soaking wet. Maybe if they changed her more often, she would not have so many UTI's. When she goes to the hospital and they do lab work it shows E. coli [Escherichia coli] in her urine. Review of Resident #150's admission record revealed an admission date of 06/01/2022. Resident #150 was admitted to the facility with diagnosis to include Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Urinary Tract Infection, Site Not Specified, Major Depressive Disorder, Recurrent, Moderate, Parkinson's Disease Without Dyskinesia, Without Mention of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections as evidenced by 1) failure of staff to provide appropriate incontinence care by two staff members (Staff A, Staff B); 2) failure to implement policies related to staff use of artificial fingernails and containment of long hair for two staff members (Staff K, Staff S); and 3) failure to ensure staff donned Personal Protective Equipment (PPE) in a contact isolation room for two staff members (Staff AA, Staff AB) out of six staff members observed. The findings included: On 7/16/25 at 9:51 AM, an observation was made of Staff B, Certified Nursing Assistant (CNA), providing incontinence care to Resident #7. The resident had a urinary catheter and had been incontinent of stool. The CNA was observed to use cleansing wipes to clean the resident's peri area, then using the same wipes, she cleaned the resident'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 · D2025-07-17 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of enteral nutrition was completed for one resident (#125) out of one resident reviewed.Findings included:On 07/16/2025 at 1:11 p.m. Resident #125 was observed in his room administering his enteral nutrition independently into his gastrostomy tube (g-tube). The resident's head of bed was observed to be flat. Resident #125 stated the nurses give him his enteral nutrition during the scheduled meal times. He stated he self-administers the enteral nutrition into his g-tube.Review of the admission record for Resident #125 revealed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of thyroid gland, unspecified severe protein calorie malnutrition, gastroesophageal reflux disease and gastrostomy status.Review of Resident #125's quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #125 had a brief interview for mental status (BIMS) score of 15 out 15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report allegations of serious injury of unknown source and neglect for one resident (#56) of two residents sampled.Findings included: A record review for Resident #56 revealed she had an unwitnessed fall on 07/02/2025. Review of the nursing progress note dated 07/02/2025 revealed the resident had attempted to get out of bed without assistance and was found “face on the floor” with a moderate amount of blood on her facial/nose area. The resident was transferred to a local hospital via Emergency Medical Services (EMS) where she was diagnosed with a skull fracture. The resident was care planned for falls with interventions that included “Utilize total mechanical lift with staff assist of 2 for transfers”. “Remind resident to request assistance prior to ambulation/transfers as needed”. “Keep call light within reach.” Further review of the medical record revealed she was admitted to the facility on [DATE], with diagnoses to include cognitive communication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify a resident and the resident's representative of a hospital transfer in writing prior to the transfer for one resident (#149) out of four residents reviewed.Findings included: During an interview on 07/14/2025 at 12:10 p.m., Resident #149 stated she just returned from a hospital stay. “The hospital wanted me to stay until Saturday, but I told them I had to be back to the facility on Friday so that my bed at the facility was not given away. I don’t remember being given anything explaining my options for holding my bed before I went to the hospital.” Review of Resident #149's Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Resident #149’s admission record revealed a readmission date of 07/11/2025 from an acute care facility. Resident #149 was admitted to the facility with diagnosis to include chronic obstructive pulmonary disease (COPD) with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to notify the state mental health authority/state intellectual disability authority after a significant change in the mental or physical condition of a resident who has mental illness for one resident (#3) of nine residents reviewed.Findings included:Review of Resident #3's electronic medical record revealed an original admission date of 02/10/2021 and a Preadmission Screening and Resident Review (PASRR) dated 02/08/2021 provided by the hospital pre-admission. In section 3, this is documented as a non-provisional admission, and section 4 is documented as no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR not required. A PASRR Resident Review- Evaluation Request, dated 04/23/2023, was present with no signatures and no evidence of a level II request for evaluation from the state agency.Review of Resident #3's diagnoses list revealed a diagnosis of major depressive disorder on 10/29/2024. Further review revealed a request for a psychiatric meeting dated 10/29/2024, with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · 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 failed to implement patient-centered interventions related to adaptive dining equipment to promote independence while eating per occupational therapy and physician order for one resident (#13) out of one resident reviewed. Findings included: On 07/16/2025 at 12:29 p.m. Resident #13 was observed in the room wearing a clothing protector with an opened meal tray on the overbed table in front of the resident. The resident was observed holding a regular everyday eating fork. The resident stated a staff member was supposed to get weighted silverware, but they hadn't been sending one with the meals. Review of Resident #13s admission Record showed the resident was admitted on [DATE] and 02/05/2025. The record included diagnoses not limited to Parkinson's disease without dyskinesia without mention of fluctuations, unspecified convulsions, and type 2 diabetes mellitus with hyperglycemia. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews the medical physician failed to provide the facility with written, signed and dated progress notes following each visit for one (#13) of 34 sampled residents. Findings included:On 7/14/24 at 2:54 p.m. Resident #13 was observed and interviewed in the resident room. The resident was sitting in wheelchair and answered questions appropriately. The resident reported falling two weeks ago and required stitches and a second fall while using the door to maneuver in wheelchair. Review of Resident #13s electronic progress notes and the uploaded documents revealed the most recent Palliative Care - Follow up note was written for a service performed on 2/14/25. Review of the electronic practitioner notes showed psychiatry notes. The electronic Advanced Registered Nurse Practitioner (ARNP) notes revealed the last note was written 8/21/23. The electronic record did not include any specified MD Note and the last Physician Progress Note was dated 4/2/25 by the Physical Medicine and Rehabilitation physician for a service date of 2/27/25. An…
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 18 citations
- Potential for harm · D2025-07-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure medications were administered per physician orders and failed to document physician notification for missed medications for one resident (#110) of one dialysis residents reviewed.Findings included:Review of Resident #110's admission record revealed she was originally admitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD) and dependence on renal dialysis.Review of Resident #110's Medication Administration Record (MAR) for the months of June and July 2025 revealed the resident was not receiving medications as ordered. The MAR showed numerous notes of a number 1 documented indicating Refused medications. The review showed the medications were not administered as prescribed in the months of June and July 2025 as follows: Lactobacillus capsule, Give 1 capsule by mouth one time a day for prophylactic was missed 31 times.House protein, one time a day, for at risk for malnutrition related to dialysis, offer 30 cc…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for one (#23) of eight residents observed. These errors constituted a 7.69% medication error rate.Findings included:1.On 7/15/25 at 4:26 p.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #23. The staff member removed a glucometer from the top drawer of the medication cart, and placed it in a clear plastic cup with a lancet and glucose testing strip. Staff I entered the resident's room, cleaned left index finger of resident with alcohol pad, lanced the finger and reported to the resident a blood glucose reading of 215. The staff member returned to the medication cart and cleaned the glucometer. Staff I documented in the medication record a blood glucose of 283, which the computer calculated a dose of insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-17 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to ensure food allergies were accommodated for one resident (#23) of one resident sampled for food allergies. Findings included: An observation and interview was conducted on 7/14/25 at 12:20 p.m. with Resident #23. The observation showed the resident lying in bed and able to answer questions intelligently and appropriately. The resident reported feeling the portion sizes had decreased and felt (pronoun) had lost weight. The resident reported the facility used mayonnaise made with mustard and was allergic to mustard seeds.Review of the admission Record showed Resident #23 was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, morbid (severe) obesity due to excess calories, and adult failure to thrive.Review of Resident #23s quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 of 15 for a Brief Interview of Mental Status, indicating an…
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 before2025-03-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure an effective infection prevention program was implemented for four out of four residents reviewed for on-going skin rashes. Findings included: An interview was conducted on 3/5/25 at 3:47 p.m. with a family member of Resident #8. The family member said in September/October 2024 the resident had scabies. She said no one in the facility noticed. The family member said she is a medical provider herself and had to tell them to call the doctor and have the resident treated. She said Resident #8 was treated and started getting better, but in the beginning of December the resident had the rash back again with itching all over. She said at that time she found out when the resident was treated for scabies previously, his room and personal items had not been cleaned properly. The family member said she spoke to someone higher up and they said a deep cleaning of the room and personal items were not completed because the facility didn't feel…
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 before2024-08-14 · tag F0553 — failed to let residents help plan their care — patternAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 facilitate timely care plan meeting notifications to allow the representative or resident to participate in the care plan meetings, and failed to provide care plan summaries of the meetings to the representatives and/or three residents (#6, #17, and #23) of three sampled residents. Findings included: 1. On 8/12/24 at 10:33 a.m. Resident #6 was observed lying in bed and reported having the ability to feed self, having a good appetite, and not having gone to the hospital recently. Review of Resident #6's admission Record revealed the resident was admitted on [DATE], discharged [DATE] and re-admitted on [DATE], with a hospital leave beginning on 7/7/24 and returning to the facility on 7/10/24. The resident's primary diagnoses included unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The record included other diagnoses not limited to unspecified encephalopathy,…
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 before2023-03-22 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 include the resident representative in all aspects of the person-centered care planning and the right to participate in the care and treatment planning and process for one (Resident #72) out of fifty-one sampled residents. Findings included: On 3/19/2023 at 10:20 a.m., Resident #72 was observed in her room and seated upright in her bed, with her over the bed table positioned in front of her. During an attempt to interview resident #72, it was noted she had low cognitive functions and was not able to speak with relation to her medical care and services. She was able to answer basic yes and no questions and indicated she was feeling fine and having a good morning. Resident #72 was not aware if she or anyone in her family were involved with the quarterly care plan meetings/conference. On 3/20/2023 at 1:30 p.m., an interview with Resident #72's Power of Attorney (POA), who was also a family member, revealed Resident #72 was at the facility for long term…
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 · D2023-03-22 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide one (Resident #134) of 51 residents with a written notification for a room change. Findings include: On 03/19/2023 at 10:00 am., Resident # 134 was observed lying down in bed under her covers. Resident #134's call light was observed within her reach. A review of the admission Record revealed Resident #134 was admitted to the facility on [DATE] with diagnoses included but not limited to Nontraumatic Intracerebral Hemorrhage, Unspecified, Acute Embolism and Thrombosis of Unspecified Femoral Vein, and Type 2 Diabetes Mellitus without Complications. A review of the admission Minimum Data Set (MDS) dated , 2/22/2023, Section C- Cognitive Patterns, Brief Interview for Mental Status, (BIMS) revealed Resident #134's BIMS score was 15, which indicated intact cognition. A review of the Electronic Medical Record, (EHR) revealed Resident #134 was admitted to [room number] on 3/15/2023, then moved to [room number] on 3/16/2023. A 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.
- Potential for harm · D2023-03-22 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 #19) of fifty-one sampled residents was assessed upon admission related to activities. Findings included: On 3/19/2023 at 10:30 a.m., an interview with Resident #19, who was lying in bed in her room, revealed staff did not get her up so she could attend the Church activity this morning. She revealed staff, at times, would not get her up to go to activities. She required assistance to get up out from bed and required assistance transferring from the room to the dining room. It was observed at 10:20 a.m., prior to visiting Resident #19 while in her room, the main dining room had a group of residents seated at a large table and with a Church activity already in progress. A review of the posted current month's (3/2023) activities calendar, revealed an activity on Sunday, 3/19/2023 was Church at 10:00 a.m. Photographic evidence obtained. On 3/20/22023 at 8:40 a.m., Resident #19 revealed she was happy for Bingo later in the afternoon 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 · D2023-03-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for three (Residents #90, #47 and #38) of four residents sampled for PASARR Level II Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #90 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] showed under Section I active diagnoses, the resident had anxiety disorder, depression and Schizophrenia diagnoses indicated. A significant change in mental status MDS for Resident #90 dated 12/29/22 showed under Section I active diagnoses, the resident had anxiety disorder, depression and Schizophrenia diagnoses indicated. Review of Resident #90's PASSAR Level I screen dated 08/25/21 revealed Resident #90 had bipolar disorder, depressive disorder and schizoaffective diagnoses indicated. The diagnosis of Schizophrenia was not indicated. The review showed a level II PASARR…
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 before2023-03-22 · 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 observation, record review, and interview, the facility failed to ensure care plan interventions were implemented for three (Residents #19, #98, and #114) of fifty-one sampled residents. Findings included: 1. A review of the current medical record revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed Resident #19 was her own responsible party. Review of the current Minimum Data Set (MDS) Annual assessment dated [DATE], revealed: Cognition/Brief Interview for Mental Status: Score = 6 which indicated severe cognitive impairment ; Activities of Daily Living ADL - BED MOBILITY = Extensive Assistance with One person, TRANSFER = Extensive Assistance with Two person; Further review of the MDS and Diagnoses sheet did not indicate any extremity Range of Motion (ROM) deficits. A review of the current Physician's Order Sheet (POS) for the month 3/2023, revealed the following orders: (a) Apply Left ankle Splint as tolerated due to reduced…
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 · D2023-03-22 · 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 observation, interview, and record review, the facility failed to ensure one (Resident #19) of fifty-one sampled residents, was offered and provided assistance to activities of her choice during two of four days observed (3/19/2023, and 3/20/2023). Findings included: On 3/19/2023 at 10:30 a.m., an interview with Resident #19, who was lying in bed in her room, revealed staff did not get her up so she could attend the Church activity this morning. She revealed staff, at times, would not get her up to go to activities. She required assistance to get up out from bed and required assistance transferring from the room to the dining room. It was observed at 10:20 a.m., prior to visiting Resident #19 while in her room, the main dining room had a group of residents seated at a large table and with a Church activity already in progress. A review of the posted month's (3/2023) activities calendar, revealed the activities on Sunday, 3/19/2023 were Church at 10:00 a.m. and Bingo at 2:15 p.m. Photographic evidence…
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 · D2023-03-22 · 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 interview and record review, the facility failed to monitor for behaviors and side effects for psychotropic medications for one (Resident #9) of five residents reviewed for unnecessary medications. The facility also failed to limit as needed antianxiety medication for one (Resident #9) of five residents reviewed for unnecessary medications. Findings included: Resident #9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was a hospice resident and her medical diagnoses included but were not limited to recurrent depressive disorders and anxiety disorder. Review of Resident #9's physician orders revealed an order with a start date of 12/31/22 and no end date for Trazadone 100 mg 1 tablet by mouth one time a day for depression. Remeron 15 mg by mouth at bedtime for protein cal (calorie) nutrition which started on 12/30/22 with no end date. Further physician order review revealed an order with a start date of 1/13/23 and no end date for Lorazepam 0.25 ml buccally every 12 hours…
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 before2023-03-22 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two (Residents #98 and #114) of fifty-one sampled residents were provide with food items of choice and preference; and failed to ensure Resident #114 received a meal tray which did not include items she was allergic to, during two of four days observed on 3/19/2023, and 3/21/2023. Findings Included: On 3/19/2023 at 12:10 p.m. Resident #98 was observed seated in the main dining room and eating her meal. She waved over this writer as she wanted to talk about what she was served. Her meal tray/plate was observed with what appeared to be two slices of thick turkey, brown gravy on the turkey, mashed potatoes with what appeared to be brown gravy on it, and bread stuffing with what appeared to be a brown gravy all over it. The brown gravy was on all three main food items. Photographic evidence was taken. On 3/19/2023 at 12:10 p.m., during an interview with the resident, she revealed she hates gravy and had asked time and time again for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one month (March) of three months reviewed. The facility also failed to maintain an ongoing surveillance program to prevent reoccurring urinary tract infections for one (Resident #80) of 51 sampled residents. Findings included: 1. A review of the facility's infection prevention and surveillance book revealed tracking and trending of infections for January, 2023 and February, 2023. There was no evidence of an ongoing infection prevention and control program to prevent infections for the month of March. A review of the facility's Nursing Home Key Staffing Form revealed the Assistant Director of Nursing (ADON) was the infection preventionist. An interview was conducted on 3/22/23 at 4:40 p.m., with the Director of Nursing (DON) who had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-07-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection control and prevention program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) as evidenced by their failure to ensure that facility staff members, seven of which were observed, were screened for signs and symptoms each day before working and failed to supervise the screening of three visitors prior to entry to the facility with the potential to expose a total of 146 residents for two of two days observed. Findings included: During an interview with the facility Administrator (NHA) on 07/27/21 at 9:10 a.m., he confirmed that there was only one entrance used by employees: the front main lobby entrance. He confirmed facility employees should not be using any other entrance doors in the building prior to being screened for COVID-19. An observation was conducted on 07/28/21 at 6:50 a.m. from the parking lot outside the facility main lobby entrance. There were no vehicles parked in the parking…
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 before2021-07-30 · 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, staff and resident interviews and medical record review, the facility failed to develop care plan problem areas with goals and interventions for one resident (#192), related to use of antibiotics for infections and failed to implement care plan interventions for one resident (#94), related to not using fall floor mats when the resident was in bed of 51 sampled residents. Findings included: 1. On 7/28/2021 at 9:07 a.m., 7/29/2021 at 7:06 a.m., and 7/30/2021 at 7:22 a.m. Resident #192 was observed in his room lying in bed under the covers and with the call light placed within his reach. Further observations revealed an intravenous (IV) therapy pole, IV bag and pump system at his bedside. Resident #192 was confirmed receiving Antibiotic IV therapy for an infection, per his interview. Resident #192 revealed he was admitted with an infection and has been receiving antibiotics since his admission. Review of Resident #192's admission Record revealed he was admitted to the facility on [DATE] for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-07-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify, examine, and assess a change of condition in accordance with the professional standards of practice for one resident (#84) related to discolorations and bruises on the resident's left upper arm out of 51 sampled residents. Findings included: An observation on 07/27/2021 at approximately 9:30 a.m. revealed Resident #84 asleep in her bed. Her left arm was uncovered. A small dark purple bruise, approximately the size of 8 cm (centimeters) x 8 cm, and a larger light purple bruise, approximately the size of 18 cm x 18 cm, were observed on her left upper arm. A review of Resident #84's admission Record revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but not limited to frontal lobe executive function deficit following cerebral infraction, sequelae of other cerebrovascular disease, hemiplegia and hemiparesis following cerebral infraction, affecting right dominant side, and dementia. Record 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.
- Potential for harm · D2021-07-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner in one medication room (200 Wing) of four medication rooms, and failed to properly dispose of a medication patch for one resident (#50) of 35 residents on a pain management program. Findings included: On 07/27/21 at 10:17 a.m. an observation of the bathroom for Resident #50, revealed a Lidocaine patch dated 7/23/21, stuck to the edge of the mirror in the bathroom. When asked about the Lidocaine patch, Resident #50 said that she thought that her CNA (certified nursing assistant) may have removed the patch when she had a shower but was not sure. Review of the July 2021 physician orders for Resident #50 revealed an order for a Lidoderm Patch 5% (Lidocaine) apply to Lt (left) knee topically two times a day for left knee pain pls (please) cut patch in 1/2 longitudinally and place in lt knee 1 inch away from surgical wound on each side, start date 6/1/21. On 07/27/21 at 11:10 a.m. an interview was conducted with Staff B,…
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
$17,345 in federal fines across 1 penalty.
- $17,345 — penalty dated 2025-07-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 35 homes this chain runs (chain average 3.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LEXINGTON SNF HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/27/2022 |
| DAVIS, KATRINA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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 105072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-17, 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.