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South Heritage Health & Rehabilitation Center

718 Lakeview Ave S, Saint Petersburg, FL 33705 · Non profit - Corporation · 74 certified beds · (727) 894-5125 Medicare & Medicaid certified

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Flagged for abuse2 actual-harm citations$145,109 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $145,109 in federal fines (most recent 2025-09-02)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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
700 6th St S 2nd Floor · (727) 893-6198 · Call to confirm hours
Pharmacy
2215 Dr Martin Luther King Jr St S · (727) 823-4948 · Call to confirm hours
Grocery
2230 Dr Martin Luther King Jr St S · (727) 550-0341 · Call to confirm hours
Park
642 22nd Ave S · (727) 826-9774 · 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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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 increased6.1%8.7%15.4%better
Long-stay residents who lose too much weight6.0%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
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 injury4.0%2.5%3.3%worse
Long-stay residents whose ability to walk worsened7.3%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.7%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers7.1%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control4.2%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.8%94.7%79.4%better
Short-stay residents rehospitalized after admission35.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit18.6%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.752.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.721.151.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

10.3%U.S. median 10.7%
Went back to hospital
64.5%U.S. median 56.6%
Met the expected recovery
0.44U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 64.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 31% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.4–16.910.7%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 discharge64.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge41.9%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 discharge45.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.431.02Oct 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

0.41
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.03
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.28
RN hoursweekends
52.4%
Total nursing turnover
76.9%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 58.7 residents a day — about 79% occupied, or roughly 15 beds typically open. It usually has some room. 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 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.09 hrs/resident/day on weekends vs 3.23 on weekdays — 4% thinner on weekends. RN hours go from 0.47 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 3 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

11
deficiencies at the latest standard inspection (2025-02-13)
7
at the previous standard inspection (2023-02-10)

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.

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.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2025-09-02 · 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 interview and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#1) out of seven sampled residents. Resident #1 sustained an unwitnessed fall on 08/21/25 and was not assessed after the fall. Resident #1 complained of hip pain on 08/23/25, an X-ray was obtained on 08/24/25 and Resident #1 was transferred to a higher level of care due to a right hip fracture on 08/24/25 and required surgical intervention.Findings included: An interview was conducted with Resident #2 on 09/02/2025 at 10:08a.m. Resident #2 was the roommate of Resident #1 and recalled the events of 08/21/2025 when Resident #1 had a fall. She stated the night of her roommate's fall; she was starting to fall asleep when she heard a loud sound and heard her roommate grunting ouch. Resident #2 said she remembered seeing her roommate in her wheelchair near the door shortly before the fall, but she was unsure as to what she was doing when the actual fall occurred. After she heard her…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-25 · 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 observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of three sampled residents, was provided transfer assistance in accordance with the resident's ability, care plan, facility policy, and/or the mechanical lifts manufacturer's recommendation, resulting in harm to Resident #1. Findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. The electronic medical record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, subsequent encounter for closed fracture with routine healing (created 3/1/23), and displaced transverse fracture of shaft of left femur subsequent encounter for closed fracture with routine healing (created 3/28/25). Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS)…

    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 · D2026-04-25 · 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

    Based on interview and record review, the facility failed to protect the resident's right to seek medical services outside the facility, resulting in delayed emergent care and services for one resident (#5) of two residents sampled.Findings included: During a follow-up telephone interview on 4/25/26 at 2:50 p.m. with Resident #5's family member, the family member revealed being upset and frustrated with the facility because they did not want to send Resident #5 out to the ER (emergency room). The family member stated the resident had requested to go to the hospital following discomfort after laparoscopic surgery. The family member stated Resident #5 had symptoms of pain, bloating and had been vomiting all night. He stated a nurse said the inhouse doctor would assess Resident #5 first. He stated she was given nausea medication and continued to have diarrhea all night through the next day. The family stated having begged the nurse to send the resident out. He stated he eventually called non-emergency police to do a wellness check and request Resident #5 to be sent out. The family…

    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 · D2026-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure nail care was provided to one resident (#4) out of three resident reviewed for total assistance with activities of daily living (ADLs).Findings included: A review of Resident #4's admission record showed an admission date of 1/20/26. Further review of the admission record showed diagnoses to include quadriplegia, unspecified, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other lack of coordination.On 4/25/26 at 9:19 a.m., an interview and observation occurred with Resident #4. Resident #4's nails were observed approximately one to one and a half inches long. During the interview, he stated he wanted his nails cut, and he had been asking the assigned certified nursing assistant (CNA) for the last three days. Resident #4 said the assigned CNA would tell him, No, not yet I'm on break. He said one of the days the assigned CNA assisted with soaking his nails for 30 minutes. Resident #4 said when she came back, she said he had to wait for them to be trimmed because it was 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 · D2026-04-25 · 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, record review, and interviews, the facility failed to ensure diet-related physician orders were implemented for one resident (#4) out of three resident reviewed. Findings included: On 4/25/26 at 12:30 p.m., an observation of Resident #4's lunch meal revealed the meal ticket did not show large or double portions was documented. A review of Resident #4's admission record showed an admission date of 1/20/26. Further review of the admission record showed diagnoses to include quadriplegia, unspecified, muscle wasting and atrophy, not elsewhere classified, multiple sites, and other lack of coordination. A review of Resident #4's physician orders revealed the following: House diet Regular texture, Regular(Thin) consistency, No pork, lactose intolerant, no dairy (milk or cheese), with a start date of 1/26/26. Resident may have double portions for all meals six times a day, with a start date of 3/7/26. A review of Resident #4's care plan revealed the following: NUTRITIONAL: [Resident #4] has a potential nutritional problem r/t [related to] Diagnoses - Quadriplegia,…

    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 before2025-10-15 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 to ensure the medication error rate was less than 5.00%. Twenty-two medication administration opportunities were observed, and fifteen errors were identified for two residents (#3 and #2) of two residents observed. These errors constituted a 68.18% medication error rate. Failure to ensure the accurate administration of medications has the potential to greatly affect the effectiveness of the medication and jeopardize the health and safety of the resident. Findings included:1.On 10/15/25 at 10:06 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #3. The resident's medication profile was colored red, showing medications were late. The staff member removed an insulin pen and insulin syringe lying both on top of the medication cart then dispensed the following medications:- saccharomyces boulardii over-the-counter (otc) 500 milligram (mg) tablet- haloperidol 2 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 · Ecited before2025-10-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to ensuring one of one observed needle attached to an insulin syringe was appropriately sheathed, staff failed to provide a barrier between an insulin syringe and an over bed table, failed to clean hands in between residents and handling random resident equipment stored in hallway, failed to don gloves prior to the administration of eye drops for one (#2) of one resident receiving this type of medication, and failed to ensure two (B & C) of three direct care nurses fingernails had the ability to be cleaned thoroughly and adequately to prevent the transmission of microbes. Failure to not implement and educate staff regarding infection control measures could cause serious harm to residents by not ensuring cross contamination between environmental and residents. Findings included:On 10/15/25 at 10:06 a.m. Staff A was observed during Resident #3's administration of medications. The observation showed Staff B extract 24 units from an insulin degludec…

    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 before2025-10-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of the facility policy, the facility did not ensure a sanitary and home-like environment was provided in the main shower room and in two shared bathrooms (100/102 and 129/131) out of thirteen rooms with shared bathrooms.Findings included: On 10/15/25 at 9:43 a.m., an observation of the main shower room revealed clumps of hair and debris in the drain. Further observations of the main shower revealed a white shower chair, by the door, which had a clear cup with a green colored substance and multiple black particles on the left leg and arm handle. On 10/15/25 at 9:45 a.m., an observation of the shower area in room [ROOM NUMBER] and 102 revealed a bedpan on the shower chair with black debris and particles inside. Further observation of the floor revealed multiple strands of dark colored hair as well as multiple areas of black bio-growth. On 10/15/25 at 10:08 a.m., an observation of the shower area in room [ROOM NUMBER] and 131 revealed multiple areas of green and black…

    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 · F2025-04-25 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility did not ensure a Registered Nurse (RN) was providing services for eight consecutive hours a day, seven days a week, for the period of 4/6/25 to 4/12/25. Findings included: A review of the staff schedule dated 4/5/25 - 4/6/25 revealed the nursing staff on each shift (10:45 p.m. - 7:15 a.m., 6:45 a.m. - 3:15 p.m., and 2:45 p.m. - 11:15 p.m.) were all Licensed Practical Nurses (LPNs) and RN was indicated next to a staff name that was crossed out. On 4/24/25 at 3:34 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility completed their staffing based on census to determine how many Certified Nursing Assistants (CNAs) and nurses they need per day. She said between calling and requesting off, they haven't had enough staff on certain days and she finds out afterwards when staff do not come in, After the fact. She confirmed the facility is supposed to have an RN on duty and, Maybe the RN called off that day. She said she doesn't know because she was out of town. The DON said when she was out of town, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-25 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to provide nursing staff with the competencies and skills to provide appropriate nursing services to one resident (#1) of three sampled residents related to 1.) not providing a safe mechanical lift transfer which resulted in a severe bodily injury, 2.) not accurately documenting the administrations of controlled medications, and 3.) failed to notify the emergency contact of the resident requiring a transfer to an acute care facility following a fall. Findings included: 1. Review of the facility's reportable log showed an event involving Resident #1 occurred on 3/23/25. The event resulted in Fracture/Dislocation/transfer outside. Review of the Situation, Background, Appearance, and Review and Notify, dated 3/23/25, revealed Resident #1 had a fall with worsening of chronic pain in the front left thigh and front left knee and rated the intensity of pain 7 of 10. The summary of staff observation and evaluation revealed the resident was…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility did not ensure the designated representative/emergency contact was notified regarding a change in condition, related to an accident resulting in hospitalization, for one resident (#1) of three residents sampled. Findings included: A review of Resident #1's admission Record revealed an original admission date of 3/1/23 and a re-admission date of 3/28/25. Review of the admission Record revealed diagnoses to include displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other lack of coordination, weakness, unsteadiness on feet, need for assistance with personal care, contracture, left knee, unspecified fracture of left lower leg, and subsequent encounter for closed fracture with routine healing. A review of Resident #1's admission Record revealed her family member (EC) is the emergency contact/recipient for verbal patient health information (PHI). A review of Resident #1's skilled…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to maintain an accurate accounting of narcotic medication for one resident (#1) of one resident sampled for the administration of pain medication. Findings included: On 4/23/25 at 10:40 a.m. Resident #1 was observed sitting in the Dining Room with a family member. The resident reported her legs and hands were hurting while rubbing the top of left leg and the oxy was not working. The resident reported a recent surgery to the left leg due to a staff member pivoting her to transfer. Review of Resident #1s quarterly Minimum Data Set (MDS) assessment, dated1/8/25, revealed a Brief Interview of Mental Status score of 15 of 15, indicating the resident was cognitively intact. The assessment revealed Resident #1 was dependent upon staff for sit to lying, lying to sit, and bed to chair transferring. The assessment showed the resident received scheduled and as needed pain medication for occasional pain. Review of Resident #1s April Medication Administration Record (MAR) revealed the following orders: - Ordered 3/28/25:…

    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
Show the remaining 19 citations
  • Potential for harm · F2025-02-13 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation staff interview and facility record review, the facility failed to ensure the kitchen dish washing machine was operating at optimum levels, to include excessive concentration with the chemical sanitizer delivery, in one of one facility kitchen, during one (2/11/25) of three days observed. Findings included: On 2/11/2025 at 9:08 a.m. the facility's kitchen was toured with the Dietary Manager, Staff A. Staff A, the only staff member in the kitchen demonstrated on how the dish washing machine is used. He revealed he had primed the machine for operation just minutes before. Staff A revealed the dish washing machine was a Low Temperature operation and indicated the wash temperature was to reach 120 degrees F. (Fahrenheit), and the final rinse was to reach 120 degrees F. Staff A continued to say the machine has a chemical chlorine agent delivery system and the chemical chlorine sanitizer should be measured between 50 - 100 Parts Per Million (PPM), via litmus testing strip. Review of the dish machine's specification plate attached to the bottom frame revealed the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · 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, interviews and facility record review, the facility failed to ensure resident spaces and equipment were maintained in a sanitary manner in two of two units (Main, West), during three of three days observed (2/11/2025, 2/12/2025, and 2/13/2025). Findings included: On 2/11/2025 at 10:55 a.m. 2/12/2025 at 8:30 a.m. and 2/3/2025 at 11:00 a.m. the following was observed: 1. Resident room [ROOM NUMBER] bathroom was observed with a recent wall repair between the sink and the toilet. It was further observed a white panel approximately two feet by two feet covering a hole in the wall. The panel was observed torn off the wall. The bathroom was also observed without a trash can, and the toilet tank was observed without a lid. Photographic evidence was taken. 2. Resident room [ROOM NUMBER] shared bathroom was observed with a metal glove box holder affixed to the wall on the left side of the sink wall. The metal box was observed heavily rusting and with paint chipped and peeling, leaving a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-13 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility did not ensure prompt efforts were made to resolve grievances for two (#33 and #13) of six residents sampled. Findings included: During an interview on 2/12/2025 at 9:20 a.m. Resident #33 stated during the hurricane evacuation their wheelchair was lost. Resident #33 stated speaking to the Social Service Director (SSD) upon returning from the evacuation, as the chair given is not as wide as the prior chair. Resident #33 stated notifying the SSD that someone else was in the chair (as Resident #33's name was on the chair). Resident #33 stated not having any resolution as Resident #33 is still in this chair that was too small and preferred the wider chair. Review of the grievance log from September 2024 to January 2025 showed an absence of grievances for Resident #33. 2.On 2/11/25 at 10:44 a.m., an observation of Resident #13 revealed he was sitting in his wheelchair to the left of the bed, by the door. He expressed concerns related to his wheelchair…

    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 · E2025-02-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and policy review, facility did not ensure medication was stored appropriately on three out of three units in the facility related to medication in resident rooms on the north and main units, unsecured medication is an office on the central unit, and improperly stored medication in two medication carts on the north and central units. Findings included: An audit of the central medication cart and interview was conducted on 2/12/25 at 3:34 p.m. with Staff H, Licensed Practical Nurse (LPN). The cart contained a bottle of Sodium Bicarbonate 10 gr (grain) that had been opened on 11/30/23 and expired on 01/2025. The drawers of the cart had dirt, debris, pieces of packaging, rubber bands, and glucose test strips in them. Staff H said the night shift is supposed to clean the medication cart and check them for expired medication. She agreed the cart was dirty and said night shift obviously hadn't cleaned it. An audit of the north medication cart and interview was conducted on 2/12/25 at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility did not ensure Preadmission Screening and Resident Review (PASARR) Level I screens were completed accurately for three residents (#64, #65, and #40) out of sixteen sampled residents. Findings included: Review of admission Records showed Resident #64 was admitted on [DATE] with diagnoses including post-traumatic stress disorder. Review of Resident #64's physician orders showed an order for Bupropion HCL ER 150mg for depression. Review of Resident #64's Care plans revealed a focus area of Psychotropic medication use related to antidepressant to manage depression, dated 12/9/24. Review of Resident #64's PASARR Level I screen, dated 11/8/24, did not indicate the resident had any mental illness or suspected mental illness. An interview was conducted on 2/12/25 at 5:15 p.m. with the Director of Nursing (DON). She reviewed resident #64's PASARR Level 1 screen and confirmed it was not correct and should have been updated. An interview was conducted on 2/12/25 at 5:24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · 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 develop a contracture management splinting care plan with goals and interventions for one (#45) of thirty-two sampled residents. Findings included: Review of the current care plan for Resident #45 with next review date of 5/27/2025 revealed an ADL focus - [Resident #45] has an ADL Self Care Performance Deficit r/t (related to) weakness, impaired mobility, activity intolerance, multiple comorbidities, with interventions in place as reviewed. The review showed there was no care plan problem area with goals and interventions related to contracture management and use of a Right-hand splint/orthotic. Further, there were no other assessments, progress notes, Medication Administration Record and Treatment Administration Record for months 1/2025 and 2/205 revealing treatment for contracture management with use of Right-hand splint/orthotic. On 2/11/2025 at 9:45 a.m. Resident #45 was noted in his room and seated in a wheelchair next to his bed. On…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · 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

    Based on observation interviews and record review, the facility failed to ensure nail care was provided to a resident who needed assistance for one (#55) of three residents reviewed for activities of daily living (ADL). Findings included: On 2/11/25 at 10:06 a.m. an observation of Resident #55 revealed he was laying down in bed, facing the window. The resident's hands were observed and revealed long, untrimmed fingernails on both hands with dark brown/black debris underneath three of his nails. Resident #55 stated he could not recall when he last received nail care. He stated he wanted his nails trimmed. On 2/12/25 at 9:42 a.m., an observation of Resident #55 revealed the same concerns observed on 2/11/25. (Photographic Evidence Obtained) Review of Resident #55's admission record revealed an admission date of 6/28/24 with diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, type 2 diabetes mellitus without complications, other lack of coordination, other abnormalities of gait and mobility, unsteadiness on feet, schizoaffective disorder,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · 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

    Based on interviews, observations, and record reviews the facility failed to provide enteral nutrition per physician orders for one (#220) out of five residents with enteral nutrition orders. Findings included: An interview and observation was conducted with Resident #220 on 2/11/2025 at 10:25 a.m. Resident #220 was lying in bed, looking out the window. Resident #220 said his enteral feeding had not been on for a while. Upon observation of the enteral feeding pump, it was noted it was not running, the [brand name] 1.5 calorie bottle was observed with approximately 450 ml (milliliters) of enteral feeding remaining of the 1000 ml bottle. The date 2/10/25 was the only other piece of information seen written on the label that was not from the manufacturer. An interview and observation was conducted with Resident #220 on 2/11/2025 at 4:10 p.m. Resident #220 was lying in bed, listening to the TV. Resident #220 said the enteral pump had not been running. Observation of the enteral feeding pump confirmed it was not running, the [brand name] 1.5 calorie bottle was observed with approximately…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility did not ensure pharmacy recommendations were implemented for two residents (#64 and #2) out of five residents sampled for unnecessary medications. Findings included: Review of the admission records showed Resident #64 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). Review of Resident #64's physician orders showed an order for Breo Ellipta Inhalation Aerosol Power Breath Activated 200-25 mcg/act. 1 inhalation one time a day for asthma, dated 12/2/24. Review of Resident #64's Consultant Pharmacist's Medication Regimen Review, dated 12/6/24 showed the following: This resident is receiving Breo. Steroid inhalers can cause oral thrush which may be minimized by rinsing the mouth with water after each dose of the inhaler. Please consider adding the following verbiage to the order as a reminder. Rinse mouth with water and spit back into cup after use. The recommendation was not signed and there was no indication it was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview and policy review the facility failed to ensure the medication error rate was less than 5.0%. Thirty medications opportunities were observed, and three medication errors were identified for three residents (#32, #36, #11) of three residents observed. These errors constituted a 10.0% medication error rate. Findings included: An observation was conducted during medication administration for Resident #32 on 2/12/25 at 9:20 a.m. with Staff F, Licensed Practical Nurse (LPN). Staff F prepared and administered the following medications: -Vitamin B-12 500 mcg (microgram) x 1tablet -Cetirizine HCL 10 mg (milligram) x 1tablet -Folic Acid 1 mg x 1 tablet -Famotidine 20 mg x 1 tablet -Allopurinol 300mg x 1 tablet -Acetaminophen 500 mg x 2 tablets. Review of Resident #32's physician orders showed the following: -Claritin Oral tablet 10 mg. Give 1 tablet by mouth one time a day for allergic rhinitis, dated 11/28/23. There was no order for Cetirizine HCL 10 mg x 1. Review of Resident #32's Medication Administration Record (MAR) showed Claritin Oral…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review facility did not ensure proper infection control practices for one resident (#64) out of sixteen sampled residents related to scabies treatment. Findings included: An observation and interview was conducted on 2/11/25 at 11:03 a.m. with Resident #64. She was observed to have raised several scabbed spots covering both legs. She said she had been itching. A follow-up interview was conducted with Resident #64 on 2/13/25 at 11:55 a.m. The resident said she was still itching. She explained the bumps and itching started on her arms and chest then moved to her legs. She said when she lays down her back was starting to itch. She said the nurse puts medication on that helps some. Review of admission record showed Resident #64 was admitted on [DATE] with diagnoses including peripheral vascular disease and chronic pain syndrome. Review of Resident #64's 1/2/25 quarterly Minimum Data Set (MDS) Section C, Cognitive patterns showed the resident had a Brief Interview for Mental…

    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 · Ecited before2023-02-10 · 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, interviews, and policy review the facility did not ensure a safe, clean, and homelike environment in nine resident rooms (108, 117, 116, 119, 123, 124, 126, 127, and 121) out of 34 rooms and four bathrooms (110, 123, 124 & 125, and 126 & 127) out of 22 bathrooms, one hall (Main) out of three halls, and one patio (dining area) out of two patios observed. Findings included: An observation was made on 2/7/23 at 9:10 a.m. of rooms [ROOM NUMBERS]. Both rooms had closet doors that were not on the tracks. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 10:23 a.m. in room [ROOM NUMBER]. On the wall under the window there was a broken plastic box with exposed wires on the wall. (Photographic Evidence Obtained.) An observation was made on 2/7/23 at 10:41 a.m. in room [ROOM NUMBER]. On the wall under the window there was broken/cracked plaster/drywall. The window was not sealed up and there were open gaps to the outside. (Photographic Evidence Obtained.) An observation was made…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure care and services were provided in accordance with professional standards of practice for facility acquired pressure injuries for one resident (#1) by not seeking surgical intervention in a timely manner and for not ensuring orders were in place and followed for wound care for two residents (#30 and #7) of a total of three residents sampled. Findings included: 1. On 02/07/23 at 10:00 a.m. Resident #1 was observed in bed with an air mattress in place. On 02/08/23 at 10:16 a.m. a phone interview was conducted with Resident #1's representative and has been with him for over ten years. When asked about the intensity his wounds she said the physician was talking about a skin graft to the buttock's wounds. She said she was looking forward to the procedure so he (Resident #1) would be able to get out of bed more often, and that she could take him outside during their visits. A record review of the admission Record form revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-10 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and medical record review, the facility failed to ensure medications were administered without irregularities and followed as ordered for one resident (#1) out of five residents sampled as evidenced by failing to follow blood pressure parameters. Findings included: On 02/07/2023 at 10:00 a.m. Resident #1 was observed lying in bed and receptive to an interview, his speech was difficult at time to understand and he appeared thin and frail. Review of the admission Record indicated Resident #1 resided at the facility for twenty years. The diagnoses included atherosclerotic heart disease of native coronary without angina pectoris, hypertension, chronic kidney disease stage 3, and hypotension. Review of the February 2023 physician orders revealed an order for: Midodrine HCL oral tablet give 10 mg (milligrams) by mouth three times a day related to HYPOTENSION, UNSPECIFIED, give if BP (blood pressure) is Less than 90/60, dated 09/15/2022. Review of the January 2023 Medication Administration Record (MAR) showed the Midodrine HCL administrations as: 01/01/2023…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-10 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to provide timely notification to the physician for one resident (#17) out of two residents, who were dependent on staff for total enteral nutritional support by way of a gastrostomy tube and enteral feedings, related to a significant weight loss of 38.6 pounds within a 26 day period. Findings included: On 02/07/23 9:40 a.m. Resident #17 was observed lying flat in his bed with the head of the bed (HOB) flat. He was receptive to an interview when approached. The resident's stomach was exposed revealing a gastrostomy tube that was attached to a enteral feeding machine. The machine was turned on and a bottle of Glucerna 1.2 was observed to be hanging with the pump running at 100 cc (cubic centimeters) per hour. At that time, a certified nursing assistant entered the room and said he was going to provide the resident with his morning activities of daily living (ADLs). On 02/07/2023 at 10:13 a.m. Resident #17 stated, I had loose stools, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-10 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 personal privacy was maintained for one resident (#34) out of 22 residents sampled. Findings included: An interview and observation was conducted at 9:10 a.m. on 02/07/2023 with Resident #34. Resident #34 was observed well-groomed, sitting up in her wheelchair watching TV. During the room observation it was observed that Resident #34's room door was off the hinges and could not close shut to give Resident #34 privacy. Resident #34 said she did not like that her room door was not able to close shut because whenever a CNA (certified nursing assistant) provides her with personal care, she feels like someone can walk in her room and see her getting dressed. Resident #34 said her room door has not been able to shut close for a while, and she has reported her concerns to the CNAs, but nothing had been done about it. Review of the admission Record revealed Resident # 34 was admitted on [DATE] with diagnoses to include chronic obstructive…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-10 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain kitchen equipment in a clean manner by not ensuring three drip trips were free from grease for one of one stove in one of one kitchen. Findings included: On 02/02/2023 at 9:00 a.m. an initial tour of the kitchen was conducted with the Dietary Manager and revealed three unclean drip trays on top of the stove. The three drip trays were observed with grease piled up on the foil liner. On 02/02/2023 at 9:10 a.m., an interview was conducted with the Dietary Manager. The Dietary Manager said the kitchen staff should have checked and changed the drip tray liners at the end of their shift. The Dietary Manager said the drip trays should be deep cleaned weekly and the drip tray foil should be changed out every evening. Review of the facility policy and procedure titled, Cleaning and Sanitation, dated September 2021, showed the facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and equipment, walls. floors, ceilings, equipment, and utensils are clean,…

    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 · D2023-02-10 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 medical record review the facility failed to collaborate with the hospice agency related to current plans of care for one resident (#8) out of one resident sampled with hospice services. Findings included: An interview was conducted with Resident #8 on 2/7/23 at 11:07 a.m. The resident stated she was on hospice. She stated an aide and nurse come to see her, but she didn't know how often. A review of admission Record indicated Resident #8 was admitted on [DATE] with a re-admission date of 11/3/22. Her diagnoses included malignant neoplasm of overlapping sites of unspecified bronchus and lung and hemiplegia and hemiparesis following cerebral infarction. A review of the active physician orders as of 2/9/23 revealed an order for hospice services for a diagnosis of lung cancer, dated 2/16/22. Resident #8's facility care plan, initiated on 2/16/22 and revised on 2/06/23, showed the following: Terminal Diagnosis. [Resident #8] is diagnosed with a terminal condition and is at risk…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-05-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record & policy review, the facility failed to identify and provide wound care effectively for tunneling or undermining wounds for one (#8) of three sampled residents with identified pressure sores; failed to ensure wound care visits were completed as ordered; and failed to identify a special air loss mattress was set in accordance with Resident #8's wound care needs, impacting the healing potential for the only resident with worsening wounds. Findings Included: Review of the facility CMS form 672, Resident Census & Conditions of Residents, revealed one resident, Resident #8, with worsened pressure ulcers. Review of Resident's #8's medical record did not reflect any wound care or physician notes. Review of the electronic record did not reveal any of the physician notes for wound care or from the facility physician related to wound care. The Director of Nursing (DON) confirmed she was unable to locate any documents for outpatient wound care and physician notes for Resident #8 and requested the notes were sent to the facility on 5/18/21 at 9:45 a.m.…

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

    Quality of Life and Care 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

$145,109 in federal fines across 2 penalties.

  • $54,704 — penalty dated 2025-09-02
  • $90,405 — penalty dated 2025-04-25

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 SENIOR HEALTH SOUTH — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 1 of 51.8-0.8 vs chain
Staffing 2 of 52.9-0.9 vs chain
Quality measures 3 of 53.8-0.8 vs chain
The other 7 homes this chain runs (chain average 1.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
SENIOR HEALTH PROPERTIES-SOUTH INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/30/2000
SENIOR HEALTH SOUTH EX LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/01/2025
OMEGA HEALTHCARE INVESTORS, INCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 09/01/2005
DEPIANO, RICHIndividualCORPORATE OFFICERsince 04/01/2009
JAFFE, HOWARDIndividualCORPORATE OFFICERsince 04/01/2009
MULLEN, ANNIndividualCORPORATE OFFICERsince 04/01/2009
RICHMOND, PENNYIndividualCORPORATE OFFICERsince 04/01/2009
CONSULTING SUPPORT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
FACILITY SUPPORT COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
KANE FINANCIAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
CROCKETT WILSON, NEKEISHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2010
WHITE, SAMANTHAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/21/2021
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 08/19/2016

CMS files one row per role, so the 20 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.8M
Net patient revenuemost recent cost report
-2.9%
Operating marginrevenue minus expenses
$287K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 7%Other / private 6%

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $287K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$345per resident / day
operating cost
$10,494per month
≈ monthly operating cost
$335per 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 105117. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-13, 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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