Indian Beach Nursing And Rehab Center
1755 18th St, Sarasota, FL 34230 · Non profit - Other · 101 certified beds · (941) 955-4915 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $427,597 in federal fines (most recent 2025-12-17)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.3% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.3% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 29.6% | 4.6% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.2% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 14.0% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 41.8% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.1% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.3% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 0.0% | 9.1% | 12.0% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.49 | 2.13 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.37 | 1.15 | 1.80 | better |
* 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.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
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.
34.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 34% 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 | 34.7%CMS range 23.9–48.4 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.3–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 62.5% | 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 | 55.0% | 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 | 40.0% | 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 | 87.3% | 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 | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.2% | 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 | 7.2%CMS range 3.7–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 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 101 beds and averages 95.9 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.21 hrs/resident/day on weekends vs 3.30 on weekdays — 3% thinner on weekends. RN hours go from 1.13 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
23 citations, most serious first. The 14 most serious are shown; the remaining 9 are one tap away and print in full.
- Immediate jeopardy · Kcited before2025-05-24 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25, verified the maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81…
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.
- Immediate jeopardy · K2025-05-24 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 The immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. The facility is and will continue to maintain hourly temperature logs until all air conditioner units are repaired. 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.
- Immediate jeopardy · Kcited before2025-05-24 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The immediate actions implemented by the facility and verified by the survey team on 5/24/25 included: On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees. On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms. On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees. The facility is and will continue to maintain hourly temperature logs until all air conditioner units are repaired. 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.
- Actual harm · I2025-12-17 · tag F0602 — failed to protect residents from theft of their belongings — widespreadProtect each resident from the wrongful use of the resident's belongings or money.
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 facility policy the facility failed to protect the residents' rights to be free from misappropriation of residents' property for 6 (Residents #1, #2, #3, #4, #5 and #6) of 6 residents reviewed out of 51residents whose personal funds are managed by the facility. The findings included:Review of the Facility's Policy titled Abuse, Neglect, Exploitation & Misappropriation with an effective date of [DATE], and a revision date of [DATE] documented: It is inherent in the nature and dignity of each resident at the center the he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged…
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 before2025-12-17 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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, review of the facility's policies and procedures, residents and staff interviews, the facility administration failed to utilize its resources effectively and provide the necessary oversight to prevent the misappropriation of residents' personal funds for 6 (Residents #1, #2, #3, #4, #5 and #6) of 6 of 51 residents whose funds are managed by the facility.The findings included:Review of the Business Office Manager's job description revealed the duties and responsibilities included to maintain current and accurate computer data including documentation of all account activity performed in A/R (Account Receivable) systems. Complete cash log as required. Maintain compliance with all state, federal, and government agencies. Perform all other business-related duties as assigned. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation with an effective date of [DATE] and a revision date of [DATE] revealed, The center is committed to the prevention 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 · Dcited before2025-12-17 · 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
Based on record review, review of facility policy and procedure and staff interview, the facility failed to report an allegation of misappropriation of resident property within required timeframe for 1 of 3 incidents reviewed.The findings included:Review of the Facility's Policy Abuse, Neglect, Exploitation & Misappropriation effective date 11/30/2014, revision date 11/28/2017 documented Policy: It is inherent in the nature and dignity of each resident at the center the he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any…
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 · D2025-12-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, review of the facility's policy and procedure, residents and staff interviews, the facility failed to thoroughly investigate an allegation of misappropriation of residents' property for 1 of 1 incident investigation related to misappropriation of residents' personal funds reviewed.The findings included:Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation & Misappropriation with an effective date of [DATE] and a revision date of [DATE] revealed, It is inherent in the nature and dignity of each resident at the center he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property . Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or…
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 · D2025-08-12 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and facility staff interview, the facility failed to protect residents' rights to personal privacy for 2 (Residents #16 and #7) of 2 residents observed in unauthorized videos posted on staff personal social media account accessible to the public.The findings included:Review of the Employee Handbook, section E, Resident Confidentiality Policy, it stated In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the Patient [NAME] of Rights, employees must respect the resident confidentiality and may not divulge any information contained in a resident's record to any unauthorized persons, including co-workers. In addition, employees must refrain from discussing any protected health information (PHI) of a resident, which an unauthorized person may overhear, both on and off the worksite. Page 36 of the employee handbook stated .Disclosing information about residents, unless authorized to do so, can be very harmful .Everyone, particularly our residents, has a right to privacy. The employee handbook stated in the section titled, Social…
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 · D2025-01-09 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete a significant change in status assessment for 1 (Resident #17) of 1 sampled resident with a 9.41% weight loss over a six month period and developed an unstageable pressure ulcer. The findings included: Clinical record review for Resident #17 revealed an admission date of 9/1/23. Diagnoses included COPD (Chronic Obstructive Pulmonary Disease), Hypertension, Dysphagia (swallowing difficulties), Depression, Anxiety, and Bipolar Disorder (mood swings ranging from depressive lows to manic highs). The Quarterly Minimum Data Set (MDS) assessment with a target date of 11/14/24 noted Resident #17's cognition was moderately impaired with a Brief Interview for Mental Status score of 09. Resident #17 used a wheelchair for mobility and required substantial assistance from staff to roll from left to right, transfer, and going from a lying to sitting position. The assessment noted Resident #17 was not on a physician-prescribed weight-loss regimen and had a weight loss of 5% or more in the last month or 10% or more in the last…
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 before2024-09-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, residents and staff interviews, the facility failed to ensure timely repairs to maintain a safe and comfortable environment for 8 (Residents #1, #2, #6, #19, #20, #21, #22, and #23) of 15 residents of the [NAME] wing (300 hall). The findings included: On 9/25/24 at 6:15 a.m., during a tour the temperature in the 300 hallway felt warmer than the rest of the facility. The thermostat in the hallway next to room [ROOM NUMBER] did not display a temperature. Photographic evidence obtained. On 9/25/24 at 6:29 a.m., a hygrometer was used to measure the temperature in the room shared by four Residents, (Residents #1, #2, #19 and #20). The temperature was 82.4 degrees Fahrenheit (F). On 9/25/24 at 6:30 a.m., Resident #1 was observed in bed, uncovered, wearing a brief. In an interview, Resident #1 said, It's hot. A large fan was observed blowing warm air into the room. Certified Nursing Assistant (CNA) Staff A was observed in Resident #1's room. She said the room was hot. Staff A said…
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 before2024-09-25 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to demonstrate prompt efforts to address and resolve grievances related to comfortable temperature, pest control and staff treatment of residents for 10 (Residents #1, #2, #7, #6, #5, #8, #9, #10, #11 and #13) of 10 sampled residents who complained about unresolved grievances. The findings included: The facility's policy for Complaint/Grievance with an effective date of 9/7/23 noted, The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution . The resident should have reasonable expectations of care and services and the center should address those expectation in a timely, reasonable, and consistent manner . An employee receiving a complaint/grievance from a resident, family member and/or visitor…
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 · E2024-09-25 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to implement effective pest control measures to address ongoing sightings of roaches. The findings included: On 9/25/24 at 5:45 a.m., Licensed Practical Nurse (LPN) Staff E was observed swiping a live brown crawling insect from the top of the medication cart of the secured unit. LPN Staff E said it was a small roach. The live insect was observed crawling away on the floor. Staff E did not attempt to kill the insect. On 9/25/24 at 8:45 a.m., in an interview Resident #7 said the facility had roaches. The resident said despite the multiple complaints about the roaches, they're still there and it's not any better. On 9/25/24 at 10:05 a.m., LPN Staff F said she sees roaches at the facility but mostly when it rains. She was not sure on how often they spray for roaches. On 9/25/24 at 10:21 a.m., in an interview the DON said she was aware of the complaints related to the ongoing issue related to pest control. The facility was trying…
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 · D2022-09-09 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident, staff interviews, and records review, the facility failed to ensure 1 (Resident #16) of 1 resident reviewed had clothing in good condition. The findings included: On 9/6/22 at 9:50 a.m., Resident #16 said she had asked the nursing staff multiple times over the past several months if she could get new pajamas because the ones she had were torn and had holes in them. Resident #16 said she didn't have any clothing to wear except one extra pair of pajamas which were torn. Resident #16 said because she had no clothing, she has had to wear the same pajamas every day for months. On 9/6/22 at 10:15 a.m., observation revealed Resident #16 had one pink set of pajamas top and bottom which had a large tear, one purple pajama with a large tear, and one blue jacket in her closet. No other clothing was noted in Resident #16's room. On 9/8/22 at 8:00 a.m., via observation noted Resident #16 wearing the same worn and torn pajamas she wore on 9/6/22. Resident #16 still had one pink set of pajamas,…
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 before2022-09-09 · tag F0585 — failed to handle grievances — isolatedHonor 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 record review, resident interview, and staff interviews, the facility failed to implement their policy and have documentation of prompt efforts to resolve a grievance for 1 (Resident #45) of 2 residents reviewed for unresolved grievances. The findings included: The facility's Filing Grievances/Complaints policy (Revised [DATE]) indicated, . Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. Upon receipt of a grievance and/or complaint [blank space] will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary 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.
Show the remaining 9 citations
- Potential for harm · Dcited before2022-09-09 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review the facility failed to revise and/or update the plan of care for 1 Resident (#24) of 1 resident with exit-seeking behaviors. The findings included: On 9/6/22 review of Resident #24's medical record revealed he currently resided in the facility's locked and secured memory care unit. Resident #24 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, old myocardial infarction, major depressive disorder, mood disorder, anxiety disorder, and adjustment disorder. A nursing progress note dated 7/7/22 at 6:00 a.m., noted Resident #24 used his window to exit his room on the secure memory unit and was found outside the facility. They brought Resident #24 back inside the facility. An untimed nursing progress note dated 8/10/22, stated while the nurse was doing her rounds in the memory care unit, she observed Resident #24 outside the building in the courtyard. The nurse wrote that she brought Resident #24 into the building and Resident #24 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 · Dcited before2022-09-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure controlled drugs (narcotic) count records where complete for 2 (Split Hall and [NAME] Hall) of 2 controlled drugs records reviewed. The findings included: On 9/7/22 at 11:00 a.m., a review of the Controlled Drugs-Count Record for the [NAME] Hall and Split Hall provided by the Assistant Director of Nursing (ADON) showed, Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on the controlled Drug Administration Record. 1. The Controlled Drugs-Count Record for the Split Hall for August 2022 and September 2022 lacked the signature of the oncoming nursing staff for the first shift on 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/5/22, 8/10/22, 8/11/22, 8/12/22, 8/13/22, 8/14/22, 8/16/22, 8/17/22, 8/18/22, 8/21/22, 8/22/22, 8/23/22, 8/28/22, 8/30/22, 8/31/22, 9/2/22, 9/5/22, 9/6/22, and 9/7/22. For the 2nd shift on 8/2/22, 8/4/22, 8/5/22, 8/7/22, 8/8/22, 8/9/22, 8/11/22, 8/12/22, 8/13/22, 8/14/22, 8/15/22,…
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 before2021-03-18 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain a safe, sanitary, comfortable and home like environment for residents by not having clean surfaces; resident room furniture and common areas in disrepair; not repairing damaged walls in resident rooms and bathrooms; and having thread bare/torn linens in resident rooms. Not maintaining a sanitary environment had the potential to cause infections and cross contamination and bio growth. The findings included: On 3/15/21 and 3/17/21, during a tour of the facility, the following was observed: On 3/15/21 at 10:20 a.m , observation of room [ROOM NUMBER] was not homelike with bare walls and furniture in disrepair. room [ROOM NUMBER] - missing sections of blinds in the lower left corner of the window. room [ROOM NUMBER] - dresser was peeling, raised and pitted Formica with exposed wood and window blinds were in disrepair. room [ROOM NUMBER] - window blinds broken in lower left corner, drop ceiling grid rusted. The restroom door frame was rusted 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 · Dcited before2021-03-18 · 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 record review, facility policy review, and staff interview, the facility failed to report resident-to-resident abuse to the appropriate state agency for 2 of 2 reports reviewed. Failure to report had a potential for further incidents of abuse to occur to vulnerable residents. The findings included: On 3/17/21, review of the facility's Abuse Prevention Policy specified, 1. Breeze Care Center is committed to protecting our resident form abuse by anyone including, but not limited to: facility staff, other residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. This Center will thoroughly investigate all reports of suspected abuse (mental, physical, sexual, or verbal) or neglect or exploitation regardless of the source of the information (staff member, family member, visitor, Adult Protective Services (APS), resident, etc.). Report it to the Administration/designee and/or the Director of Nursing immediately. Regardless of who the suspected abuser is…
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 before2021-03-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to revise a resident's care plan to address the identified problem of physical aggression resulting in injury towards another resident. The facility did not identify triggers, plan care, and provide individualized interventions to prevent and minimize agitation towards others for 1 (Resident #75) of 5 residents reviewed for behaviors. The findings included: The facility's policy Care Plans-Comprehensive, revised October 2010, states An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs is developed for each resident. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents change. On 3/15/21 at 10:17 a.m., Resident #75 was observed walking in the hallway of the 700 unit. The resident was confused and not responding…
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 · D2021-03-18 · 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
Based on observation, resident and staff interview, and record review, the facility failed to provide activities to meet the interests of 3 (Resident #7, #14, and #67) of 4 residents reviewed for activities. The lack of an ongoing activity program and lack of contact and interaction with the community could lead to a decline in residents' mental and psychosocial well-being. The findings included: 1. On 3/15/21 at 11:00 a.m., Resident #7 was observed in bed with the television (TV) on. Resident #7 was nonverbal but could understand when you ask him a question. No one on one activity noted for resident #7. On 03/16/21 at 10:28 a.m., Resident #7 was observed just lying in bed, there was no TV or radio on in the room. No one on one activity noted for Resident #7. On 3/16/21 4:00 p.m., Resident#7 was observed in bed watching TV no one noted in his room. No one on one activity noted for Resident #7. On 3/17/21 at 10:05 a.m., Resident #7 was just changed and cleaned, was able to tell me with eye movement he wanted the channel on his TV changed. No one on one activity noted for Resident #7.…
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 · D2021-03-18 · 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, staff and resident interview, and record review, the facility failed to administer prescribed and available medication to prevent 1 (Resident #76) of 1 resident reviewed from itching his skin causing multiple areas scratched to have broken and bleeding skin on his forearms, legs, and trunk. Resident did not receive his ordered medication for 8 days after it arrived, even though staff knew about the resident's skin condition. The findings included: On 3/15/21 at 9:36 a.m., Resident #76 was observed laying in his bed with his arm exposed on top his sheets. Resident bilateral arms had multiple scratch marks and what appeared to be scrapes. One area on resident's left forearm was approximately 6 inches long and 1inch wide and appeared to have dried blood on it. The resident's right forearm had multiple quarter size areas of scratched skin that also appeared to have dried blood. Resident's fingernails were also noted to have dried red substance under each nail. On 3/15/21 at 9:36 a.m., in…
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 before2021-03-18 · 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 record review, staff and pharmacist interview, the facility failed to ensure timely administration of physician-ordered medications received from the pharmacy and/or available in the facility's emergency drug kit (EDK) to meet the needs of 2 (Residents #75 and #76) of 7 reviewed for medications. This resulted in Resident #76 not receiving ordered medications, causing to resident to scratch and itch to the point of breaking his skin and causing bleeding in several areas of forearms. The findings included: The facility's policy 1A1: Provider Pharmacy Requirements, dated April 2017, stated Providing routine and timely pharmacy service as contracted, and emergency pharmacy service 24 hours per day, seven days per week. emergency or stat medications are available for administration no more than 4 hours after the order is received by the pharmacy. All other new medication orders are received and available for administration as soon as possible on the next routine delivery, unless indicated otherwise by…
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 · D2021-03-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and staff interview, the facility failed to maintain complete and accurate records in the areas of Activities of Daily Living (ADL), resident weights, and wound and treatments for 4 (Residents #15, #28, #65, and #76) of 18 residents reviewed. Accurate and complete records were necessary to document the course of a resident's care provided by the facility. The findings included: 1. On 3/15/21 at 11:00 a.m., reviewed Resident #15's clinical record. Diagnosis included right sided cerebral vascular accident (CVA) with left sided paralysis, hypertension (HTN), gastro-esophageal reflux disease (GERD), hyperlipidemia, Depression, Diabetes Mellitus (DM) and schizophrenia disorder. Comprehensive care plan reviewed included focused areas of concern on activities of daily living needs, incontinence concerns and documenting Resident #15 at risk for decline in nutritional status. Documentation in Resident #15's care plan showed Resident needs assistance with ADL's, extensive assist, limited assist both checked on care plan. Resident #15 Mini Nutritional…
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
$427,597 in federal fines across 2 penalties.
- $160,505 — penalty dated 2025-12-17
- $267,092 — penalty dated 2025-05-24
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 ELIYAHU MIRLIS — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.1 | -1.1 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 1 of 5 | 3.2 | -2.2 vs chain |
The other 12 homes this chain runs (chain average 2.1★, 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 |
|---|---|---|---|---|
| 1755 18TH STREET SARASOTA HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2023 |
| MIRLIS, ELIYAHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 99% | since 08/01/2023 |
| ROCHE, DWIGHT | Individual | MANAGING CONTROL - GOVERNING BODY; CONTRACTED MANAGING EMPLOYEE; W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2023 |
| THORNGREN III, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/01/2023 |
CMS files one row per role, so the 10 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $161K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105774. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, 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 →
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