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Sarasota Health And Rehabilitation Center

1524 East Avenue South, Sarasota, FL 34239 · Non profit - Other · 144 certified beds · (941) 365-2422 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20252 immediate-jeopardy citations$230,102 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 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 $230,102 in federal fines (most recent 2025-01-14)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1435 S Tamiami Trl · (941) 554-4301 · Call to confirm hours
Pharmacy
1281 S Tamiami Trl · (941) 365-9116 · Call to confirm hours
Grocery
1960 Hillview St · (941) 210-3535 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2256 Bahia Vista St · (941) 955-6479

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.9%8.7%15.4%better
Long-stay residents who lose too much weight5.3%5.5%5.4%typical
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 infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.2%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.2%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers5.3%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control3.6%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table8.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine94.8%94.7%79.4%better
Short-stay residents rehospitalized after admission27.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.9%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.632.131.67typical
Long-stay outpatient ER visits per 1,000 resident days0.981.151.80better

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.

26.5% 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 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

26.5%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
43.2%U.S. median 56.6%
Met the expected recovery
0.56U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 43.2% 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 88 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 47% 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 SNF26.5%CMS range 18.9–35.951.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.7–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge43.2%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 discharge45.5%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 discharge39.8%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened0.8%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 hospitalization7.8%CMS range 4.9–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.021.02Oct 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

0.59
RN hours/ resident / day
0.64
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.38
RN hoursweekends
43.4%
Total nursing turnover
48.3%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 128.5 residents a day — about 89% occupied, or roughly 16 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.26 hrs/resident/day on weekends vs 3.54 on weekdays — 8% thinner on weekends. RN hours go from 0.67 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2024-06-05)
2
at the previous standard inspection (2022-08-25)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · K2025-05-02 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility's policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from abuse. The facility neglected to have effective processes in place in the secured unit to supervise 15 (Residents #13, #6, #14, #1, #2, #15, #16, #17, #3, #4, #7, #8, #10, #9, #12) of 15 cognitively impaired residents with aggressive behaviors resulting in multiple avoidable resident-to-resident altercations. On 3/12/25, Resident #13 with known aggressive behavior towards others was not adequately supervised. Resident #6 was blocking the door to the hallway. Resident #13 hit Resident #6 to get past him. On 3/12/25, Resident #14 with known aggressive behavior towards others was not adequately supervised. Resident #14 ran into Resident #13 with her wheelchair then hit Resident #13. On 3/14/25, Resident #2 with a diagnosis of dementia with other behavioral disturbance wandered unsupervised into Resident #1's room. Resident #2 scratched Resident #1's cheek when…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Kcited before2025-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to implement processes on the secured dementia unit to ensure adequate supervision of 15 (Residents #13, #6, #14, #1, #2, #15, #16, #17, #3, #4, #7, #8, #10, #9, #12) of 15 cognitively impaired residents with aggressive behaviors to prevent multiple avoidable incidents of resident-to-resident physical altercations. On 3/12/25, Resident #13 was not adequately supervised. Resident #6 was blocking the door to the hallway. Resident #13 hit Resident #6 to get past him. On 3/12/25, Resident #14 was not adequately supervised. Resident #14 ran into Resident #13 with her wheelchair then hit Resident #13. On 3/14/25, Resident #2 wandered unsupervised into Resident #1's room. Resident #2 scratched Resident #1's cheek when she asked him to leave the room. On 3/18/25, Residents #15, #16 and #17 were not adequately supervised in the activity room of the secured unit. Resident #15 hit Resident #16. Resident #17 then hit Resident #15. On 3/20/25, Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent repeated falls for 3 (Residents #1, #2 and #3) of 3 residents identified to be at risk for falls and sustained multiple falls at the facility, including falls with injuries requiring emergent transfers to acute care hospitals. The findings included: The facility policy titled Fall and Injury Reduction Policy, effective March 2023 indicated the policy was to assist the facility with reducing the likelihood of a fall or injury while maintaining or maximizing dignity and independence through education of staff and residents, early identification of risk factors by collecting data, identifying resident behaviors which may increase the likelihood of such occurrence. 1. Review of Resident #1's clinical record revealed an admission date of 11/1/23. Diagnoses included vascular dementia, generalized anxiety disorder, and insomnia. Review of the admission Minimum Data Set (MDS) Assessment with an assessment reference date of 11/8/23 noted the resident's cognition was severely…

    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 · E2025-11-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to follow infection control procedures to prevent the potential spread of scabies to residents, staff and visitors in 1 (Memory Care Unit) of 3 units.The findings included:Review of the Facility policy and procedure titled, Infection Prevention and Control Program with an effective date of October 2021 revealed, The Infection Prevention and Control Program is comprehensive program that addresses detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, and personnel. Goals: (a) Provision of a safe, sanitary, and comfortable environment. (b) decrease the risk of infection and communicable diseases development and transmission to residents, visitors, volunteers, and personnel. (c) Monitor for occurrence of infections and communicable diseases and implement appropriate prevention measures to reduce occurrences.Review of the Facility Policy and Procedure Scabies: Management effective August 2025…

    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 before2025-11-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to have documentation of a thorough investigation for an injury of unknown origin for 1 (Resident #2) of 3 residents reviewed. The findings included:Review of the facility's policy and procedure titled, Abuse Prevention Program with a review date of September 2025, revealed, The facility has designated and implemented processes, which strive to reduce the risk of abuse . Investigation: NHA [Nursing Home Administrator] or designee is notified and will initiate and conclude a complete and thorough investigation within the specific timeframe. Investigation may include but may not be limited to: Resident statements/interviews; Employee statements/interviews . Observation of resident(s), staff, environment . Re-enactment of event .Review of the clinical record for Resident #2 revealed an admission date of 1/1/24 with a most recent admission date of 9/22/25. Diagnoses included displaced fracture of base of neck of right femur, unspecified dementia, and anxiety disorder.Review of the Discharge Minimum Data Set (MDS) with 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-27 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility's policies and procedures and staff interviews, the facility failed to protect the health, welfare and rights of each resident by failing to ensure 1 (Staff A) of 5 staff reviewed was screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before beginning employment. The findings included: Review of the facility's Abuse Prevention Program effective 2012 and most recent change date of November 2024 revealed, The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property . Implementation and ongoing monitoring . Potential employees will be screened, per federal &/or state regulation, during the hiring process for history of abuse, neglect, or mistreatment of residents. Screening will consist of . Criminal background checks will be completed to identify any potential employee unfit to work in LTC (Long Term Care) . Review of the facility's current employees list revealed Staff A was a dietary aide…

    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 · D2025-01-14 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 honor the resident or the responsible party's right to be informed of the risks, benefits, side effects, and alternatives of psychotropic medications administered by the facility to 1 resident (#7) of 3 reviewed for informed consent for psychotropic medications. The findings included: Review of the medical record revealed Resident #1was admitted to the facility on [DATE]. The comprehensive assessment dated [DATE] revealed Resident #7 had diagnosis of non-Alzheimer's dementia. The resident's diagnosis list did not include anxiety, depression, or psychotic disorder. The resident's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. On 7/30/24, the physician certified the resident was incapable of making informed medical decisions because the resident could not understand the consequences. The resident's son was appointed as health care surrogate (HCS) on 7/29/24. The HCS was responsible for making health care…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 interview and record review the facility failed to thoroughly investigate one (Resident #1) of two residents surveyed for an injury of unknown origin when the injury was identified as being an older injury the facility failed to look back at an injury which had occurred three days prior to the injury being assessed and investigate if the injury had occurred during that same time period. The findings included: Resident #1 is a [AGE] year-old female who was admitted to the facility on [DATE] with Cerebral Infarct, Schizophrenia, Dementia, Bipolar Disorder, Hemiplegia of the left side, Anxiety, EPS, Chronic Pain, and Osteoarthritis. The Quarterly Minimum Data Set (MDS) dated [DATE] shows Resident #1 had a Brief Mental Status Interview (BIMS) score of 00. This score shows a severe cognitive impairment. Section GG of the MDS shows Resident #1 was dependent on staff for providing personal care and mobility of transferring and toileting. A progress note dated 6/20/24 at 5:36 p.m. reads, Staff notice resident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 provide the delivery of social services for discharge and transfer assistance for 1 (Resident #7) of 3 residents reviewed for discharge and transfer from the facility. The findings included: Review of the facility Social Work policy effective February 2021 revealed, The facility will provide an adequate number of staff to provide for the medically related social services needs of resident/patient(s). The Social Worker/designee .function as the Discharge Planner and are responsible for formulating the initial discharge plan and projected discharge date .Identify and seek ways to support residents' individual needs and preferences, customary routines, concerns and choices. Review of the record revealed Resident #7 was admitted on [DATE] with diagnosis of toxic encephalopathy (A brain disease that can cause memory loss, seizures and coma.) and dementia. Review of the care plan by the social worker initiated on 4/24/24 revealed Resident #7 and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-05 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 record review, and staff interviews, the facility failed to ensure they maintained communication between the nursing facility and the dialysis center related to the ongoing assessment of a dialysis resident before and after each dialysis treatment for 1 (Resident #24) of 1 resident who was receiving dialysis. The findings included: The facility's undated policy titled, Dialysis Management (Hemodialysis) stated the facility would coordinate care and services for hemodialysis residents . Complete the Dialysis Communication Tool before and after dialysis and follow up on any special instructions from the dialysis center. The Dialysis Communication Tool form instruction stated the purpose of the form was to maintain communication between the dialysis provider and the facility clinical staff. The nurse assigned to the resident scheduled for dialysis would ensure a dialysis communication tool was completed and sent with the resident to the dialysis center. Nursing would ensure sections 1, 2 and 3 were…

    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 · E2024-06-05 · tag F0791 — failed to provide routine dental services — pattern
    Provide or obtain dental services for each 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, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to provide or obtain dental services to meet the needs of 4 (Resident #25, #44, #45, #94) of 6 residents reviewed for dental services. The findings included: The facility Dental Services Policy and Procedure effective March 2023 stated, The facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures. This dental care may be provided in-facility or by scheduling and transporting to a dental provider. In case of an emergency the resident will be transported to a facility that provides emergency dental services. Whenever possible the facility will secure a dental contract to provide in-house dental services; If an in-house dental contract is not available, the facility will maintain a dental provider list in the community that will provide dental services to the residents; 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 · E2024-06-05 · tag F0850 — failed to provide social-work services — pattern
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility's policy and procedure and staff interview, the facility licensed for 169 beds failed to ensure the full-time social worker had the required qualifications. The findings included: On 6/1/124, review of the daily census showed 119 current residents. Review of the facility Policy and Procedure for Social Services effective February 2021 noted, The facility strives to ensure the Social Services staff have qualifications that are commensurate with State and Federal regulations, defined job responsibilities, applicable licensure law, regulation and applicable certification to meet the residents/patient's needs . On 6/4/24 at 9:10 a.m., the Social Service Director said she became the full-time Social Worker at the facility in March 2024 when the previous Social Worker left. She said she held a bachelor's degree in social work; however, she did not have one year of supervised social work experience in a health care setting working directly with individuals. On 6/4/24 at 6:00 p.m., in an interview the Regional Consultant said the previous social worker left…

    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 · D2024-06-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 clinical record review, and staff interviews the facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives of 1(Resident #92) of 2 residents reviewed for code status and advanced directives. The findings included: Review of the clinical record for Resident #92 revealed an admission date of [DATE]. Diagnoses included anxiety disorder, and Parkinson's disease. The admission Minimum Data Set (MDS) assessment with a target date of [DATE] noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 4. The Quarterly MDS assessment with a target date of [DATE] noted a BIMS score of 3 (severe cognitive impairment). Review of the resident's advance directives dated February 5, 2024, noted Resident #92 designated his sister as durable power of attorney. This designation did not include health care decisions. Review of the physician's orders revealed on [DATE] the physician issued a Do Not Resuscitate Order (DNR), directing the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-06-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, clinical record review, and staff interview, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the dental status for 1 (Resident #25) of 4 residents reviewed for accurate dental assessment. Inaccurate MDS assessments could result in a resident not receiving or a delay in the appropriate health care. The findings included: On 6/2/24 at 10:55 a.m. via observation noted Resident #25 had multiple missing and broken teeth. Resident #25 said she was admitted to the facility with multiple missing, and broken teeth. She said she had told multiple nursing staff she would like to have all her teeth extracted so she could get upper and lower dentures. Review of the MDS, a resident assessment and care screening tool, dated 2/15/24 coded Resident #25's Brief Interview for Mental Status (BIMS) score as 14 out of 15. A BIMS score of 13 to 15 meant the resident was cognitively intact and capable of daily decision making. Section L (Oral/Dental Status) stated Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to provide necessary assistance with grooming and nail care for 2 (Resident #29 and #44) of 3 dependent residents reviewed for activities of daily living. The findings included: Review of facility Certified Nursing Assistant (CNA) job description, indicated the CNA is responsible for assisting with direct resident care within the scope of their practice. Work includes components of direct patient care such as hygiene. Direct care responsibilities include: Ensures that each resident's personal care needs are being met in accordance with the resident's wishes, Bathes residents, provides nail and hair care and provides denture care. 1. Review of Resident #29's clinical record revealed admitting diagnoses included a history of traumatic brain injury, epilepsy, dementia, stiffness of joints, speech and language deficit. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #29 had a Brief Interview for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure 2 Residents (#24, and #106) of 5 residents reviewed for attended activities of their choice, to ensure they maintained and/or improved their psychosocial well-being and independence. The findings included: 1. On 6/2/24 at 10:30 a.m., 11:16 a.m., 12:35 p.m., and 3:00 p.m., Resident #24 was observed in her room, in bed. The television or radio was not on and the resident was not observed in an in-room or an out of room facility activity program during the day. On 6/4/24 at 9:30 a.m., 11:30 a.m., 1:25 p.m., and 4:00 p.m. Resident #24 was observed in her room, in bed, without the television or radio on. The resident was not observed in an in-room or an out of room facility activity program during the day. Review of Resident #24's clinical record revealed she was admitted to the facility on [DATE] with diagnoses of anemia, end stage renal disease, heart failure, history of falling, gastroenteritis, and colitis. The Activity…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide timely assistance to address lost prescription glasses for 1 (Resident #94) of 2 residents reviewed for vision services. The findings included: Review of the facility's policy and procedures titled, Vision/Hearing Services with an effective date of February 2021 noted, The facility will assist residents in obtaining routine and prompt vision/hearing care. The Social Services department will work to assist and /or coordinate services, such as . Prompt referrals (i.e. glasses, etc.) 3. Identify those residents who require a prompt referral . Lost . glasses, or other assisted devices. Review of the clinical record for Resident #94 revealed an admission date of 11/1/23. The admission Minimum Data Set (MDS) assessment with a target date of 11/8/23 noted Resident #94's ability to see in adequate light (with glasses or other visual appliances) was impaired. Resident #94 was able to see large print but not regular print in newspapers/books. Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide care and services to prevent a decline in range of motion for 1(Resident #23) of 3 sampled residents with limited range of motion. The findings included: Review of the facility's policy titled, Restorative Nursing Programs with a revision date of October 2017 showed, The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The Interdisciplinary Team (IDT), resident, and or family identify the needs of the resident, and collaboratively determine appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: Contracture Management and Prevention-This program includes the provision of active, and or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records review, staff interviews and facility policy review the facility failed to provide personal hygiene care and incontinence care for 5 ( Residents #1, #3, #4, #5, and #6) of 6 residents reviewed for personal hygiene and incontinence care. The findings included: 1. Review of clinical records for Resident #1 admitted to the facility on [DATE] and transferred to the hospital on 1/19/2024. Resident care plan documents Resident #1 has an ADL (Activities of Daily Living) Self Care Performance Deficit due to pain, weakness. Interventions included Assist of one for personal hygiene and an assist of two staff for toileting. Review of past 30-day Certified Nursing Assistant (CNA) Point of Care (POC) documentation (documents care provided) from the transfer to the hospital on 1/19/24 showed 57 opportunities to provide personal hygiene care with 15 shifts documented and 42 shifts with no documentation. Review of incontinence care provided to resident showed 57 opportunities for CNAs to provide…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of policies and procedures, observation, and staff interviews, the facility failed to provide oxygen therapy in accordance with physician's orders for 2 (Resident #82 and #94) of 4 residents reviewed for oxygen administration. Failure to follow prescribed oxygen therapy may result in inadequate oxygen treatment or increased risk of side effects and complications. The findings included: The facility's Oxygen Therapy policy (SMS O 2 ED 2013) documented, Initiation of oxygen. Verify physician order . Apply device to the patient with appropriate liter flow. The Oxygen concentrator policy (undated) noted to, Verify and understand the physician's order, know the flow rate and duration of use . Adjust the flow meter control knob to the flow setting prescribed by the physician. The graduated line of the meter should be aligned with the center of the floating ball. 1. Review of the clinical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE], noting resident#82 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure common practice standards were followed for timely dressing changes for a PICC (Peripherally Inserted Central Catheter) inserted into the arm through a vein into a larger vein in the chest for 1 Resident (#313) of 1 resident reviewed with a PICC line. Timely dressing changes decrease the risk of complications including local and systemic infection related to the intravenous catheter. The findings included: The Facility's Policy for Dressing Change for Vascular Access Devices, 08/16, from the Infusion Therapy Policy & Procedure Manual copyright 2011 PharMerica Corporation read, Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and PRN (As needed) . On 8/22/22…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-03-04 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 and comfortable environment for residents by not ensuring chairs were cleaned, closets and dresser drawers were functional, overbed tables were free from rust, walls and doors were maintained without damage and air vents were cleaned and uncovered on 1(Memory Care Unit) of 1 Memory Care Unit reviewed. The findings included: On 3/1/21 at 10:00 a.m., a wall outlet was observed uncovered in the activity room on the Memory Care Unit. Photographic evidence obtained On 3/4/21 8:51 a.m., observed damage to the entrance door of room [ROOM NUMBER] and a dresser drawer was missing from room [ROOM NUMBER]. Photographic evidence obtained On 3/4/21 at 8:52 a.m., observed damage to the entrance door of room [ROOM NUMBER], the dresser drawer was observed off the track and not functional. There was a brown stain observed on a seat of a chair next to the A-bed, and there was damage on the wall observed next to the chair. There was damage…

    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
  • No harm found · B2024-06-05 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, record review and staff interview the facility failed to ensure the required nursing staff information was posted daily and failed to maintain the posted daily nurse staffing data for 18 months as required. The findings included: On 6/2/24, 6/3/24 and 6/4/24, during random observations, the daily nurse staffing with the required information was not posted or readily available to residents and visitors. On 6/4/24 at 12:30 p.m., in an interview the Administrator stated that the facility had not posted the required daily staffing with the required information since 2/29/24. The Administrator provided one daily nursing staff posting dated 2/29/24. He acknowledged that the Federal Staffing should be posted daily in a prominent place in the facility.

    Nursing and Physician Services 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

$230,102 in federal fines across 5 penalties.

  • $9,580 — penalty dated 2025-01-14
  • $161,457 — penalty dated 2025-01-14
  • $6,032 — penalty dated 2024-06-05
  • $6,180 — penalty dated 2024-06-05
  • $46,853 — penalty dated 2024-01-25

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 FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 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 52.2-1.2 vs chain
Health inspection 1 of 51.9-0.9 vs chain
Staffing 4 of 53.2+0.8 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 16 homes this chain runs (chain average 2.2★, 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
FI-WALDEMERE, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/23/2002
FLORIDA INSTITUTE FOR LONG TERM CARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/08/2025
JAFFE, HOWARDIndividualCORPORATE OFFICERsince 07/01/2014
KATZ-HALL, KATHYIndividualCORPORATE OFFICERsince 07/01/2014
MULLARKEY, JAMESIndividualCORPORATE OFFICERsince 07/01/2014
RICHMOND, PENNYIndividualCORPORATE OFFICERsince 07/01/2014
AEGIR HEALTH MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2025
CONSULTING SUPPORT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/08/2025
FACILITY SUPPORT COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
KANE FINANCIAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
AMADOR, TRESSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2017
RICHARDS, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/08/2020
OMEGA HEALTHCARE INVESTORS, INCOrganizationADP OF THE SNFsince 07/01/2003
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 08/19/2016

CMS files one row per role, so the 21 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$13.8M
Net patient revenuemost recent cost report
-5.2%
Operating marginrevenue minus expenses
$224K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 8%Other / private 9%

About 83% 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 $224K 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

$333per resident / day
operating cost
$10,124per month
≈ monthly operating cost
$317per 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 105155. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-05, 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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