Siesta Key Health And Rehabilitation Center
4602 Northgate Court, Sarasota, FL 34234 · For profit - Limited Liability company · 120 certified beds · (941) 355-2913 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 7 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 19% of its spending goes to commonly-owned related companies
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.7% | 5.5% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.9% | 0.7% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.4% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.7% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.5% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.3% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.0% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 42.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.4% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 4.12 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.24 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 71.4% 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 35 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 0.39 therapist hours per resident per day in 2026Q1 — more than 67% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.6–15.4 | 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 | 71.4% | 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 | 57.1% | 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 | 60.0% | 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 | 100.0% | 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 | 96.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.6% | 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 | 3.1% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 120 beds and averages 89.9 residents a day — about 75% occupied, or roughly 30 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.32 hrs/resident/day on weekends vs 3.47 on weekdays — 4% thinner on weekends. RN hours go from 0.62 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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 unchanged from the previous inspection. 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.
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.
26 citations, most serious first. The 18 most serious are shown; the remaining 8 are one tap away and print in full.
- Immediate jeopardy · K2023-08-06 · 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 observations, record review and staff interviews, the facility failed to implement processes to ensure the residents' right to a safe and clean environment in that they failed to ensure an environment free of disease-causing pests. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility consistently failed to implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to provide a safe and sanitary environment free of disease causing pests created a likelihood of spread of diseases through direct or indirect contact with infected rodents which could result in serious illness, or death, resulting in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. Rodents can also damage building structures and start fires by gnawing…
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 · K2023-08-06 · 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 Based on observations, record review, review of the facility's policies and procedures and staff interviews, the facility failed to protect the residents' rights to be free from neglect in that they failed to adequately address ongoing presence of rats in the facility, including the kitchen. On 12/19/22 the facility became aware of the rodent infestation in the building, including the kitchen, and neglected to implement appropriate immediate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people from direct or indirect contact with infected rodents which could result in serious illness, or death. Rodents can also damage building structures and start fires by gnawing electrical wiring. The facility failed to consistently implement recommendations from the contracted pest control company, including trimming back over hanging trees next to the building to prevent wildlife easier access to the building. The facility failed to identify and repair all rodent entry points into…
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 · K2023-08-06 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to mitigate rodent infestation in the foodservice establishment and failed to take effective measures to protect packaged food, clean equipment, single service, and single use items from contamination from rodents. On 12/19/22 the facility became aware of rodent infestation in the kitchen and failed to take effective immediate actions to eradicate rodent infestation, store and prepare food in a manner to prevent contamination from disease causing rodents. This failure created a serious threat to residents health and safety due to the spread of certain diseases from rodents to people from cross contamination of food and equipment from infected rodent urine, feces, and saliva which could result in serious illness or death and resulted in the determination of Immediate Jeopardy at a scope and severity of pattern (K) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ…
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 · K2023-08-06 · 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
Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure a safe and sanitary environment free from disease causing pests. On 12/19/22 the facility administration became aware of a rodent infestation. The facility Administration failed to take appropriate actions to eradicate the rodent infestation. Certain diseases can spread from rodents to people through direct or indirect contact with infected rodents which could result in serious illness, or death of residents. Rodents can also damage building structures and start fires by gnawing electrical wiring, the extent to which is not known at this time. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of ready to use packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility Administration failure to take…
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 · K2023-08-06 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to show effective communication and coordination to develop and implement adequate corrective actions related to pest control and rodent infestation to ensure a safe and sanitary environment free from disease causing pests, which could lead to the spread of diseases from direct and indirect contact with infected rodents. On 12/19/22 the facility administration became aware of a rodent infestation. On 7/31/23 through 8/3/23 multiple observations of rodent feces on the kitchen floor, and on the shelves of the dry storage food area used to store ready to eat food. Observation of single service packets of mayonnaise with visible rodent bite marks stored in a basket in the kitchen. The facility's lack of an effective ongoing QAPI (Quality Assurance and Performance Improvement) process to protect residents' health and safety created a likelihood of serious illness or death for the residents from direct or indirect contact with infected rodents resulted in the determination…
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 · K2023-08-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility policy and resident and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the developement and transmission of zoonotic (animals) and vector-borne (e.g., mosquitoes, ticks, and fleas) disease and infections by rodent infestation. The facility failed to follow infection control practices and failed maintain urinary catheter drainage in a sanitary manner for 2 (Resident #4 and Resident #5) of 2 residents reviewed for urinary catheters. The facility failed to ensure staff followed infection prevention measures by failure to follow personal protective equipment (PPE) guidelines for residents on transmission based precautions for COVID-19, and failure to handle medications in a sanitary manner. The facility became aware on 12/19/22 of a rodent infestation in the building. On 7/31/23 through 8/3/23 multiple…
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 · K2023-08-06 · 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, interview and record review, the facility failed to ensure adequate pest control measures to eradicate an ongoing rodent infestation. On 12/19/22 the facility became aware of rodent infestation in the building, including the kitchen. The facility failed to consistently implement the recommendations from the contracted pest control company to trim back over hanging trees next to the building to prevent wildlife from getting easier access to the building. The facility failed to identify and repair all rodent entry points. The failure to implement adequate measures to eradicate and contain a rodent infestation created a serious threat to residents health and safety due to the spread of certain diseases from direct or indirect contact with rodents and resulted in the determination of Immediate Jeopardy (IJ) starting on 12/19/22. On 8/4/23 at 7:28 p.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The Immediate Jeopardy was ongoing. The facility census…
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 · G2023-08-06 · tag F0791 — failed to provide routine dental services — isolatedProvide 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 observations, record review, resident and staff interviews the facility failed to ensure 2 (Resident #29 and Resident #88) of 2 residents reviewed experiencing mouth pain, received dental services to meet their needs. The findings included: The facility policy for Dental Services Implemented 1/2022 and last revised 5/2022 stated, it is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease/dental radiographs as needed, dental cleaning, fillings, minor partial or full denture adjustments, smoothing broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-30 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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, residents representatives and staff interviews, the facility failed to ensure the Residents funds were conveyed to the appropriate party within the required 30-day timeframe after death or discharge from the facility, for 3 (Residents #15, #26, #27) of 3 Residents reviewed.The findings included:Review of the facility policy Refund of Overpayments Policy #10410, effective date February 1, 2019, revised date [DATE] states, Refunds Due Resident: 2. Within thirty (30) days of death of a resident, the residents personal funds and final accounting of those funds will be made available to the residents representative or to the probate administering the residents care.1. Review of the clinical record for Resident #15 revealed an admission date of [DATE] and a discharge date of [DATE]. On [DATE] at 2:10p.m., in a telephone interview, Resident #15's Power of Attorney said that while his mother was in the facility she had about $1800.00 or more in her account. He said his mother died in [DATE]. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-01 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, residents and staff interviews, the facility failed to provide the necessary services to maintain personal hygiene for 3 (Residents #25, #68 and #12) of 4 dependent residents reviewed for activities of daily living (ADL). The findings included: The facility policy Activities of Daily Living (ADL's) implemented 11/3/20 (revised 11/29/22) documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #12 had a readmission date of 8/1/22 with diagnoses including dementia, depression and anxiety. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 4/30/24 documented the resident required substantial to maximum staff assistance for personal hygiene. The MDS noted Resident #12's cognitive skills…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-01 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 (Resident #63) of 7 residents reviewed by failing to follow physician's orders parameters for medication administration. The findings included: Review of facility policy titled Medication Administration dated 5/24/2023 showed, Policy Statement: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice. Policy Compliance Guidelines: 8. obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . Clinical record review revealed Resident #63's diagnoses included Essential (Primary) Hypertension (High Blood Pressure). Review of the physician's orders revealed Resident #63's medication regimen included: Amlodipine Besylate 10 mg (milligrams) one tablet by mouth one time a day related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-01 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, review of facility's policies and procedures and staff interviews, the facility failed to ensure the medication regimen review identified medications administered without adequate monitoring for 1 (Resident #63) of 7 residents reviewed for unnecessary medications. The findings included: Review of the facility's policy and procedure titled, Medication Regimen Review with a date reviewed/revised of 1/2022 noted, The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart . Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. The MMR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. b. Collaboration with other members of the interdisciplinary team . Facility…
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 before2024-02-23 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 issue in writing the Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 3 (Residents #17, #463, and #464) of 3 residents reviewed for advanced beneficiary notices. This had the potential for residents to not be aware of the right to appeal the facility decision to terminate Medicare services. The findings included: The facility policy Advanced Beneficiary Notices documented, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . A Notice of Medicare Non-Coverage (NOMNC) Form shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization . The notice shall be written legibly in a language and or format that the resident/representative understands. Verbal…
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 before2024-02-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Residents #7, #12 and #461) of 3 residents reviewed for Activities of Daily Living (ADL). The findings included: The facility policy Activities of Daily Living (ADL's) (Revised 11/29/22) documented, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #7 was had an admission date of 5/26/22. Diagnoses included Parkinson's disease, Huntington's disease, dementia, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment…
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 · D2024-02-23 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical records, review of facility policies and procedures, and staff interviews, the facility the facility failed to implement meaningful resident centered activities to meet the interest and wellbeing of 2 (Resident #7 and #12) of 2 residents reviewed for activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. The findings included: The facility policy Activities implemented 11/2023 (revised 2/24) documented, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but not…
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 before2023-08-06 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to ensure 7 (Residents #35, #40, #55, #67, #73, #194, #88) of 7 residents received medications in accordance with professional standards of practice by failing to order medications on a timely manner or failure to administer medications in accordance with the physician's orders. The findings included: Review of facility policy titled, admission Orders, revised 5/2022 which states, A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and /or verbal orders for the residents' immediate care and needs. 1. The written and/or verbal orders should include at a minimum: (a) Dietary, (b) Medication orders if indicated; (c) Routine care orders. 2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. 3. The orders should provide information to maintain 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 · E2023-08-06 · tag F0730 — patternObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and staff record review the facility failed to ensure 4 (Staff O, CC, DD, and FF) of 5 staff employee records had a performance review completed at least once every 12 months with in-service education based on the outcome of the performance reviews. The findings included: Review of the Facility Assessment Tool last updated on 5/19/23, noted documentation in the Staff Training/Education and Competencies section the nurse aides are required to have in-service training throughout the year. In-service training must . address areas of weakness as determined in nurse aides' performance reviews as noted in the Facility Assessment Tool and the training may address the special needs of residents as determined by the facility staff. On 8/3/23 a review of Staff O's employee file, a CNA (Certified Nursing Assistant), revealed a date of hire of 6/11/14. Further review of Staff O's employee file failed to reveal documentation of an annual performance review for 2022 nor 2023. On 8/3/23 a review of Staff CC's employee file a CNA, revealed a date of hire of 11/21/12.…
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 · E2023-08-06 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, resident records review and facility policy review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. The facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Keep medication cart clean, organized and stocked with adequate supplies . 11. Compare medication source with medication administration record (MAR) to verify resident name. form, dose, route, and time. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise…
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 8 citations
- Potential for harm · E2023-08-06 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, resident records review and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Two nurses and 25 opportunities were observed. Six medication errors were identified, resulting in a 24% medication error rate. The findings included: Review of facility policy titled, Medication Administration, revised 5/3/2022 which states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 11. (b) Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 8/2/23 at 8:04 a.m., observed Licensed Practical Nurse (LPN), Staff H, administer seven different scheduled medications to Resident #40. The physician's orders included Cyclobenzaprine HCl Tablet 10 milligrams (mg) one tablet by mouth three times a day related to chronic pain syndrome. LPN Staff H did not administer the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-06 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record review, the facility failed to ensure residents with chewing or swallowing problems were served diets in a form to meet their individualized needs as prescribed by their physician for 2 (Resident #58 and #61) of 9 residents reviewed. This failure could potentially cause inadequate nutritional intake or swallowing concerns. The findings included: The facility dietary guideline titled: Texture Progression stated Pureed: all foods must be presented in a form that is homogenous and cohesive in nature, e.g. foods should have a pudding or mousse like consistency. Most foods would be pureed and/or strained to ensure a smooth cohesive consistency without lumps. On 7/31/23 at 11:54 a.m., Certified Nursing Assistant (CNA) Staff Q was observed feeding Resident #58 a pureed diet. The blueberry muffin was not pureed into a homogenous smooth texture. The CNA stated, those look like blueberries, its chunky. Photographic evidence obtained On 8/1/23 at 12:23 p.m., Resident #61 and Resident #58 were observed eating lunch. Both Residents had orders for a pureed diet and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-06 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, review of facility policy, record review and staff interview the facility failed to act promptly upon the grievances expressed by the resident group. The facility failed to have documentation of their response and rationale. Five residents participated in the Resident Council interview. The findings included: The facility policy Resident and Family Grievances (revised 3/8/22) documented it is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve include facility acknowledgement of complaint/grievance and actively working toward resolution of that complaint/grievance. 1. At the Resident Council meeting, attended by five residents, on 8/1/23 at 2:10 p.m., Resident #2 said she had not received her scheduled showers since May 31, 2023. Resident #2 said she had reported her concern regarding showers during the council meetings. On 8/1/23 at 2:15 p.m., the Activity Director confirmed Resident #2 had expressed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 staff interviews and record review the facility failed to ensure they had discussed formulating an advance directive which would include the right to accept or refuse medical or surgical treatment with the resident or their representative for 1 (Resident #86) of 3 residents reviewed for advance directives. The findings included: A review of the facility policy, The Residents' Rights Regarding Treatment and Advance Directives implemented 11/2020, and last reviewed/revised on 1/2022 stated it was the policy of the facility to support and facilitate a resident's right to request, refuse, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Under the Policy Explanation and Compliance Guidelines, number 5 stated the facility would identify or arrange for an appropriate representative for the resident to serve as the primary decision maker if the resident was assessed as unable to make relevant health care decisions. On 8/1/23 review of Resident #86's medical records…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, record review and staff interview the facility failed to provide the necessary care and services to maintain personal hygiene and nutrition for 4 (Resident #2, #52, #55 and #65)) of 4 residents reviewed for activities of daily living (ADL). The findings included: The facility policy Activities of Daily Living documented, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in Activities of Daily Living (ADL's) do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #2 had an admission date of 7/13/23 with diagnoses including Multiple Sclerosis, muscle weakness, and Bipolar disorder. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-06 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff and resident interview the facility failed to ensure a resident with lost glasses received the proper treatment to maintain vision and assist with arrangements to have the glasses replaced in a timely manner for 1 (Resident #88) of 1 resident reviewed for vision impairment. The findings included: The Facility policy titled Hearing and Vision Services, revised 5/2022 stated the facility is to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Employees should refer any identified need for vision services to the social worker or social service designee. The social worker or designee will assist the resident by making appointments and arranging for transportation. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision. Assistive devices to maintain vision include glasses, contact lenses, and magnifying lens or other devices used by the 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.
- Potential for harm · D2023-08-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 observation, review of facility policy, review of the clinical records and staff interviews, the facility failed to provide appropriate restorative services and physician ordered interventions for the management of contractures (fixed deformity of joints) for 1 (Resident #31) of 1 resident reviewed with positioning devices. The findings included: The facility policy Restorative Nursing Programs (revised 5/2022) documented, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The interdisciplinary team with the support and guidance form the physician, will assure the ongoing review, evaluation, and decision…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-06 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, records review, and facility policy review, the facility failed to ensure medications left at the bedside were appropriately stored for 1 (Resident #73) of 1 resident observed with unsecured medications at the bedside and 1 (North Hall) of 2 medication carts observed. The findings included: Review of facility policy titled, Medication Storage, revised [DATE] noted, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. Review of facility policy titled, Destruction of Unused Drugs, revised 5/2022 which stated,…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; lowest-rated first.
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 | Since |
|---|---|---|---|
| BEARD, LAURA | Individual | W-2 MANAGING EMPLOYEE | since 04/20/2020 |
| GORELICK, BATYA | Individual | CORPORATE OFFICER | since 04/20/2020 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% 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 $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 105407. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-01, 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.