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Vivo Healthcare Sebring

3011 Kenilworth Blvd, Sebring, FL 33870 · For profit - Corporation · 104 certified beds · (863) 382-2153 Medicare & Medicaid certified

Call the home — (863) 382-2153 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • 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.

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

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1800 Lakeview Dr · (863) 386-0276 · Call to confirm hours
Pharmacy
1542 Lakeview Dr · (863) 304-8792 · Call to confirm hours
Grocery
1544 Lakeview Dr · (863) 402-0240 · Call to confirm hours
Park
1989 Lakeview Dr · Typically dawn to dusk
Place of worship
1000 Persimmon Ave · (863) 402-1053

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.3%8.7%15.4%better
Long-stay residents who lose too much weight10.4%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms4.0%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 injury0.4%2.5%3.3%better
Long-stay residents whose ability to walk worsened5.7%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.3%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control11.2%10.5%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table4.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.4%94.7%79.4%better
Short-stay residents rehospitalized after admission19.6%26.1%22.6%better
Short-stay residents with an outpatient ER visit10.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.052.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.651.151.80better

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.

55.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.0%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 52.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.0%CMS range 46.6–63.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.6–15.610.7%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 discharge52.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.0%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 discharge57.5%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 identified95.9%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%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 hospitalization10.4%CMS range 6.7–14.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 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

0.33
RN hours/ resident / day
0.98
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.40
Total nurse hours/ resident / day
0.18
RN hoursweekends
48.9%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 104 beds and averages 88.4 residents a day — about 85% 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.20 hrs/resident/day on weekends vs 3.48 on weekdays — 8% thinner on weekends. RN hours go from 0.39 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

12
deficiencies at the latest standard inspection (2024-05-20)
6
at the previous standard inspection (2022-05-12)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and record review the facility failed to store food in accordance with professional standards for food safety, related to label and dating opened items, discarding items that were expired and not discarding items covered in bio-growth, in one of one walk-in cooler. Findings Included: During an observation of the walk-in cooler on 04/13/2026 at 10:53 a.m. the following was observed: A box of individually wrapped butter was found open, with butter smeared on the box and at least two of the individually wrapped blocks were open, exposing the butter. The box and the individual blocks were not dated/labeled. A produce box containing green bell peppers. Inside the box were approximately a dozen peppers with black circles on the surface that had a fuzzy black and white bio growth, and two of the peppers had a fuzzy white blue/green substance on the pepper. A produce box containing approximately 10 heads of cabbage. The cabbage heads had black spots all over the circumference of the head.A box of turkey franks that was open, exposing the franks. During 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-03 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than five percent. A total of twelve medication administration opportunities were observed with four errors for two (#4 and #5) of four residents sampled for medication administration, which resulted in a medication administration error rate of 33.33%. Findings included: A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypertension and nontraumatic intracranial hemorrhage. A review of Resident #4's physician orders revealed the following orders: - An order dated 4/23/2024 for levetiracetam 1000 milligrams (mg) one tablet by mouth (PO) every 12 hours at 8:00 AM and 8:00 PM for seizures. - An order dated 5/10/2024 for metoprolol tartrate 50 mg one tablet PO two times a day at 8:00 AM and 9:00 PM for hypertension. An observation of medication administration was conducted on 9/3/2024 at 9:12 AM with Staff A, Licensed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-20 · tag F0644 — pattern
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I for three residents (#63, #56 and #30) of twenty four sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified. Findings included: 1. Review of Resident #63's admission Record revealed an original admission date of 11/23/23 and a readmission date of 4/23/24. The admission Record showed diagnoses to include anxiety disorder as of 2/26/24 and depression as of 2/26/24. Review of Resident #63's medical record revealed a PASARR Level I, dated 11/23/23, and new one completed on 4/16/24. The PASARR Level 1 completed on 4/16/24 did not include the diagnoses of anxiety and depression in Section 1 A MI (mental illness) or suspected MI. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section I -…

    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 · E2024-05-20 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure behavior monitoring for psychotropic medication was in place for five residents (#32, #56, #59, #63 and #65) and failed to appropriately monitor the side effects for psychotropic medication for one resident (#56) of seven sampled residents. Findings included: 1. Review of Resident #56's admission Record revealed an original admission date of 8/16/22 and a readmission date of 10/2/23. The admission Record showed diagnoses to include other stimulant abuse, generalized anxiety disorder, persistent mood (affective) disorder, binge eating disorder, and chronic pain syndrome. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section E - Behaviors showed no behaviors were exhibited. Section N - Medications showed the resident was taking antianxiety antidepressant medications. Observation on 5/18/24 at 12:27 p.m.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-20 · 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 On 5/20/2024 at 3:38 p.m. an observation of room [ROOM NUMBER] B revealed a can of activICE (over the counter topical pain reliever) sitting on the table next to the bathroom door. The cap was missing. The resident in the room stated it was hers but she can't use it anymore because the spray top is missing due to falling on the floor. Based on observation, record review, and interview the facility failed to provide an environment that was clean, safe, and sanitary for residents on one units (B Wing) of two units and two shower rooms (A Wing and B Wing) of two shower rooms. Findings included: On 5/20/24 starting at 3:00 p.m., observations were made of the resident rooms and shower rooms on the A Wing and B Wing. The following was observed: - A wheelchair in hallway across from the activity room with a ball of an unknown pink substance stuck to the seat of the chair and armrests that were ripped revealing foam interior. The was observed on 5/18/24, 5/19/24 and 5/20/24. - An observation of room [ROOM NUMBER] Bed 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-20 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to assess two residents (#73 and #178) out of twenty-eight sampled residents for the self-administration of medications and to ensure the self-administered medications were safely stored. Findings included: 1. On 5/18/24 at 12:14 p.m. Resident #73 was observed and interviewed in the resident's room. The observation revealed an allergy nasal spray bottle, 3 vials of an unknown type of eye drop and a medication bottle with a green top sitting on top of the bedside dresser underneath the resident's computer monitor. The resident reported having a lot of environmental allergies and the nasal spray was Fluticasone. Review of Resident #73's admission Record revealed the resident was admitted on [DATE]. The record revealed diagnoses not limited to sequela unspecified fracture of right femur, unspecified rheumatoid arthritis, and history of falling. The admission Record showed the resident suffered from almond, bread, tree, and shrub pollen…

    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 · D2024-05-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 record review, interview and observation, the facility failed to ensure reasonable accommodations were made to ensure one resident (#29) of twenty four sampled residents was provided the right sized incontinent supplies. Findings included: An interview was conducted with Resident #29 on 5/18/24 at 11:52 a.m. in her room while she was in bed. She stated for the last two weeks she hasn't been able to get medium size pull ups. She said, That is what I always wear. Right now I'm wearing small youth and they are tight. I have severe diarrhea and these are so tight. She confirmed she has told staff members but could not recall their names. Review of the admission Record for Resident #29 revealed her most recent admission to the facility was 2/28/23 with diagnoses to include depression, anxiety, muscle wasting and atrophy, difficulty in walking, muscle weakness and need for assistance with personal care. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 3/27/24, revealed in Section C- Cognitive…

    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 · D2024-05-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure a care plan had been developed and implemented for one resident (#70) out of one resident sampled for respiratory services. Findings included: On 5/18/24 at 12:31 p.m. Resident #70 was observed lying in bed with a Continuous Positive Airway Pressure (CPAP) machine on the bedside dresser next to the resident. The tubing and cannula attached to the machine were lying on top of it. The resident reported staff do not clean it, did not have anything to clean it with, and she would do it when she discharged to home. On 5/19/24 at 9:27 a.m. Resident #70 was observed lying in bed with the CPAP tubing and cannula sitting on top of the machine. Review of Resident #70's physician orders revealed an order for Bipap to be on every night at 129 setting, started on 3/19/24. The orders did not include an order to clean the equipment after resident use. Review of Resident #70's care plan, on 5/18/24 at 2:19 p.m., revealed no care plan related to 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to revise the comprehensive care plan related to dialysis services for one resident (#45) of two residents sampled for dialysis. Findings included: Review of the admission Record for Resident #45 revealed he was admitted to the facility on [DATE]. The admission Record revealed diagnoses of end stage renal disease, and dependence on renal dialysis. Review of the active physician orders for May 2024 revealed and order for Dialysis - [Name of Dialysis Center, address and phone number] [name of transport company] transport chair time 0630 (a.m.)/PU (pick up) time 5:30-6a (a.m.) on Tuesday, Thursday and Saturday, 5/2/24 start. During an interview with Resident #45 on 5/18/24 at 12:54 p.m. he stated he goes to dialysis three times a week on Tuesday, Thursday and Saturdays. Review of the active care plan, initiated 2/22/23 and revised 11/20/23, revealed a Focus for renal failure with dialysis T/Th/S (Tuesday/Thursday/Saturday) at [name of dialysis center].…

    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 · D2024-05-20 · 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 observations, record reviews, and interviews the facility failed to assess altered skin conditions and provide wound care according to facility protocol, physician orders, and professional standards for two residents (#15 and #71) out of two residents sampled for non-pressure related skin conditions. Findings included: 1. On 5/18/24 at 10:30 a.m. Resident #15 was observed sitting in the hallway between the two units of the facility. An undated white 2x2 bordered dressing stained with a red substance was observed on the resident's right ankle and a whitish/gray 2x2 bordered dressing dated 5/16/24 was observed on the resident's left ankle. The resident allowed photographic evidence to be obtained. On 5/18/24 at 3:04 p.m. Resident #15 was observed with the same dressings on each lower extremity. On 5/19/24 at 9:01 a.m. Resident #15 was observed with an undated 2x2 white bordered dressing stained with reddish-brown drainage on the right ankle. The observation revealed a dated 2x2 grayish-white dressing on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-05-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a pharmacy recommendation and physician order was implemented for one resident (#65) of two residents sampled for monthly drug regimen review. Findings included: Review of Resident #65's electronic medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, adjustment disorder with mixed anxiety and depressed mood. A review of the resident's physician orders revealed a current order, dated 4/7/2024, for Seroquel oral tablet 200 MG [milligram] (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for mood disorder. During a review of Resident #65's medical record, specifically the Consultant Pharmacist Medication Regimen Review, dated 4/25/20247, it revealed a recommendation suggesting adding an order to monitor for behaviors related to the use of Quetiapine (Seroquel). 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-20 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to monitor side effects for one residents (#63) related to diuretic therapy and pain medication of seven sampled residents. Findings included: Review of Resident #63's admission Record revealed an original admission date of 11/23/23 and a readmission date of 4/23/24. The admission Record showed diagnoses to neuromuscular dysfunction of bladder, pain in right hip, obstructive and reflux uropathy, acute kidney failure, and chronic kidney disease stage 3B and osseous and subluxation stenosis of intervertebral foramina of lumbar region. During an interview and observation on 5/18/24 at 11:37 a.m. Resident #63 was in bed with a family member visiting. Resident #63 stated she doesn't get out of bed and was recently readmitted from the hospital. She confirmed she had wounds and receives all her medications. Review of the Minimum Data Set, dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and four errors were identified for two residents (#78 and #3) of ten residents observed. These errors constituted a 16% medication error rate. Findings included: 1. On 5/19/24 at 2:09 p.m. an observation of medication administration with Staff C, Registered Nurse (RN) was conducted with Resident #78. Staff C dispensed the following medications: - Divalproex Delayed Release (DR) 250 milligram (mg) tablet - Magnesium Oxide 400 mg over the counter (otc) tablet On 5/19/24 at 2:09 p.m. the observation revealed the above medication profiles were colored red, showing the medications were late. Staff C, RN confirmed dispensing two tablets. Review of Resident #78 May Medication Administration Record (MAR) revealed the following medications and scheduled times to be administered: - Divalproex Sodium oral tablet Delayed Release 250 mg - Give 1 tablet by mouth three times a day for mood disorder.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to adhering to transmission-based precautions for one resident (#69) out of one resident observed with Contact Precautions and providing eye drops to one resident (#58) out of one resident observed during the administration of eye drops. Findings included: 1. On 5/18/24 at 12:36 p.m. an observation revealed Resident #69's had a sign posted on their door that showed, Special Contact Precautions in addition to standard precautions. The sign advised for All family and visitors: Please report to nurses station or see staff BEFORE entering room. The posting instructed Before entering, everyone MUST: - Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water. - Wear gown before entering and remove upon exiting. - Wear gloves before entering and remove upon exiting. - Before exiting, everyone MUST wash hands with soap and water. On 5/18/24 at 12:36 p.m., an observation was made of Staff C, Registered Nurse (RN) who knocked on the door 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain accurate and complete medical records by failing to fully document the occurrence of falls in the medical record for two (#3 and #4) of three residents sampled for documentation related to falls. Findings included: A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and dementia. A diagnosis of traumatic subdural hemorrhage without loss of consciousness was added on 12/23/2023. Resident #3 was discharged from the facility on 1/15/2024. A review of the facility's incident log for December 2023 revealed Resident #3 had an unwitnessed fall on 12/19/2023 at 4:34 PM. A review of Resident #3's progress notes dated 12/19/2023 at 9:00 PM revealed Resident #3 was transferred to the hospital and was diagnosed with a subdural hematoma. A review of Resident #3's progress notes did not reveal documentation related to Resident #3's fall on 12/19/2023 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-12 · 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

    Based on observation, record review, and interview, the facility failed to ensure proper storage of respiratory equipment for five (Resident #3, #28, #45 #48, #49) of 17 facility residents receiving respiratory therapy during three (5/9/2022, 5/10/2022, and 5/11/2022) of four days observed. Findings included: 1. On 05/09/2022 at 10:07 a.m. and 12:13 p.m., Resident #49's nebulizer mask was observed on top of the nebulizer machine. Additionally, the oxygen nasal cannula and tubing were observed hanging over the oxygen concentrator. On 05/10/2022 at 08:50 a.m., observation revealed Resident #49's nebulizer facemask was not stored in the plastic storage bag, and the oxygen nasal cannula and tubing were hanging over the oxygen concentrator. On 05/11/2022 at 08:49 a.m., Resident #49's oxygen tubing was observed hanging over the oxygen concentrator, and the unbagged nebulizer facemask was on top of the bedside table. An observation was conducted with the Director of Nursing (DON) on 05/11/2022 at 10:15 a.m. During the observation, the DON confirmed Resident #49's nebulizer facemask was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and policy review, the facility did not ensure the kitchen was maintained in a sanitary manner during 3 of 4 days of survey. Findings included: An initial tour of the facility's kitchen was conducted on 05/09/22 at 09:48 AM. The tour was facilitated by the assistant certified dietary manager/CDM2 The kitchen tour revealed concerns with dirty vents located above food prep areas and clean dish storage areas. The vents were noted with dust, debris, and bio-growth. The CDM2 stated maintenance is supposed to clean the vents once a month. Concerns with Bio growth on the edge of the sink in dishwashing area were identified. The CDM2 stated they would clean it up. The CDM2 said, that is not sanitary. The CDM2 stated they have had that problem before. Photographic evidence was obtained. On 05/11/22 at 11:15 AM, a kitchen tour was conducted with the Registered Dietician (RD). An observation was made of ceiling vents in dish storage area and food service areas with dirt, debris, and bio growth. An interview was conducted on 05/11/22 at 11:35 AM with the RD.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-05-12 · 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 observations, interviews, record review and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 and other infections on two (101-110 and 119-128) of six hallways and one of one laundry area. Findings included: 1. On 5/9/22 beginning at 11:30 AM, Staff I, Certified Nursing Assistant (CNA) was observed delivering and setting up lunch trays for residents in rooms 101 through 108. No hand hygiene by Staff I was observed between each tray delivered. 2. On 5/9/2022 at 11:23 a.m. a lunch meal tray service was observed in the hallway of the facility serving rooms 119 to 128. Staff A, CNA was observed getting a tray from an open metal dining cart and taking the tray into room [ROOM NUMBER]. Staff A was observed proceeding to get another tray from the cart without conducting hand hygiene and taking the tray into room [ROOM NUMBER]. Staff A could be seen setting up 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one (#21) of 30 sampled residents. Findings included: On 5/09/22 at 10:45 a.m., Resident #21 was observed lying in bed. The resident did not respond to questions related to care and services. A review of the Physician Order Report from 4/12/22 to 5/12/22 revealed the following orders: Nortriptyline 50 mg oral once a day at night started on 12/9/21 for depression Nortriptyline 10 mg (milligrams) oral twice a day started on 1/25/22 for depression Wellbutrin SR 100 mg oral twice a day started on 2/4/22 for depression Paxil 10 mg oral once a day started on 4/18/22 for depression Trazadone 150 mg oral once a day at night started on 4/18/22 for depression A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section E--Behavior: indicated…

    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 · D2022-05-12 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to provide dressing changes to an intravenous (IV) catheter site in accordance with physician orders for one (#5) of four residents in the facility receiving IV therapy. Findings included: During a facility tour conducted on 05/09/22 at 10:01 AM, Resident #5 was observed laying on bed. Resident #5 was noted with a peripherally inserted central catheter (PICC) line with a gauze dressing dated 04/01/22 14:00 hours (2:00 PM) on the left arm. An attempt to interview Resident #5 was unsuccessful. (Photographic evidence was obtained.) A minimum data set (MDS) assessment for Resident #5 dated 03/30/22, section C cognitive patterns showed Resident #5 was not able to complete the brief interview for mental status interview, indicating severe cognitive impairment. Section G functional status showed Resident #5 required extensive assistance and dependency on staff for activities of daily living (ADLs). Additional observations on 05/10/22 at 09:03 AM and 05/11/22 at 8:44 AM, revealed the dressing dated 04/01/22 was still…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure medications were stored and secured appropriately in one (A Wing) of two treatment carts and three (B-North, A-North, A-South) of four medication carts. Findings included: 1. On [DATE] at 3:29 PM, observation with Staff O, Registered Nurse (RN) of the A wing Treatment Cart revealed: • Nyst Ointment 100,000 USP opened, no date, no resident identifier, no pharmacy label • SSD Silver Sulfadiazine Cream opened, resident label not identifiable, no open date • Latanoprost Opthalmic Solution 125 mcg located in treatment cart • Muprocin Ointment 2% with no resident identifier or Pharmacy label, open date not observed • Calamine Lotion manufacturer expiration date on bottle 03/2022 An interview with Staff O at the time of the observation confirmed the Nyst ointment, SSD Silver Sulfadiazine Cream, and Mupirocin ointment was not labeled for pharmacy, resident or identified with a date opened. Staff O stated, The Latanoprost Opthalmic Solution…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-02-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide a clean and homelike environment by leaving resident personal belongings in bags and boxes for five residents (#8, #10, #28, #35, and #41) of 26 sampled residents for four of four days. Findings included: 1. A review of Resident #8's medical record revealed that Resident #8 was admitted to the facility on [DATE] with diagnoses of dementia, COVID-19, cognitive communication deficit, and need for assistance with personal care. An observation was made on 02/10/2021 at 11:45 a.m. of Resident #8 eating lunch in his room. A large box was observed in the corner of Resident #8's room containing several belongings. An interview was conducted with Staff H, Certified Nursing Assistant (CNA) following the observation. Staff H, CNA stated that the large box in Resident #8's room contained his personal belongings from his previous room and they had not yet been put away. Staff H, CNA also stated that Resident #8's belongings were not unpacked…

    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 · D2021-02-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure that care was provided in a dignified manner for one resident (#28) of one resident sampled for dignity. Findings included: A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, hemiplegia, and acute pyelonephritis. A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 had impaired cognitive skills as evidence by decision making problems, short term memory problems, long term memory problems, and problems understanding others. Interventions included promote dignity by conversing with the resident and ensuring privacy while providing care. A review of Resident #28's Physician Order Report from 1/11/21 to 2/11/21 revealed an order, dated 12/24/2020, for an indwelling catheter size 18 french with 10 cubic centimeter balloon to straight drainage. Special instructions: privacy bag…

    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 before2021-02-12 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure self-administration of medications was clinically appropriate for one resident (#28) of four residents sampled for medication administration. Findings included: A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report from 1/11/21 to 2/11/21 revealed an order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on 02/10/2021 at 11:03 a.m. of Resident #28…

    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 · D2021-02-12 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of facility policy, the facility failed to make prompt efforts to resolve a grievance for one resident (#9) of one resident sampled for grievances. Findings included: A review of Resident #9's medical record revealed that Resident #9 was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit and need for assistance with personal care. An interview was conducted on 02/10/2021 at 11:03 a.m. with Resident #9. Resident #9 stated that her dentures were missing for two days. Resident #9 also stated that she wrapped her dentures in a brown paper napkin and placed them on her bedside table. When she woke up the next morning, they were gone from her bedside table. Resident #9 stated that she was not sure what the facility was doing regarding her missing dentures and she reported that they were missing to the nursing staff. A review of Resident #9's Progress Notes revealed a note, dated 02/03/2021 at 11:22 a.m., that a Certified Nursing…

    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 · D2021-02-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a baseline care plan that included minimum healthcare information necessary to properly care for two residents (#2 and #276) of nine residents with an indwelling urine catheter. Findings included: On 02/11/2021 at 10:10 a.m. an observation of Resident #276 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor under the bed. On 02/11/2021 at 10:23 a.m. an observation of Resident #2 revealed the resident had an indwelling urine catheter. The indwelling catheter bag was observed in a vanity cover and laying flat on the floor. Review of the clinical record for Resident #276 showed an admission date of 01/11/2021 and admitting diagnoses that included, but not limited to muscle weakness, COVID-19, pneumonia, hypertension and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling urinary catheter. Further…

    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 before2021-02-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 observations, interviews, and review of facility policy, the facility failed to store respiratory equipment in accordance with professional standards of practice for two residents (#28 and #35) of three residents sampled for respiratory care. Findings included: 1. A review of Resident #28's medical record revealed that Resident #28 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). A review of Resident #28's care plan revealed a problem, revised on 12/03/2020, that Resident #28 utilized oxygen therapy secondary to COPD. Interventions included medications, nebulizers, and puffers as ordered. A review of Resident #28's Physician Order Report dated 1/11/21 - 2/11/21 revealed a physician's order, dated 12/23/2020, for ipratropium-albuterol solution for nebulization, 0.5 milligrams (mg) - 3 mg per 3 milliliter (ml) solution; 1 dose inhalation three times a day for a diagnosis of COPD. An observation was made on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-02-12 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards in one medication room (100 unit) of two medication storage rooms in the facility and two (100 unit and 200 unit) of six medication carts in the facility. Findings included: A medication cart inspection on the 100 unit was completed on 02/12/2021 at 11:42 a.m. with Staff E, Licensed Practical Nurse (LPN). A container of blood glucose test strips within the medication cart were observed to have no date on the provided label. An observation of the label revealed text that read Use within 90 days (3 months) of first opening. Staff E, LPN stated that they were never told that they needed to date blood glucose test strips once they were opened and observed that label. Staff E, LPN addressed that the blood glucose test strips should be dated per the label instructions. A medication storage room inspection on the 100 unit was completed on 02/12/2021 at 12:01 p.m. with Staff E, LPN. An inspection of a medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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

No federal fines in the current CMS record.

Part of a chain

This home belongs to VIVO HEALTHCARE — 12 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 3 of 52.4+0.6 vs chain
Health inspection 2 of 51.9+0.1 vs chain
Staffing 2 of 52.7-0.7 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 11 homes this chain runs (chain average 2.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
SEBRING HOLDCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 09/01/2023
JEK HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2023
NMJ HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 09/01/2023
CUKIER, JOSEFIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
FRIEDLAND, SHALOMIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
BONNER, EDWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023
GLUCK, BENJAMINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2023
MONTSDEOCA, GARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2023
JAKOBOVITS, NATHANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/29/2025
KAGAN, JEFFREYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 05/30/2025
NMJ IRRV TR IIOrganizationTRUSTEE OF THE SNFsince 09/01/2023
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 09/01/2023
JEK IRRV TR IIOrganizationADP OF THE SNFsince 05/30/2025
PEASE BELL CPAS LLCOrganizationADP OF THE SNFsince 09/01/2023
SUMMATION FINANCIAL SERVICES LLCOrganizationADP OF THE SNFsince 09/01/2023
VIVO HEALTHCARE CONSULTING LLCOrganizationADP OF THE SNFsince 09/01/2023

CMS files one row per role, so the 20 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$6.0M
Net patient revenuemost recent cost report
-6.7%
Operating marginrevenue minus expenses
$108K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 15%Other / private 25%

This home reported $108K 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

$343per resident / day
operating cost
$10,441per month
≈ monthly operating cost
$322per 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 105352. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-20, 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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