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Springs At Boca Ciega Bay

1255 Pasadena Ave S, Suite C, South Pasadena, FL 33707 · For profit - Limited Liability company · 109 certified beds · (727) 828-3500 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)4 immediate-jeopardy citations
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 4 immediate-jeopardy problems — the most serious level
  • 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 (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Worth a closer look. This home's quality-measure rating runs 4 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
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
630 Pasadena Ave S · (727) 345-7100 · Call to confirm hours
Pharmacy
6850 Gulfport Blvd S · (727) 202-3877 · Call to confirm hours
Grocery
6801 Gulfport Blvd S · (727) 384-0750 · Call to confirm hours
Park
64th St S & Gulfport Blvd S · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased11.5%8.7%15.4%better
Long-stay residents who lose too much weight3.1%5.5%5.4%better
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 symptoms3.0%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 injury1.4%2.5%3.3%better
Long-stay residents on antianxiety or hypnotic medication4.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.6%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control13.8%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 table5.4%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.0%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine93.1%94.7%79.4%better
Short-stay residents rehospitalized after admission39.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit7.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days0.322.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.541.151.80better

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.

59.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 416 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
0.59U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.59 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF59.7%CMS range 55.2–63.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.7–12.810.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 5.4–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.50
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.59
Total nurse hours/ resident / day
0.34
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 109 beds and averages 73.8 residents a day — about 68% occupied, or roughly 35 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.59 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.30 hrs/resident/day on weekends vs 3.71 on weekdays — 11% thinner on weekends. RN hours go from 0.57 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

7
deficiencies at the latest standard inspection (2024-02-22)
4
at the previous standard inspection (2022-01-07)

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 14 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure advanced directive wishes and physician orders were followed for one resident (#1) out of six residents sampled for advanced directives.On [DATE], facility staff initiated cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) on Resident #1 after determining no pulse or respirations. The resident had wishes to not be resuscitated and had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. Paramedics ceased chest compressions and Resident #1 expired. Cardiac compressions were provided to Resident #1 for approximately twenty minutes. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2026-01-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents were free from abuse by performing Cardiopulmonary Resuscitation (CPR) against the resident's wishes for one resident (#1) out of six residents sampled for Advance Directives.On [DATE], Resident #1 experienced a change of status when his oxygen saturation levels dropped to 55% (Normal oxygen saturation levels range from 95%-100%). Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) were initiated by staff. Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2026-01-23 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 honor a Do Not Resuscitate (DNR) order for one resident (#1) out of three residents sampled. Facility staff unnecessarily provided chest compressions for twenty minutes causing physical harm and a traumatic end of life. On [DATE], Resident #1 was found unresponsive by facility staff. Facility staff performed Cardiopulmonary Resuscitation (CPR), including chest compressions, without confirming Resident #1's preferred resuscitation status. The resident had a physician order for DNR, dated [DATE]. Emergency Medical Services (EMS) were called to the facility, and paramedics took over chest compressions. After twenty minutes of CPR, facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. Paramedics ceased chest compressions and Resident #1 expired. By providing CPR, the facility staff failed to honor Resident #1's advance directive wishes and physician signed DNR form which caused…

    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
  • Immediate jeopardy · J2026-01-23 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure nursing staff were competent in identifying residents code status and following physician orders for Do Not Resuscitate (DNR) for one resident (#1) out of six residents sampled.On [DATE], Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions were initiated by staff (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly caused physical damage including fractured ribs or sternum, bruising, and internal organ injury). Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the documentation to the paramedics. Paramedics discontinued compressions. Cardiac compressions were provided to Resident #1 for approximately twenty minutes. The CPR…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-15 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an injury of unknown source-an acute right subcapital femoral neck fracture, was reported to the Agency for Healthcare Administration (AHCA), Adult Protective Services (APS), and local law enforcement within 24 hours of becoming aware of the X ray results, for one resident (#2) of six sampled residents. Findings included: Record review showed Resident #2 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included cerebrovascular disease, prior intracerebral hemorrhage, hypertension, dysphagia, hemiplegia following cerebral infarction, and a need for extensive assistance with personal care.A Brief Interview for Mental Status (BIMS) dated 08/29/2025 documented a score of 6, indicating severe cognitive impairment.Review of the facility's event log (03/01/2026-05/16/2026) showed:04/08/2026: Unwitnessed fall with a skin tear to the left elbow; no additional injuries documented.04/28/2026: Unwitnessed fall; nursing assessment documented no…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2026-06-15 · 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 record review and interview, the facility failed to implement a care planned intervention for the use of floor mats for one resident (Resident #2) of six sampled residents. Resident #2's care plan included the use of floor mats when the resident was in bed; however, the intervention was not in place at the time of the resident's fall on 04/08/2026.Findings included: Record review showed Resident #2 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included, but were not limited to, cerebrovascular disease; urinary tract infection; nontraumatic intracerebral hemorrhage, unspecified; personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits; atherosclerotic heart disease of native coronary artery without angina pectoris; cervical spondylosis without myelopathy or radiculopathy; essential hypertension; dysphagia following cerebral infarction; hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side; need for assistance…

    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 no plan of correction
  • Potential for harm · Dcited before2026-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide adequate supervision to reduce the risk of accidents for one resident (#3) of six sampled residents. Resident #3 experienced six falls between 05/13/2026 and 06/06/2026. Only four of the falls were recorded in the facility's fall log, and the required post fall investigations and care plan revisions were not consistently completed.Findings included: On 06/15/2026 at 1:23 p.m., Resident #3 was observed seated in a wheelchair as family members prepared to take the resident on a leave of absence. Record review showed Resident #3 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, encephalopathy, paroxysmal atrial fibrillation, need for assistance with personal care, and a cognitive communication deficit. A Brief Interview for Mental Status (BIMS) dated 05/07/2026 documented a score of 1, indicating severe cognitive impairment.A review of the care plan revealed a problem area…

    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 no plan of correction
  • Potential for harm · D2026-06-15 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure a resident experiencing a new onset of significant pain was assessed, had pain characteristics documented, and the pain was reported to the physician and hospice in a timely manner for one resident (#2) of six sampled residents. Findings included:A review of Resident #2's clinical record showed a documented new onset of pain on 05/03/2026 at 5:57 p.m., rated 8/10, with no documented anatomical location and no documented physician notification. On 05/04/2026 at 5:01 p.m., pain was documented as 7/10, and on 05/05/2026 at 11:29 a.m., as 10/10, again with no anatomical location documented and no evidence of physician notification.Review of nursing documentation on 05/05/2026 at 11:29 a.m. showed communication with hospice. An X-ray was ordered on 05/06/2026, with results on 05/07/2026, identifying an acute right subcapital femoral neck fracture. A final Radiology Report Findings showed an Acute right subcapital femoral neck fracture, 1/2 shaft-width superior lateral displacement, Soft tissue swelling; no dislocation…

    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 no plan of correction
  • Potential for harm · E2026-01-23 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy reviews, Quality Assurance Performance Improvement (QAPI) documentation, and interviews the facility failed to ensure staff were educated and had the tools to respond to a resident's change in condition related to knowing if the Certified Nursing Assistant's (CNA) were allowed to perform cardiopulmonary resuscitation (CPR) and if code blue forms were utilized during a code.Findings included:Review of Resident #1's record showed signed Do Not Resuscitation Order (DNRO) on [DATE]. Review of Resident #1's hospital records (found in the facility's uploaded miscellaneous documents for the resident) showed the acute care facility, had noted on 12/24 and [DATE] the resident's code status was Do Not Resuscitate (DNR). The uploaded documents did not reveal the order had been rescinded. Review of Resident #1's physician orders showed a DNR order was initiated on [DATE]. Review of Resident #1's progress notes showed the resident suffered a change in condition while at the facility on [DATE].…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as indicated by the following: - Refrigerated, ready-to-eat, Time/temperature Control for Safety foods were stored too long under refrigeration and not date-marked to indicate when the food must be consumed or discarded. - The kitchen area was not protected from contamination from unauthorized employees entering the area and not wearing hair restraints. - Stored packaged food was not protected from potential cleaning chemical contamination in the food storage room. - The surface material of equipment was not kept in good condition and was not smooth and easily cleanable. - Clean eating equipment was not stored in a manner to prevent contamination of the mouth/food contact surfaces. - Clean equipment was not stored to protect from contamination from the outside environment and wildlife. - Food was not labeled to its identity. - Staff did not know…

    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 · F2024-02-22 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to develop and implement appropriate plans of actions to correct identified quality concerns related to resident falls. This concern has the potential to affect all residents in the facility. The findings include: On 2/22/24 at approximately 12:39 PM, an interview was conducted with the Risk Manager in the presence of the Regional Nurse Consultant. During the interview the Risk Manager stated that he has been in is position since September 2023 and that part of his position was quality improvement. He stated that as part of his performance improvement efforts he tracks falls in the facility by nursing station. At this time he presented a graph titled Falls by Unit that included the number of falls that had occurred in each month of 2023 for Station 1 (25 falls), Station 2 (26 falls), and Station 3 (181 falls). The graph demonstrated that 87% of the falls that had occurred in the facility in 2023 had occurred on Station 3. The graph also supported that Station 3 had 25 falls in the month of November while stations 1 and 2 had…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-22 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide resident centered restorative services to maintain or improve mobility for three residents (#62, #47, and #46) of three residents sampled for restorative services. Findings included: A review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the left hip and bilateral knees, muscle weakness, need for assistance with personal care, and reduced mobility. A review of Resident #62's physician's orders revealed an order, dated 1/30/2024 for restorative services for active range of motion (AROM) to bilateral lower extremities (BLE), wheel chair mobility, and active range of motion to bilateral upper extremities (BUE). The order did not reveal a frequency of how often Resident #62 was to receive restorative services. An interview was conducted on 2/19/24 at 4:13 PM with Resident #62 in the resident's room. Resident #62 was observed up in her wheelchair near her bed.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 provide the appropriate transfer/discharge notice to the resident and their responsible party and failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge for one resident (#98) of two sampled residents reviewed for transfer and hospitalization. The findings included: A record review was conducted for Resident #98 which revealed a pink form titled SNF (Skilled Nursing Facility) to ED (Emergency Department) Handoff dated 12/29/23. The form indicated the resident was being transferred to the ED for abnormal vital signs and altered mental status. Review of the record revealed the resident did not return to the facility. Review of the Agency for Health Care Administration (AHCA) Nursing Home Transfer and Discharge Notice, form 3120-0002, listed Resident #98's name, the facility name, address, facility contact person and telephone number, and the signature of the Unit Manager (UM). All other areas of the form were blank to include the resident's representative contact information, date…

    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 · D2024-02-22 · 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 revise the care plan for one resident (#13) of 20 sampled residents whose care plans were reviewed, to reflect the current interventions to manage healing and prevention of pressure ulcers. Findings included: Resident #13 was originally admitted on [DATE] and the most recent admission was 1/20/23. The resident was hospitalized on [DATE] with no pressure ulcer present upon transfer to the hospital Resident #13's pertinent diagnoses included Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness and tremors); Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); severe protein-calorie malnutrition; hypo-osmolality (increased body fluid volume and decreased solute volumes in the blood) and hyponatremia (abnormally low sodium levels in the blood); oropharyngeal phase dysphasia (swallowing disorder); unspecified dementia,…

    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
Show the remaining 14 citations
  • Potential for harm · D2024-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, record review, and meal tray identification, the facility failed to provide the correct therapeutic diet to one resident (#55) of two residents reviewed for nutritional status who was at nutritional risk. Findings included: Resident # 55 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident #55's pertinent diagnoses included: encephalopathy (diffuse disease of the brain that alters brain function or structure that causes altered mental state and confusion), cerebral infarction [a brain lesion in which a cluster of brain cells die when they don't get enough blood] due to occlusion or stenosis of small artery; post COVID-19; dysphagia [swallowing difficulty] following cerebral infarction; acute respiratory failure with hypoxia [low levels of oxygen in your body tissues]; Type 2 Diabetes Mellitus with diabetic neuropathy [A group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-22 · 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 document observed wandering behaviors to ensure an accurate medical record for one (Resident #46) of one resident observed with wandering behaviors. Findings included: A review of Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following non-traumatic subarachnoid hemorrhage affecting right dominant side, difficulty walking, and cognitive communication deficit. A review of Resident #46's physician's orders revealed an order, dated 11/14/2023 for a wander management bracelet to the resident's left wrist. A review of Resident #46's care plan revealed a Focus area, initiated 11/14/2023, Resident #46 is an elopement risk related to being disoriented to place. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book and observe the wander management…

    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 · E2022-01-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations interviews and record reviews the facility failed to ensure necessary services to maintain a rehabilitation device in a sanitary manner for four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22) for one resident (#34) out of 29 sampled residents. Findings included: Review of the admission Record for Resident #34 showed the resident was admitted to the facility on [DATE] with diagnoses to include anterior displaced Type II dens (odontoid bone) fracture, subsequent encounter for fracture with routine healing, spondylolysis of cervical region, repeated falls, pain in right shoulder and other abnormalities of gait. A review of the Quarterly Minimum Data Set (MDS) for Resident #34, dated 11/09/21, Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment. Section G Functional Status showed Resident #34 required extensive assistance for activities of daily living (ADLs) including bed mobility, transfers, locomotion in and off unit,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on of observations, interview and policy review the facility failed to ensure a clean and sanitary homelike environment related to a spot on the wall and baseboard in two places for one resident room (48) of twenty-six rooms observed on Station 3 for three days (01/04/22, 01/05/22 and 01/06/22) of four days. Findings included: On 01/04/22 at 9:15 a.m., an initial observation was conducted of resident room [ROOM NUMBER] on the hall of Station 3. During the observation a spot was seen on the wall in the middle of the room, which extended down to the baseboard in two places. (Photographic Evidence Obtained) A subsequent observation was conducted on 01/04/22 at 12:47 p.m. During the observation a family member in the room visiting the resident was interviewed. The family member indicated the resident was admitted on the evening of 12/31/21, and further revealed he never sees anyone cleaning the room. The family member stated, The housekeeping could be better. During the interview the family member revealed he…

    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 · D2022-01-07 · 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 observation, record review, and interviews, the facility failed to ensure appropriate and sanitary storage of respiratory equipment of an oxygen nasal cannula for one resident (#193) of sixteen residents who use oxygen for four of four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22). Findings included: On 01/04/22 at 11:38 a.m., an observation was conducted of Resident #193's room. During the observation the oxygen nasal cannula and tubing was located on top of the oxygen concentrator and not stored appropriately in a storage bag. (Photographic Evidence Obtained) On 01/05/22 at 9:44 a.m. an observation was conducted of Resident #193's nasal cannula and tubing to be on top of the concentrator. Resident #193, who was sitting in a wheelchair and watching television, indicated she put it there when she was done wearing it because there wasn't a plastic storage bag by the concentrator to put it in. An observation was conducted on 01/06/22 at 10:17 a.m., of Resident #193's oxygen tubing and nasal cannula…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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 interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication order was limited to a 14 day duration for one resident (#26) of five residents reviewed. Findings included: Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, and anxiety disorder according to the resident face sheet. Continued review of the Physician's Order Summary revealed an order for Xanax (Alprazolam) 0.25 milligram (mg) 1 tab orally (PO) every 4 hours as needed for anxiety, with a start date of 11/24/21; the end date was listed as 'indefinite.' On 01/05/22 at 12:35 p.m. Resident #26 was observed sitting upright in bed and eating lunch. The resident was groomed and paying attention to the television. An interview was attempted; however, the resident was not interviewable. In an interview with Staff A, Licensed Practical Nurse (LPN) on 01/05/22 at 12:58 p.m., the LPN confirmed the resident was on PRN Xanax and gets it…

    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 · E2020-01-24 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and medical record review, the facility failed to ensure that a standard infection control was utilized during incontinent care with one (#30) resident out of 35 sampled residents; that a blood monitoring device was cleaned and disinfected in-between three (60, 9 & 17) residents out of a total of nine residents with blood monitoring orders; contaminated dressing of bodily fluids were removed after completion from one (#4) resident environment; and that supervision was provided to one (#23) of one resident with conjunctivitis to prevent recontamination. Findings included: 1. On 1/21/2019 at 10:50 a.m., Resident #30's bedroom door was closed. As the door was knocked on, a faint response stating just a minute could be heard. At that exact time, a nurse was present and stated the resident was being provided with care. She said we could go in. On entrance to the bedroom, a pair of pants, a soiled incontinent product, a towel and wash cloth laid strewn on the floor bare surface. The nurse said softly, Let me get some gloves. The curtain divider was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-24 · 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 observation, interview and record review, the facility failed to honor residents' rights to dignity for 1 of 35 (#83) sampled residents, related to the dining experience and the height of the table. Findings included: Observations in the restorative dining room for the midday meal on 1/21/20 at 12:29 PM revealed that Resident #83 was noted to be seated in her wheelchair at a table with 3 other residents. The table was noted to be at a height of the resident's chin. The resident ate her entire meal in this position. Continued observations at this time revealed that there were 4 staff persons present in the dining room; none of the staff present made any attempt to adjust the resident's position at the dining table. Observations in the restorative dining room for the midday meal on 1/23/20 at 12:01 PM revealed that Resident #83 was seated in her wheelchair at a table with 3 other residents. Resident #83 was noted to be seated at a table that was at the height of the resident's chin. An interview with the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-24 · 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 care plan that included instructions needed to provide care, related to the use of an elastic wrap bandage for 1 of 35 (#149) sampled residents. Findings included: Observations of Resident #149 on 1/22/20 at 8:41 AM revealed that the resident had an elastic wrap bandageto her left hand. It was noted that there was no medical tape on the bandage that would indicate when the elastic wrap bandage was placed on her hand. An interview with the resident at this time revealed that this bandage was old and was ok as it keeps her hand warm. Review of the resident's record revealed that this resident was admitted to the facility on [DATE]. Review of Resident #149's current care plan revealed no care plan in place for, and no mention of the use of, the elastic wrap bandage. Review of #149's record revealed that there was no current order for the use of a bandage to her hand. Review of an admission nursing note, dated 1/8/20 15:05, revealed…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, facility failed to ensure residents were free of accidents hazards, related to bed not maintained in the low position while in bed, for 1 of 35 (#52) sampled residents. Findings included: On 01/21/20 at 11:15 am, Resident #52 was observed in bed at a high position. Resident #52 was observed awake with an uncontrollable cough. Resident #52 did not respond on command, but continued coughing. On 01/24/20 at 11:30 am, Resident #52 was observed in an elevated bed asleep. The resident did not awake when his name was called to arouse him. On 01/24/20 at 01:35 pm, an interview with Staff I, Licensed Practical Nurse, revealed Resident #52's bed level is changed during meal-times. Staff I stated The part of the meal tray that has the wheels cannot fit under the bed. We lift the bed so the tray can fit properly. On 01/24/20 at 01:52 pm, Resident #52 was observed in bed with the bed in high position. The resident was observed asleep with head of bed raised. On 01/24/20 at 01:57 pm Staff J, Licensed Practical Nurse accompanied surveyor into the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-24 · 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 observation, interview and medication storage, the facility failed to ensure that one (high hall) out of three medications carts were stored according to professional principles, related to the cart contained: medication without a resident identifier, medication without an active Physician order, and a torn controlled substance card holding a pill in place with a piece of tape, out of a total of six medication carts identified by the facility. Findings Included: On [DATE] at 11:45 a.m. the medication cart on high hall was observed, alongside Licensed Practical Nurse I (LPN I). A box contained a label for albuterol for 7 days. LPN I indicated that the last day for the medication was on [DATE]. She confirmed no active order was in place (photographic evidence was obtained). One box of debrox ear drops were noted that had a written date of [DATE]. The box had been opened, with the bottle tip missing its plastic seal. The box did not contain a resident identifier. LPN I confirmed the observation and said…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-01-24 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and medical record review, the facility failed to ensure that dental services were provided to one (#4) out of thirty-five residents for over for twenty months. Findings Included: On 01/22/20 at 10:17 a.m., Resident #4 was observed lying in bed. He was asked if he had any problems chewing or swallowing. He made eye contact with stimuli. His lower bottom teeth were crooked and yellow in appearance. The lower left was lacking teeth. He was asked if he had any pain or soreness in his mouth, as he continued to watch the surveyor and not respond. On 1/23/2020 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. He appeared receptive to the observation, as he did not demonstrate nor verbalize his rejection to the WN when he was asked. The WN went to his bedside as she asked him if he was in any pain. He only looked at her without any change noted to his face. She asked him for second time if he was in pain. Again,…

    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 before2020-01-24 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner, related to the dish machine, cleaning of dish cloths and a stove backsplash. Findings included: Observations of the facility kitchen on 1/21/20 at 9:52 AM revealed that the dish machine had a dirty dish curtain stored on top of the dish machine and hanging over the clean side of the dish machine. Closer observations of the dish machine revealed that around the opening of the clean side of the dish machine was a white chalky substance. (Photographic evidence obtained) Continued observations at this time revealed a tray came out of the clean side of the dish machine, containing what was supposed to be clean cutlery. Closer observation of the tray revealed that there were 3 dish cloths mixed into the cutlery. When questioned why the dish cloths were mixed in with the cutlery, the Certified Dietary Manager (CDM) immediately pulled them out of the tray and mumbled those should not be in there. An interview, on 1/21/20 at 9:55 AM, with the CDM revealed that she…

    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 · D2020-01-24 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 2 of 6 (top left, top middle) burners on the stove and a reach-in refrigerator located in the satellite kitchen. Findings included: Observations of the main kitchen and the satellite kitchen during the comprehensive tour of the kitchen on 1/23/20 at 11:13 AM revealed that the main kitchen houses a 6-burner stove. Close observation of the stove revealed that the top left burner and the top middle burner did not have pilot lights lit. Continued observations of the stove at this time revealed that the Dining Service Director lit both burners with a cigarette lighter. Both burners were turned on and then turned back off. The pilot light on the back center burner remained lit; however there was no pilot light on the rear left burner. The Dining Service Director reported that this was the second time this week that he had to light the pilot lights. Continued interview with the CDM and the Dining Service Director revealed that they both were 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.

    Environmental 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 SUMMIT CARE — 22 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 2 of 53.3-1.3 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 1 of 52.6-1.6 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 21 homes this chain runs (chain average 3.3★, per CMS)
1 of 5Hawthorne Center For Rehabilitation And Healing OfOcala, FL 1 of 5Valencia Hills Health And Rehabilitation CenterLakeland, FL 2 of 5Northbrook Center For Rehabilitation And HealingBrooksville, FL 2 of 5Palatka Center For Rehabilitation And HealingPalatka, FL 2 of 5Scott Lake Health And Rehabilitation CenterLakeland, FL 2 of 5Springs At Lake Pointe WoodsSarasota, FL 3 of 5Lake Bennet Center For Rehabilitation & HealingOcoee, FL 3 of 5Seven Hills Health & Rehabilitation CenterTallahassee, FL 3 of 5Timberridge Nursing & Rehabilitation CenterOcala, FL 3 of 5Ybor City Center For Rehabilitation And HealingTampa, FL 4 of 5Hawthorne Center For Rehabilitation And Healing OfBrandon, FL 4 of 5Lakeside Center For Rehabilitation And HealingJacksonville, FL 4 of 5Sandy Ridge Center For Rehabilitation And HealingMilton, FL 4 of 5Santa Rosa Center For Rehabilitation And HealingMilton, FL 4 of 5Surrey Place Healthcare And RehabilitationBradenton, FL 4 of 5Tampa Lakes Health And Rehabilitation CenterLutz, FL 5 of 5Century Center For Rehabilitation And HealingCentury, FL 5 of 5Diamond Ridge Health And Rehabilitation CenterLecanto, FL 5 of 5Hawthorne Center For Rehab & Healing Of SarasotaSarasota, FL 5 of 5Madison Health And Rehabilitation CenterMadison, FL 5 of 5North Bank Center For Rehabilitation And HealingJacksonville, FL

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

Who owns this facility

Owner / managerTypeRoleShareSince
MADISON SNF OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/02/2023
CH SUMMIT CARE HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/02/2023
SEAM NY 2020 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/02/2023
SK SUMMIT CARE II HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/02/2023
SUMMIT CARE GROUP II OPERATIONS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/02/2023
MCMANUS, JOHNIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 08/03/2023
SUMMIT CARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/04/2023
MCCALL, DAWNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/19/2024
SWENSON, DAVIDIndividualADP OF THE SNFsince 02/16/2026

CMS files one row per role, so the 12 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$13.9M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
$1.0M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 25%Other / private 26%

This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$379per resident / day
operating cost
$11,520per month
≈ monthly operating cost
$378per 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 105537. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-22, 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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