Aviata At Tallahassee
3101 Ginger Dr, Tallahassee, FL 32308 · For profit - Limited Liability company · 180 certified beds · (850) 877-2177 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — 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)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 0.7% | 2.0% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 11.3% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.4% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.8% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 6.4% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.1% | 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 table | 6.5% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.8% | 94.7% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 22.8% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.90 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.14 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.6% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.9% 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 70 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.6%CMS range 30.1–63.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.8–15.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 4.6–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.81 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 180 beds and averages 143.6 residents a day — about 80% occupied, or roughly 36 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.13 hrs/resident/day on weekends vs 3.41 on weekdays — 8% thinner on weekends. RN hours go from 0.40 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-08-13 · tag F0678 — failed to provide CPR when needed — isolatedProvide 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 record review, policy review and staff interviews, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 of 3 residents (Resident #1). The facility neglected the resident's needs for emergency care allowing the resident to expire despite a full code status.The findings include: A review of the electronic medical record (EMR) revealed Resident #1 expired on [DATE] at 1:05 PM and that CPR was not performed. Staff A, a Registered Nurse (RN), provided a statement of events that took place on [DATE]. At 1:05 PM, the nurse observed that the resident was not breathing. She checked vital signs with respirations 0, blood pressure 0, and oxygen saturation 0%. On 1:09 PM, Staff A notified the hospice nurse by phone to tell of Resident #1's death. At 3:00 PM, another nurse working in the facility noted Resident #1 was a full code. At 3:02 PM, 911 was called and CPR was started on Resident #1. At 3:06 PM, Paramedics arrived and continued CPR on Resident #1. At 3:25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and facility policy review, the facility failed to submit an incident report within the required 2 hour timeframe for 2 of 2 reports reviewed for abuse and neglect.The findings include:1. Review of an allegation of physical abuse was conducted which revealed facility staff were made aware of the incident on 4/23/26 at 2:00 PM. Further review revealed the administrator was not notified by the staff until 4/23/26 at 6:30 PM. The report was not filed with the state agency until 4/23/26 at 9:05 PM. An interview was conducted with the facility Administrator on 5/12/26 at 9:00 AM concerning the delay in reporting this incident. He stated, I don't recall why I was late reporting this incident. It could be that I was collecting data for the report. Upon reviewing the investigation report times, he confirmed that the incident was reported later than the required 2-hour time frame. 2. Review of an allegation of neglect involving 17 residents who did not receive morning medications on 4/18/26 was performed. Review of the facility's investigation revealed 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.
- Potential for harm · Dcited before2025-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 and interviews, the facility failed to maintain a clean, safe and home-like environment for 3 of 58 occupied rooms and 2 of 111 residents screened during the initial tour. (Rooms #126, #216, #200, and Residents #63 and #100)Room observations (Photographic evidence obtained of all issues) On 9/15/2025 at 11:53 AM, Room # 216 (which was occupied) bathroom's toilet lid had a crack. The room's entry area ceiling had a brown-colored rust-like metal between the tiles. On 9/16/2025 at 9:21 AM, room [ROOM NUMBER]'s wall had brown-colored stains and paint had scratches. The room was being occupied. 09/15/2025 at 12:00 PM, a small refrigerator in room [ROOM NUMBER] was observed and a foul odor was detected. Inside a spilled brown liquid was present along with two unfinished bottles of soda. The freezer compartment had ice cream spilled throughout. The resident confirmed that the refrigerator had not been cleaned in a long time. On 9/16/2025, 9/17/2025, and 9/19/2025, subsequent observations confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interviews, record review, and policy review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents by not screening 1 of 1 resident sampled for smoking. (Resident #164)On 9/18/25, a chart review was conducted of the electronic medical record (EMR) for Resident #164. No safe smoker screening was documented in the record. On 9/18/25 at approximately 3:25 pm, an interview was conducted with the Director of Nursing (DON). She was asked about the facility process for screening residents for smoking safety. She stated a smoking screen is done on every resident on admission. If the resident smokes, teaching is provided to the resident. The resident is added to the smoking list kept by activities staff. Activities staff are responsible for providing supervision and assistance to residents who smoke. When asked about Resident #164's current smoking status, she stated that the resident does not smoke. If she does want to start smoking, she will then be screened for safe smoking, provided teaching, and set up with Activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-19 · tag F0697 — failed to manage pain — isolatedProvide 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 interview, the facility failed to administer prescribe pain medication and failed to refill pain medications for 1 of 1 residents sampled for pain medication. (Resident #52) On 9/16/25, a phone interview was performed with the daughter of Resident # 52. She stated that Resident #52 had not been receiving her nightly dose of MS Contin 75 ER for several days. A phone call was performed with the facility's pharmacy on 09/16/2025 at 1:36 PM. They stated that the facility requested a refill of MS Contin 75 mg ER for Resident # 52 on 7/2/2025 (25-day supply, ended 8/6/2025) and 8/4/2025 (25-day supply, ended 8/31/2025). No further refill requests had been received since then. On 09/16/2025 at 2:30 PM, the Director and Assistant Director of Nursing were interviewed. They demonstrated the procedure for refilling medications to prevent missing any days. They were shown on the Medication Administration Record that MS Contin was documented as given although no medication refill had been received. The staff stated that the facility had some extra dosages on hand to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to provide safe and secure storage of medications for 2 of5 residents observed for medication. (Residents # 24 and 42)The findings include:Resident # 24During an observation on 09/15/2025 at 12:00 PM, Resident # 24 playing had the following medications stored at their bedside table: Medicated body Power, 2 bottles of Isopropyl alcohol 91%, Vitamins A&D Ointment, Hydrocortisone Acetate 1% Cream, Olopatadine Hydrochloride (a medicine for itchy eyes), Ophtalmic solution 0.2%, and Voltaren Arthritis pain Cream. (Photographic evidence obtained). A repeat visit on 9/16/2025 at 1:37 PM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM showed these medications were still in the bedside table. On 09/16/2025, a review of Resident #24's record shows no orders for self-administration of medications.Resident #42On 09/15/2025 at 12:30 PM, 09/16/2025 at 8:15 AM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM, Resident #42 was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to maintain medical records that were accurate and complete for 1 of 1 resident sampled. (Resident #63)The findings include:On 9/15/2025 at 11:47 AM, an interview was conducted with Resident #63. He stated he had a wound on his back that healed and another one on left arm that had not healed yet. On 9/17/2025 at 11:33 AM, an observation was made of Resident #63 receiving a clean dressing on his left posterior forearm.A review of Resident #63's medical record was conducted. Resident #63 was admitted to the facility on [DATE] with diagnoses including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and morbid obesity. Physician's orders stated, left forearm: cleanse with wound cleanser, apply xeroform then cover with dry dressing every day shift with a start date of 7/15/25. A review of the Treatment Administration Record (TAR) revealed documentation was left blank on 9/3/25, 9/7/25, 9/8/25, 9/11/25 and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-19 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 and policy review, and interviews, the facility failed to follow infection control practices for 1 of 1 resident sampled for wound care treatment (Resident #159), 1 of 2 residents sampled for droplet isolation precautions (Resident #34), and 1 of 1 resident sampled for contact isolation precautions. (Resident #107)Resident #107 A chart review conducted on Resident #107 revealed a physician order which stated, Isolation Type – CONTACT-methicillin resistant staphylococcus aureus (MRSA) every shift for monitoring. Observations of the resident’s room door revealed a sign for Enhanced Barrier Precautions (EBP) [a different category of contact precautions] hung on an over-the-door caddy containing Personal Protective Equipment (PPE) supplies such as gown, gloves, and masks. There was no signage for the ordered contact isolation precautions observed posted on the door. On 9/16/2025 at approximately 11:05 AM, an interview was conducted with the resident’s nurse Staff R, a Registered Nurse, about the resident’s current isolation status. He stated the resident is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
Based on review of resident records, interview, and review of facility policy, the facility failed to obtain consent for 1 of 2 psychotropic medications ordered for 1 of 3 residents reviewed for psychotropic medication usage. (Resident #3) The findings included: On 3/4/24, a review of the records for Resident #3 was conducted. A review of the Medication Administration Record in December 2024 indicated that, in addition to Mirtazapine (an antidepressant) 30 mg once a day, Resident #3 had been taking Trazadone (another antidepressant) 50 mg .5 tablet every 8 hours. Resident #3's record had a signed consent to take Mirtazapine 30 mg once a day. However, there was no consent for the Trazadone. A review of the psychiatric notes, dated 9/26/24, for Resident #3 was conducted. The psychiatry notes stated that Resident #3 was started on Trazodone due to an exacerbation of depression and mood disorder. The note indicated that medication changes were needed to stabilize his symptoms. The provider indicated that risks, benefits, and alternatives were discussed. The note does not clarify whom…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-14 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to maintain an adequately equipped call light system for the 100 hall of the building. The findings include: During the initial tour of the facility, it was noted that all the residents in the 100 hall were observed with hand held bells located at the bedside of each resident. When asked about this, the Administrator stated that the call light system was not working and these bells were being used in lieu of the call lights for now. He stated the call light system had been broken in the 100 hall for a very long time. However, it was noted upon looking in the rooms that there was no system of calling staff located in each of the bedrooms' private bathrooms. Upon further discussion, the Administrator stated the parts for the call light system had recently arrived and the repairs to the system should occur soon.
- Potential for harm · Dcited before2025-01-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain accurate and updated medical records for 1 out of 8 residents sampled. (Resident #2) The findings include: On [DATE], it was decided by the family that Resident #2's code status would be changed to Do Not Resuscitate (DNR). The family started the process and the facility assisted in getting the order signed by the doctor that same day. The Social Service Assistant brought back the completed to the facility at approximately 4:45 PM. On [DATE], Resident #2 was observed in bed without respirations and cold to the touch. Staff F, a Licensed Practical Nurse (LPN), and Staff G, a Registered Nurse (RN), confirmed the advance directive on the electronic medical record, and it stated Resident #2 was a Full Code. Per facilities policy, they had to double check the Advance Directives book, located at the nurse's station, but it was not there. Staff F and G started cardiopulmonary resuscitation (CPR) until paramedics pronounced the resident expired. 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.
Show the remaining 19 citations
- Potential for harm · F2024-06-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, staff interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. There were issues found with the dish cleaning process, cold food storage, non-food items and personal drinks stored on food preparation stations and a lack of hair containment during food preparation. The findings include: A tour of the kitchen was conducted on 06/17/24 beginning at 12:01 PM. Upon entering the dishwasher room, the following was observed: -Two juice cups and one soup bowl were on the floor of the dishwasher room along with garbage, debris, and a large amount of water. -The ceiling above the dishwasher was rusted through and appeared to be falling apart. -A large amount of limescale buildup was observed on the front of the dishwasher. -The hose for the hand sprayer nozzle and a pipe located under the sink area were both observed with water flowing freely from them. -There was food matter falling under the sink and disposal area due to improper water flow through the drain and garbage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-20 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on observations, review of the electronic medical record (EMR), interviews with staff and residents, and review of the facility policies and procedures, the facility failed to provide a dignified existence for 5 of 6 residents sampled for dignity. (Residents 104, 65, 116, 41, and 120) The findings include: Resident #104 During a tour of the facility conducted on 06/17/24 at 2:53 PM, Resident #104 was observed lying in bed in a hospital gown. When asked why Resident #104 was in a hospital gown, Resident #104 stated she had no clean clothes. She stated she had talked to housekeeping staff and to nursing staff and each told her the responsibility of resident's personal laundry fell on the other. Resident #104 gave the surveyor permission to open her closet, and inside the surveyor observed bags and piles of clothing. (Photographic evidence obtained with resident's verbal permission) Resident #104 verified these clothes were all dirty and in need of laundering. When asked if she was wearing a hospital gown due to her lack of clean clothing, she stated Yes, I only have one clean…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to provide a safe, clean, and homelike environment in the laundry room, main hallway, and the 100 and 200 residential areas. The findings include: On 6/19/24 at 2:51 PM, a tour of the facility laundry services area was conducted with the Facility Administrator (FA), District Manager of Housekeeping Services, the Facility Laundry Services Supervisor, and the Plant Operations Director. Upon opening the door to the soiled laundry processing area, concerns were identified. On the right side of the room was a shelf overflowing and stacked with linens to the ceiling. A blue disposal can was directly in front of the shelf with linens stacked up on top. There were also linens on the floor below the shelf. The left side of the room had another shelf stacked with pillows to ceiling. There were several items on the soiled concrete floor including towels, sheets, and gowns in bags that were partially opened. There was a bed spread thrown on the floor. In between…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-20 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation, record review, and staff interview, the facility failed to properly store medications maintain medication carts, including disposal of expired medications and properly labeling medications in 3 of 3 medication carts reviewed. The findings included: A medication cart observation was conducted on 06/20/24 at 3:15 PM with Staff N, a Licensed Practical Nurse (LPN) for the Split Haven medication cart. The following areas of concern were identified (photographic evidence obtained): -4 white unidentified tablets were observed in the top left drawer of the medication cart. LPN N disposed of these medications into the sharp's container located on the side of the medication cart when this was brought to her attention. -4 multicolored tablets were observed in the 3rd drawer on the right side of the medication cart. LPN N disposed of these medications into the sharp's container located on the side of the medication cart when this was brought to her attention. -A Levemir insulin pen lacked an open date. It is unknown if this medication was used, however, per the pharmacy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-20 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident intervew, staff interview, review of meal tray tickets and electronic medical record (EMR) review, the facility failed to serve each resident a palatable diet and failed to address special dietary needs and physician orders for 3 of 7 residents sampled for food related concerns, Resident #22, #248 and #135). The findings include: Resident #22 On 06/17/24 at approximately 01:50 PM, Resident #22 was observed with a lunch tray in front of her. She indicated she just returned to the facility from dialysis. Resident #22 reported she does not get a bagged lunch on the days she is out of the facility for dialysis. On 06/18/24 at approximately 08:28 AM, Resident #22 stated she frequently does not get what is on her meal ticket, it often is missing cereal, jelly and margarine. Resident #22 stated her roommate's family provides snacks and individual microwave meals that she supplements with. An observation at this time of Resident #22's meal ticket indicates, NO MILK, but there were two cartons of milk observed on the tray, she received toast without the jelly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-20 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and policy reviews the facility failed to maintain all garbage areas in a safe and sanitary manner. The findings include: Upon initial entrance of the facility on 06/17/24 at 11:35 AM, an observation of the dumpster area located at the side of the building in the main parking lot was made. It was observed that a moderate amount of garbage and medical waste was present on the ground in front of and surrounding the two dumpsters. The first dumpster appeared to be in clean condition. Further observation revealed approximately 12 wooden pallets were being stored behind or next to this dumpster. The second dumpster was observed to have a side access door open. Closer observation revealed a broken plastic cart, a broken and rusted metal cart, and a broken wooden table were being stored behind this dumpster. Later observations of the dumpster area conducted on 06/17/24 at 5:45 PM revealed the same amount of garbage and medical waste present on the ground in front of/surrounding the dumpsters. During this observation, the top plastic cover of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-20 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy reviews the facility failed to maintain food service related equipment in safe operating condition in the kitchen and food pantries. The findings included: Kitchen sink: During the initial tour of the kitchen conducted on 06/17/24 at 12:01 PM, upon entering the dishwasher room, it was observed that a large amount of water was present on the floor of this room. Closer observation revealed there was a sprayer nozzle hanging over a sink area which had a large amount of water coming out of the hose. It was also observed there was water pouring out of a pipe under the sink. Further observation revealed, on the right side of the dishwasher, that there was a large buildup of food particles present along with a rack of clean dishes which also contained a large buildup of food particles. An interview was conducted with the facility's Kitchen Manager at this time. The manager was asked to explain if this was the dirty side, where the dirty dishes entered the dishwasher. The Kitchen Manager stated this was the clean side, where the clean dishes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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, policy review, and record review, the facility failed to ensure accuracy of Preadmission Screening and Resident Review (PASARR) for 3 of 3 residents sampled (Residents #18, #62, and #126). The findings include: Resident #18 On 6/19/24, a review of the PASARR for Resident #18, dated 3/3/17, was conducted. There was no evidence of a Level II being completed in the electronic record although the form did denote the resident had a primary diagnosis of dementia and suspected mental illness. On 06/20/24 at 9:37 AM, an interview was conducted with the Regional Social Services Director, who reviewed the electronic chart and verbally acknowledged the document and that there is no Level II review in the electronic record. She stated she it most likely got lost during the transition of the medical record migration and it was possible it just didn't get scanned into the electronic record. On 6/20/24 at 10:32 AM, an interview was conducted with the Regional Clinical Director, who stated they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observations, staff interviews, and review of the electronic medical record (EMR), the facility failed to develop a comprehensive care plan for anxiety for 1 of 2 residents sampled. (Resident #123) The findings include: On 6/17/2024 at approximately 2:30 PM, Resident #123 was heard calling out help me, I can't breathe. Nursing staff responded and placed oxygen on the resident. The resident continued to call out and appeared anxious. On 06/20/2024 at approximately 09:18 AM, during an interview with Staff S, a licensed practical nurse (LPN), she stated, The resident can become agitated at times but is usually easy to redirect. She does not have any PRN (as needed) medications for anxiety, just scheduled Trazadone. A review of the EMR revealed the resident was admitted on [DATE] and had a diagnosis of anxiety disorder. A review of physician orders found an order initiated on 06/13/2024 for Trazodone (a medication used to treat depression) 25 mg twice a day. An order was placed on 5/17/2024 for psychology…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon record review and staff interview, the facility failed to ensure the accuracy of narcotic counts and that the stored narcotics were consistent with physician orders for 1 of 37 residents reviewed, Resident #143. The findings include: A review of Resident #143's narcotic count sheet revealed tablets were present in the medication cart for Hydrocodone/APAP Tablet 5-325 1 tablet by mouth every 6 hours as needed for non-acute pain. The count on the narcotic book sheet was 66. The number of tablets present in the medication cards was a total of 65. Staff P stated she had given Resident #143 this medication at 12:00 PM and had not signed it out of the narcotic book. She confirmed that she had signed it out of the computerized Medication Administration Record (MAR). When asked to review the physician order page, the computer order was for Hydrocodone/APAP Tablet 7.5-325 1 tablet every 6 hours related to other low back pain. Further review of the computerized MAR revealed the order was written on 05/30/24. In an interview conducted with Staff P during this observation, 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.
- Potential for harm · D2024-01-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to communicate with resident's representative concerning a resident's changes of antipsychotic medication for 1 of 1 resident sampled. (Resident #4) The findings include: On 1/16/24 at 11:28 AM, an interview was conducted with Resident# 4's Power of Attorney (POA). He stated the facility did not communicate with him about his father's use and discontinuation of antipsychotic medications. The POA stated his father was placed on antipsychotics after his initial admission, but he was not made aware. Later, the facility discontinued the antipsychotic medication, but he was not made aware this decision until his father was involuntarily admitted to a psychiatric facility pursuant to the Florida Mental Health Act of 1971 (Baker Act). On 1/16/24, a review of Resident #4's medical record was conducted. The resident was initially admitted to facility on 11/30/21 from a local hospital and discharged on 11/21/23 under the [NAME] Act order. The resident's diagnosis included paranoid schizophrenia, major depressive disorder, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-24 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, review of facility grievance logs and policy review the facility failed to ensure that all grievances had a prompt resolution for 1 of 2 residents (resident # 23) sampled for personal property. The findings include: On 3/22/23 at approximately 3:30 PM, a interview was conducted with resident #23 who stated that she reported her pants and pajamas missing a couple of months ago and that the facility said they were going to look for them but she had not heard back from them. On 3/22/23 a review was conducted of the facility's grievance log which revealed that on 1/3/23 resident #23 filed a grievance for not having enough linens, on the resolution portion of the grievance the resident stated that she now had missing pants. Further review of the grievance logs failed to reveal follow up related to the missing pants thus there was no resolution. On 3/22/23 at approximately 3:47 PM, an interview was conducted with the Social Worker who confirmed that there was not a second grievance filed concerning the missing clothing. On 3/22/23 a review was conducted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observations, record reviews, staff interviews, and policy review, the facility failed to implement the care plans for 1 of 3 residents reviewed nutrition (Resident #68), 2 of 3 residents reviewed for pain management (Resident #518 and #77) and for 1 of 1 resident sampled for bowel and bladder (Resident #28). The findings include: Resident #68 Review of resident #68's electronic record revealed a current physician order dated 1/13/23 for the resident to receive a consistent carbohydrate diet with large protein portions for nutrition and low body mass index. The current comprehensive plan of care for nutritional problem with risk for malnutrition and weight loss revealed a current intervention to provide and serve diet as ordered. An observation of resident #68 was conducted during the lunch meal on 3/23/23 at approximately 11:49 AM, in the dining room. The resident was served a plate with 3 golf ball size ravioli with red sauce, mixed vegetables in a bowl, and a roll. An interview was conducted 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.
- Potential for harm · D2023-03-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and policy review the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 1 residents reviewed for limited range of motion. (Resident #1) The findings include: Observations of resident #1 were conducted on 3/20/23 at 3:59 PM, 3/21/23 at 2:38 PM, and 3/22/23 at 12:14 PM. During the observations the resident was in bed and his right arm was observed to be bent at the elbow and his hand was up near his chin. Review of resident #1's electronic record revealed a quarterly minimum data set with an assessment reference date of 2/14/23 indicating functional limitation in range of motion impairment on both sides of upper and lower extremities. The record revealed no documentation or care plan indicating the resident was receiving services for the limitation in range of motion. An Occupational therapy Discharge summary dated [DATE] indicated the resident had upper extremity contractures and was discharged 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.
- Potential for harm · Dcited before2023-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, resident and staff interview, record review and review of facility policy, the facility failed to ensure implement interventions to prevent accidents following a resident fall for 1 of 1 resident sampled #565). The findings include: An observation of resident #565 was conducted on 03/21/2023 at approximately 1:20 PM. The resident was sleeping at that time. During observation a hematoma was noted to the left side of her head with a yellowish-green color surrounding the area down to the temple area. A follow-up observation of Resident #565 was conducted on 03/23/2023 at approximately 10:00 AM, which revealed sheep skin type pads to the upper bed rails of her bed. At this time the resident stated, They just came in and put these things on my bed. Can you take them off? I don't know where these came from. An interview was conducted on 03/23/2023 at approximately 8:30 AM, with resident #565. The resident stated she has no pain to her head. She stated she fell out of bed reaching for something 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.
- Potential for harm · D2023-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident interview, staff interview and policy review, the facility failed to provide care and services in accordance with the physician orders for 1 of 1 sampled residents with a urinary catheter (Resident #108) and failed to provide timely incontinent care for 1 of 1 residents sampled for bowel and bladder (Resident #28). The findings include: Resident #108 Review of resident #108's electronic record revealed a current physician order dated 1/12/23 to change the resident's urinary catheter every 2 weeks. Review resident #108's record revealed the catheter had not been changed since 2/11/23 (5 weeks ad 4 days) when he was sent to the hospital after the staff changed the catheter. An interview was conducted with resident #108 on 3/22/23 at 12:15 PM. He stated his catheter had not been changed since he went to the hospital last month. An interview was conducted with employee B, Licensed Practical Nurse Unit Manager, on 3/22/23 at 10:39 AM. Employee B reviewed the record and confirmed a catheter change had not been documented since 2/11/23. Further interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-24 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, and interviews, the facility failed to appropriately administer enteral feedings to prevent possible complications for 1 of 1 resident sampled for enteral feeding (Resident #123). The findings include: On 3/21/23 at 5:55 PM, an observation of Resident #123 was conducted while the resident was receiving an enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid) conducted by Staff L, a Licensed Practical Nurse (LPN). During the feeding, Staff L, LPN was observed diluting the 237 ml (milliliters) of 2.0 calories feeding with 200 ml of water. At approximately 75% of the feeding intake, Resident #123 started grimacing and Staff L, LPN concluded the feeding. On 3/22/23 at 8:35 AM, a second enteral feeding observation was conducted with Staff L, LPN. Staff L LPN repeated the previous day's process. Resident #123 received the entire 237 mls of 2.0 calorie feed and the 200 ml of water (a total of 437 mls). Resident #123 waved her hand and had some grimacing during the process. On 3/23/23 at 8:36 AM, an enteral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-24 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and review of facility policies, the facility failed to provide appropriate infection control measures during wound care for 1 of 3 residents (resident #77) sampled for pressure ulcers. The findings include: On 3/23/23 at approximately 10:40 AM, an observation was made of Nurse E, a Licensed Practical Nurse (LPN) performing wound care for resident #77 with the assistance of Nurse B, a LPN. Nurse E and B were observed to perform hand hygiene and apply clean gloves, then Nurse E cleansed the wound to resident #77 right foot with gauze and wound cleanser, then place the wound care supplies provided by Nurse B onto the resident's bed side dresser without cleaning the top of the dresser or placing a barrier to the top of the dresser. Nurse E then cleaned the wound to residents right foot again and applied calcium alginate ( a drainage absorbing agent) to the wound bed and covered with dry dressing without changing gloves and performing hand hygiene between cleaning the wound and applying the clean dressing. Nurse E was then observed to remove gloves,…
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.
- No harm found · B2024-06-20 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to consistently post nurse staffing information. The findings include: On 6/19/24 at approximately 9:11 AM, staffing was not posted on the 100 and 200 halls. On 6/20/24 at approximately 10:09 AM, staffing was not posted on the 100 and 200 halls. On 6/20/24 at approximately 10:30 AM, Staff O, Licensed Practical Nurse (LPN), for the 100 hall was interviewed. When asked if she was the one responsible for updating the board, she stated she was. When asked why it had not been updated in a couple of days, she stated she thought it was getting done. On 6/20/24 at approximately 10:34 AM, Staff N, the LPN for the 200 hall, was interviewed. When asked about the staffing board, she stated she had not updated it that day. She tries to do it first thing when she comes in but does not always have time. She also stated it is the nurse's responsibility to update it every shift, it just does not always happen right at the beginning of the shift.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-11-13 for 71 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to AVIATA HEALTH GROUP — 50 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 49 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 49; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GINGER PARENT LLC | Organization | DIRECT OWNERSHIP INTEREST | since 11/02/2023 |
| GINGER HERITAGE HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/02/2023 |
| FREUND, NOCHUM | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 11/02/2023 |
| MANN, STEFAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/04/2025 |
| MILLIARD, RAYMOND | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/29/2024 |
| DAGAN, AMITAI | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| GOLDBERGER, ABRAHAM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| GOLDBERGER, FAIGY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| HERSKOWITZ, ELIEZER | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| HERSKOWITZ, YAAKOV | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| TRAVITSKY, AARON | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/14/2025 |
| ASPIRE MGT LLC | Organization | ADP OF THE SNF | since 11/02/2023 |
CMS files one row per role, so the 15 rows in the source record cover these 12 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.
3 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.
About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $247K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105433. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-19, 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.