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Aviata At The Gardens - Tallahassee

1650 Phillips Rd, Tallahassee, FL 32308 · For profit - Corporation · 109 certified beds · (850) 942-9868 Medicare & Medicaid certified

Call the home — (850) 942-9868 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — 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)
  • nursing-staff turnover (57%) 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1607 Saint James Ct #2 · (850) 878-8714 · Call to confirm hours
Pharmacy
1605 E Plaza Dr · (850) 877-7108 · Call to confirm hours
Grocery
2819 Mahan Dr Ste 114 · (850) 597-9788 · Call to confirm hours
Park
2280 Miccosukee Rd · (850) 606-1470 · 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased5.6%8.7%15.4%better
Long-stay residents who lose too much weight7.0%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms15.2%4.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.8%2.5%3.3%better
Long-stay residents whose ability to walk worsened8.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication3.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.1%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control9.1%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table6.9%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.1%94.7%79.4%better
Short-stay residents rehospitalized after admission32.0%26.1%22.6%worse
Short-stay residents with an outpatient ER visit17.3%9.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.222.131.67worse
Long-stay outpatient ER visits per 1,000 resident days2.121.151.80worse

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.

13.1%U.S. median 10.7%
Went back to hospital
53.2%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 53.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 47 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 0.25 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.1%CMS range 8.6–18.810.7%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 discharge53.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge31.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 worsened1.7%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.42
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.36
RN hoursweekends
57.3%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 109 beds and averages 114.0 residents a day — about 105% occupied, or roughly -5 beds typically open. It runs essentially full — expect a waiting list. 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 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 2.95 hrs/resident/day on weekends vs 3.33 on weekdays — 12% thinner on weekends. RN hours go from 0.45 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

2
deficiencies at the latest standard inspection (2026-04-16)
7
at the previous standard inspection (2025-02-13)

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.

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Dcited before2026-04-16 · 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 observations, record review, resident interview and staff interview, the facility failed to develop a comprehensive care plan to address refusal of care for 1 of 26 sampled residents. (Resident #138) The findings include:Observations of Resident #138 were conducted on 4/13/26 at 1:22 PM, 4/14/26 at 12:48 PM, 4/14/26 at 4:38 PM, 4/15/26 at 9:18 AM, 4/15/26 at 12:49 PM, and 4/16/26 at 9:25 AM. During all of these observations, the resident was observed to have oily appearing, uncombed hair and some of her fingernails were about 1/2 centimeter past the nail bed. On 4/16/26, the resident was noted to have an odor. An interview was conducted with Resident #138 on 4/16/26 at 9:25 AM. She stated her last bath or shower was Saturday 4/4/26 and the staff have not offered to brush her hair or trim her fingernails at all this week. A review of Resident #138's medical record revealed she was admitted to the facility on [DATE]. A care plan was initiated on 2/10/26 for alteration in usual functional performance 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-16 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, observations, and photographic evidence, the facility failed to maintain an effective pest control program to ensure a clean, safe, and homelike environment in 1 of 2 nutritional pantries reviewed.The findings include:Observation of the nutritional pantries in the general and restorative care sides of the building was conducted on 04/15/2026 at 2:22 PM with the dietary manager. Small, dark, cylindrical pellets within the pantry cabinets were observed. In addition, upon observation, live, brown, fast-moving insects about half an inch long were observed within the nutritional pantry cabinets and at the baseboard of the wall below the cabinets. The Dietary Manager stated, yes, that is a roach. Photographic evidence was obtained of the small dark cylindrical pellets and roaches within these cabinets.An additional observation and interview were conducted on 04/15/2026 at 2:40PM with the Maintenance Director in the nutritional pantry in the general and restorative care side of the facility. When shown the small, dark, cylindrical pellets, the Maintenance…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-05 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and family interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 10 residents reviewed. The findings include: On 12/2/25 at approximately 12:00 pm, tour of the facility was conducted on the 100/200/300 halls. Upon entry to the unit, by the nurse station, a strong odor of urine permeated throughout the hallways. Again, on the same day at approximately 3:00 pm, the strong odor continued throughout the halls. On 12/3/25 at approximately 10:00 am, a second tour of the 100/200/300 halls revealed the strong odor of urine still existed. On 12-3-25 at 11:06 am, an interview with Resident #9's family member revealed Last week at 10:30 am, the hall was a mess I found him filthy, dirty, and soaking wet. She stated hospice is now coming for him 3 times a week. When hospice aides come and bathe him, they call and say they found him in a mess. The family member stated she is at the facility at least 4 times per week and there…

    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 · E2025-12-05 · tag F0761 — failed to label and store drugs safely — pattern
    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 upon observations, policy review, and interviews the facility failed to maintain proper labeling of medications with dates of when medication was opened, correctly label multi-use vial medications of when it was first accessed, follow label instructions for expiration dates, and provide safe storage of controlled drugs.The findings include: An observation of medication carts was conducted on [DATE] at approximately 3:15 pm. Medication cart 1 on the 400 unit had loose tablets in the drawers, a medicine cup of a clear gel like substances with the name [NAME] written on it in the top drawer, and an expired insulin pen dated [DATE] with a label that states to throw away any remaining medicine that remains 28 days after the first use. (Photographic evidence obtained)The medication cart on the 500 unit reveals had loose pills in the top drawer, a medication cup with unknown tablets placed in the medication drawer with no label or identification of what the medication is. When asked, Nurse E stated she does 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-05 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to maintain all the areas in the kitchen in safe and functional condition. The findings include: On 12/02/2025 at 2:43PM, observation of the kitchen food cart storage area showed walls were damaged with scuffed marks, deep scratches, deep scrapes, and broken sheetrock. The east wall has a hole above the wood bumper about the size of a fist and above the base board approximately 3 feet long. The sheetrock has broken off, exposing sheetrock metal grate. The bottom of the main door appears to be damaged, causing the wood to split. Door frames were dirty with paint chipping off. The floor appears to be dirty, floor material chipping, exposing the concrete. The mop area floor tiles were missing and the drain is missing the floor drain cover. (Photographic evidence obtained) On 12/03/25, an interview with the Regional Dietary Manager revealed two forms were completed and given to administration for repairs. An evaluation was completed in October 31,2025 from the Registered Dietician stating that all floors and walls are not in good…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-05 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, and record reviews, the facility failed to maintain an effective pest control program to ensure the facility is free of pests, specifically cockroaches.The findings include:Resident #6On 12-2-25 at 12:07 pm, Resident #6 stated she has had cockroaches in her room. She stated her family purchased a glue pad because the facility is not doing anything about the problem. An observation of the floor under the air-conditioner (AC) revealed a glue pad that had several cockroaches and a very small roach running on the floor along side the glue pad. (Photographic evidence obtained)A second observation of the resident's room was conducted on 12-3-25 at 10:00 am and revealed the glue pad contained many more dead roaches and some still alive attempting to free themselves. On 12-5-25 at 11:19 am interview was conducted with the Maintenance Director, who stated he recently had the pest control change from spray to dust in order to address the ongoing roach problem. He also stated they bought the glue strips and placed them in resident rooms…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 upon record reviews and interview, the facility failed to provide care and services to prevent worsening of wounds for 1 of 1 residents reviewed for pressure ulcers. (Resident #7)The findings include:Upon record review Resident #7 was admitted to facility initially on 5/1/25, was discharged to hospital and re-admitted to the facility on [DATE] with the diagnosis of Peripheral Autonomic Neuropathy, COPD, Rheumatoid Disease, AFIB, and Chronic Respiratory Failure. A Minimum Data Set (MDS) assessment with a date of 5/7/25 revealed that skin conditions is not coded for any pressure areas or ulcers but states she is at risk for pressure ulcers.On 5/16/25 a wound assessment was completed post re-admission from hospital that reveals wound #1 right inner thigh, measuring 4cm x 0.3 cm x 0.1 cm, etiology: pressure ulcer / injury at a stage 2 and not acquired in house. Wound #2 on the left buttocks measured 1.0 cm x 1.0 cm x 0.1 cm, etiology was incontinence associated dermatitis with stage partial thickness and not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-05 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 Interviews, observations, and facility policy review the facility failed to ensure and provide routine medications to residents in a timely manner. The facility failed to ensure the controlled drug records are in order, signed out appropriately by administering staff nurses and that all controlled medications are accounted for. While conducting observations of medication carts on 12/2/25 at approximately 3:15 pm, Nurse E opened up the narcotic medication drawer and removed 5-7 narcotic cards. A small white tablet was noted in the bottom of the drawer. She then stated the medication count sheet was blank. But she signed it out because she was told to do that today for the other nurse. On 12/2/25 an interview was conducted with Resident 12 at 08:00 pm, she stated that over the weekend she had to go without her pain medication. She stated was told by a nurse that she forgot to send in a script to the pharmacy for her pain medication. she said, This morning, I asked for a pain pill at 5:00 am and I didn't get it until 6:30 am.Upon review of Resident #12's medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-15 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and facility policy review, the facility failed to invite resident to care plan meetings for 1 of 3 residents sampled. (Resident #2)The findings include:On 7/14/25 at 5:02 PM, an interview was conducted with Resident #2. She stated she had not participated in any care plan meeting since she arrived at the facility. She further stated she had not been invited to any care plan meeting. A review of Resident #2's medical record was conducted with Staff A, the MDS coordinator. Resident #2 was admitted on [DATE]. A record of the most recent care plan meetings indicated they were conducted on 5/2/25, 2/27/25 and 11/29/24. Care plan meeting forms were signed and dated by Staff A and the Social Services Director. There was no indication that Resident #2 was in attendance. On 7/15/25 at 9:27 AM, an interview was conducted with Staff A. She stated that Resident #2 did not participate in the care plan meetings. She was unsure of the reason Resident #2 did not attend. A review 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-15 · 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

    Based upon interview, observation, and record review, the facility failed to maintain a clean environment in 2 out of 4 halls observed.The findings include:On 7/14/25 at 10:02 AM, during the initial tour, hallway 300 was noted with has a very strong urine-like smell.On 7/14/25 at 10:04 AM, Staff C, a housekeeper, was interviewed. She stated she works three days a week from 8:00 am to 2:00 pm. She will have two hallways assigned for cleaning duties. She steted she does not work on weekends. She stated sometimes she would have two extra hallways assigned when someone did not come to work. Upon asking if she was able to finish her assignments, she stated she does what she could. She stated her assignments were to clean surfaces and sweep and mop floors.On 7/14/25 at 10:17 AM, an interview was conducted with Resident # 7. She stated sometimes on the weekends she did not see housekeeping personnel. She further stated staff would sometimes come in and pick up the trash, but they would not mop or wipe the tables.On 7/14/25 at 10:27 AM, an interview was conducted with Resident #8. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2025-02-13 · 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

    Based on observation, resident and staff interviews, and record review, the facility failed to develop a comprehensive person-centered care plan to maintain the resident's highest practicable level of physical functioning for 1 of 28 sampled residents. (Resident #88) The findings include: On 02/10/25 at 01:56 PM during an interview with Resident # 88, the resident was asked if they are ever gotten out of bed. The resident replied that their wheelchair is too large and they cannot maneuver it because of the size. She stated she cannot sit up straight due to right-sided weakness and because it is very painful. The resident stated that they have not gotten out of bed but would like to if they had a more comfortable wheelchair. Resident #88 states that they have told staff but nothing has been done. On 02/12/25 at 12:10 PM, an interview was conducted with Staff H (Unit Manager for the 100, 200, and 300 halls). She stated she is new to the position since December and is still learning her role and that she was unaware of any requested equipment needs. She stated that this resident does…

    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 · D2025-02-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and record review, the facility failed to provide equipment and restorative services to prevent a further decrease in range of motion for 1 of 3 residents sampled for limited range of motion. (Resident #88). The findings include: On 02/10/25 at 02:47 PM, Resident #88 was observed to have contractures of the left arm/wrist/hand. No supportive devices were noted in the room. On 02/11/25 at 02:10 PM, Resident #88 was observed to be receiving personal care in bed from the nursing aide. Resident #88's left arm and leg were noted to be severely contracted, affecting the resident's ability to change positions. On 02/12/25 at 09:45 AM, the Director of Physical Therapy stated that he has not received any requests for equipment needs for this resident. He verified that, unless consulted, a resident that is not receiving therapy services would not be evaluated for equipment needs. On 02/12/25 at 11:55 AM, an interview was conducted with Staff G, a Licensed Practical Nurse (LPN). She confirmed that equipment needs are provided through PT/OT but the nurse…

    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 · D2025-02-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to provide appropriate urinary catheter care for 1 of 1 resident reviewed for catheter care. (Resident #97) The findings included: During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter. When asked how often the staff clean his catheter, Resident #97 stated the staff did not clean his catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #97 had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infections. A review of Resident #97's admission Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview of Mental Status Score of 11, which indicates he had moderate cognitive impairment. This MDS documented the presence of the urinary catheter. Resident #97's physician orders revealed there were orders written on 01/11/25 regarding Catheter…

    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 · D2025-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records contained complete and accurate information for 3 of 28 residents reviewed for medical records. (Residents #92, #5, #105) The findings include: Resident #92 During a tour of the facility conducted on 02/10/25 at 12:33 PM, Resident #92 was noted receiving oxygen via a nasal cannula. Closer observation revealed the oxygen tubing was dated 01/26/25 (photographic evidence obtained). A review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. Resident #92 had a medical history significant for Acute and Chronic Respiratory Failure, Apnea, Bipolar, Depression, and Dependence on Supplemental Oxygen. A review of Resident #92's Quarterly Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview of Mental Status (BIMS) score of 15, which indicates she was cognitively intact. A review of Resident #92's Care Plan revealed a care plan was written on 10/01/24 regarding altered…

    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 before2025-02-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to maintain proper isolation precautions for 2 of 2 residents reviewed for Enhanced Barrier Precautions (EBP) (Resident #97 and #67), and the facility failed to ensure proper handwashing practices during medication administration opportunities for 2 of 20 observations (Resident #71 and #563). The findings include: Resident #97 During a tour of the facility conducted on 02/10/25 at 12:50 PM, Resident #97 was noted with a urinary catheter present. Resident #97 stated the staff did not clean the catheter regularly. A review of Resident #97's medical record revealed he was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. He had a medical history significant for Paraplegia, Hematuria, and Urinary Tract Infection. A review of Resident #97's admission Minimum Data Set (MDS), dated [DATE] revealed he had a Brief Interview of Mental Status (BIMS) Score of 11, which indicates he had moderate cognitive impairment. This…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 4 of 5 residents reviewed for Influenza and Pneumococcal Vaccinations (Resident #101, #51, #105, and #96). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the Pneumococcal vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the Pneumococcal vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the Influenza vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the Influenza vaccine.…

    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 · D2025-02-13 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure vaccination consents were obtained and maintained for 3 of 5 residents reviewed for COVID-19 Vaccinations (Resident #101, #51, and #105). The findings include: A review of Resident #101's medical record for vaccinations revealed he was admitted to the facility on [DATE]. A review of the Immunization section of Resident #101's electronic medical record revealed he had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #101 was missing a consent form for the COVID-19 vaccine. A review of Resident #51's medical record for vaccinations revealed she was admitted to the facility on [DATE]. A review of the Immunization section of Resident #51's electronic medical record revealed she had refused the COVID-19 vaccine. A review of the immunization consent forms provided by the facility revealed Resident #51 was missing a consent form for the COVID-19 vaccine. A review of Resident #105's…

    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 · E2024-12-12 · tag F0926 — failed to keep the home smoke-free / fire-safe — pattern
    Have policies on smoking.
    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 and resident interviews, record review, and policy review the facility failed to take precautions to ensure safety of residents during smoking times for 6 of 10 residents reviewed. (Residents #4, #5, #6, #7, #8, and #10) The findings include: On 12/10/24 at approximately 9:00 AM an interview was conducted with Staff Member B, a Certified Nursing Assistant (CNA). She indicated that the CNA's escort the residents outside for smoking in addition to their daily assignments. She said there are quite a few smokers at the facility and no dedicated staff assigned to supervise smoking. She explained that residents get impatient waiting to go out and some of the higher functioning residents occasionally go outside to smoke without supervision. She also said that several residents in the facility have their own lighters and cigarettes that they keep in their rooms. She said Resident #4 goes out and needs close supervision because she is blind. She indicated that Resident #8 keeps a lighter 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-15 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, review of the facility grievance log, and policy and procedures, the facility failed to make prompt efforts to resolve grievances for 2 of 3 residents reviewed. (Residents #2 and #3) The findings include: On August 14, 2024 at 2:07 pm, a telephone interview was conducted with the husband of Resident #2. He stated he has filed two grievances with the previous administrator, one in August 2024 and another in July 2024. He stated they had voiced numerous complaints to the previous Nursing Home Administrator (NHA) and nothing was ever done about it. On August 14, 2024 at 2:20 pm, an interview was conducted with Resident #3. She stated that several grievances have been filed with the previous NHA about two Certified Nursing Aides (CNAs) that speak disrespectfully to the residents and failed to render assistance when needed, but nothing ever gets done about it. The same staff who disrespect and ignore the call lights continue to work on this hallway according to the resident. She also stated that, after she had lodged complaints against this CNA,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · 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 observations and interviews, the facility failed to provide a clean, safe and home-like environment for 11 of 94 occupied areas. The findings include: On 2/28/24 at 10:34, during the initial tour of the facility, the following environmental concerns were observed: Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-B had an overhead table with exposed edges. Occupied room [ROOM NUMBER]-B had a fall mat with brown-colored stains. Occupied room [ROOM NUMBER]-A had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-B had a fall mat with sticky tape covered with a dark brown substance. Occupied room [ROOM NUMBER]-A had wall paper peeling off the wall and a patched up white substance on the wall. Occupied room [ROOM NUMBER] had overhead tables with the plastic rim detached, exposing particle wood. Occupied room [ROOM NUMBER]-A had an overhead table with edges that are chipped. Additionally, the bed's frame is rusted.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to administer a medication as ordered by a physician for 1 of 3 resident sampled for medication administration. (Resident #2) The findings include: On 2/29/24, a review of Resident #2's medical record was conducted. A physician order stated to inject dexamethasone sodium phosphate (a medication used to treat many inflammatory and autoimmune disorders) 8 mg intramuscularly one time only for pain related to gout. This order was dated 12/29/24 with an end date of 12/30/24. The physician order summary was reviewed and stated it was completed. The Resident's Medication Administration Record (MAR) revealed medication was not documented as given on 12/29/23 and on 12/30/23 documentation was signed with nurse initials BT31 with a code number 9 that indicated see progress notes. A review of progress notes dated 12/30/23 at 00:40 AM and signed by Staff A, a Licensed Practical Nurse (LPN) stated dexamethasone sodium phosphate injection solution medication unavailable to administer. On 2/29/24 at 11:22 AM, an interview 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 26 residents sampled. (Residents #1, #46, #70 and #242) The findings include: Resident #46: On 11/13/23 at 12:12 PM, an interview was conducted with Resident #46. She stated the facility did not have enough supplies to provide incontinence care and did not have enough linens. She further stated she had personal clothing missing for months, including last week when laundry took some new clothes that she bought and they have not been returned yet. On 11/13/23 at 12:21 PM, an interview was conducted with Staff G, a Certified Nurse Assistant (CNA). She stated she was aware Resident #46 had been missing clothing for 30 days. She stated laundry kept telling her that they would find her clothes and they did not. She further stated the facility was always short on had washcloths, towels, and linens. A review of the facility's grievances 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · 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 interview, the facility failed to provide transfer or discharge notices to 2 out of 2 resident sampled for discharge notices. (Residents#30 and #1) The findings include: A record review revealed that the facility did not provide transfer or discharge notices at the time Residents #30 and #1 were discharged to the hospital. An interview was conducted on 11/15/23 at approximately 2:58 PM with the business office manager. She was asked where the transfer or discharge notices could be found, as they were not part of the record. She stated that medical records could provide a copy. An interview was conducted on 11/15/23 at approximately 3:08 PM with medical records. The medical records staff stated they did not have a copy of any transfer or discharge notices for Residents #30 and #1. An interview was conducted on 11/15/23 at approximately 4:19 PM with the Social Services Director. She stated she is the one that sends the discharge notices to the Ombudsman. When asked for a copy of the discharge notices for Resident #30 and Resident #1 that were sent to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to provide bed-hold notices to 2 out of 2 resident sampled for hospital discharge. (Residents #30 and #1) The findings include: A record review revealed no evidence that the facility provided a bed-hold notice at the time Residents #30 and #1 were discharged to the hospital. On 11/15/23 at approximately 2:58 PM, an interview conducted with the Business Office Manager, who stated that the facility does not do bed-hold notices. She stated, We do not do bed-hold notices for anyone, we do not need to do that. On 11/15/23 at approximately 3:20 PM, the Facility Administrator provided a copy of the facilities bed-hold policy, which states, At the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of bed-hold.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · 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

    Based on record reviews and interviews, the facility failed to develop a comprehensive care plans for antibiotic use for 1 of 1 residents sampled. (Resident #34) The findings include: On 11/13/2023, a record review was conducted for Resident #34. The resident's care plan only included a nutrition care plan. There was a baseline care plan document scanned into Point Click Care under the Miscellaneous tab that was not legible. No evidence of a care plan related to her antibiotic use could be located. (photographic evidence obtained) On 11/15/2023 at approximately 9:12 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. When asked about the comprehensive care plans for antibiotic use not being completed for Resident #34, the MDS Coordinator stated she has another MDS Coordinator who comes in and helps her and she would have been the one who did the assessment for Resident #34. The MDS Coordinator stated she is not sure why she didn't complete the care plans and stated, Honestly, she just failed to do it. When asked where the paper copy for the baseline care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and records review, the facility failed to develop and implement written standards, policies, and procedures for the Infection Prevention and Control Program (IPCP) and failed to conduct an annual review of its IPCP. The findings include: On 11/15/23 at approximately 10:50 AM, in an interview with the Director of Nursing and Unit Manager, they disclosed that they are both recently trained in Infection Control. They stated that the facility does not have a formal training program on Transmission Based Precautions (TBP), education is provided on a case by case basis. Surveillance of compliance is conducted intermittently and as needed. Any cluster of 2 or more infections are tracked and recorded. Department of Health (DOH) contact is used as a resource and reporting is done according to their DOH guidelines. On 11/15/23 at 12:10 PM, a review of Infection Prevention and Control Program (Revised date: October 2018) in the Quality Assurance and Performance Improvement manual with the Administrator revealed no review of the IPCP in the past 12 months of records. The…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, maintain, or follow policies and procedures for immunization of residents against influenza and pneumococcal disease in accordance with national standards of practice for 2 of 5 clinical records reviewed. (Residents #36 and #46) The findings include: On 11/15/23 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON) and the RN Unit Manager (UM). Patient records for five sampled patients were reviewed. Of the five residents sampled, 2 were lacking documentation of Route of Administration, amount administered, Location given, Manufacturer's Name, expiration date or Lot number for the Influenza vaccine as required by Facility policy. (photographic evidence obtained) The remaining 3 residents had signed refusals on file. The DON and UM confirmed that required documentation was not in the records provided. Per the UM, a possible secondary source of documentation could be in the pharmacy records but the missing documents cannot be retrieved because it would be kept by the previous…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
PHILLIPS PARENT LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/02/2023
AIH HOLDINGS 10 LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
ALTRANAIS CARE CENTERS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
ASPIRE INVESTORS HOLDINGS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
ASPIRE INVESTORS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
HAUTCO HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
HAUTCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
LEINEN LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
LEON PHILLIPS HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/02/2023
ROWLAND, ROBERTIndividualCONTRACTED MANAGING EMPLOYEEsince 11/02/2023
PAPINEAU, BERTIndividualW-2 MANAGING EMPLOYEEsince 07/19/2024
SHANKS, TIMOTHYIndividualW-2 MANAGING EMPLOYEEsince 08/12/2024
FREUND, NOCHUMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 11/02/2023
ASPIRE MGT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/02/2023

CMS files one row per role, so the 15 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$6.8M
Net patient revenuemost recent cost report
-46.4%
Operating marginrevenue minus expenses
$359K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 3%Other / private 19%

About 77% 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 $359K 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

$385per resident / day
operating cost
$11,708per month
≈ monthly operating cost
$263per 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 105764. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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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