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Miracle Hill Nursing & Rehabilitation Center, INC

1329 Abraham Street, Tallahassee, FL 32304 · Non profit - Corporation · 120 certified beds · (850) 224-8486 Medicare & Medicaid certified

Call the home — (850) 224-8486 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$43,264 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $43,264 in federal fines (most recent 2025-06-05)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1819 W Tennessee St · (850) 576-0147 · Call to confirm hours
Pharmacy
438 W Brevard St · (850) 412-5490 · Call to confirm hours
Grocery
1309 Alabama St · (850) 222-5147 · Call to confirm hours
Park
1401 Indiana St · 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 3 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased19.8%8.7%15.4%worse
Long-stay residents who lose too much weight11.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.3%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.9%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened11.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication4.3%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine42.6%99.2%95.3%worse
Long-stay residents with pressure ulcers7.0%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control6.2%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 table7.0%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine35.4%94.7%79.4%worse
Short-stay residents rehospitalized after admission18.0%26.1%22.6%better
Short-stay residents with an outpatient ER visit6.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.252.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.431.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

11.7%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy

Met the expected recovery: 60.9% 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 23 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 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF11.7%CMS range 7.9–18.910.7%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 discharge60.9%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 discharge65.2%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 discharge39.1%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 identified94.3%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 worsened5.7%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 hospitalization9.2%CMS range 4.7–14.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.381.02Oct 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

0.45
RN hours/ resident / day
0.74
LPN hours/ resident / day
2.43
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.33
RN hoursweekends
42.5%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 105.0 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.25 hrs/resident/day on weekends vs 3.77 on weekdays — 14% thinner on weekends. RN hours go from 0.50 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as 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

15
deficiencies at the latest standard inspection (2025-06-05)
6
at the previous standard inspection (2024-03-14)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2025-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure that a resident was free from harm and neglect when it failed ensure that residents with diabetes mellitus receive their insulin and/or blood glucose monitoring as ordered for 1 of 16 residents diagnosed with diabetes mellitus. (Resident #90) The findings include: A medical record review was conducted on Resident# 90, who was admitted in the facility on 11/10/2024. Resident #90 was noted to have an elevated blood glucose of 583 mg/dl and elevated A1C of 11.4% on 12/23/2024. There was no documented intervention or orders to address the elevated blood glucose level and elevated A1C. Record review showed no nursing actions and no medical orders had taken place on these laboratory results. Hospital records were reviewed and on 02/24/2025, the resident was transported to the hospital emergency room due to altered mental status. Resident #90 was diagnosed with diabetic ketoacidosis, encephalopathy, and a urinary tract infection (UTI).…

    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 · D2026-06-30 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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, interviews, and facility policy review, the facility failed to fully inform the residents of the risks and benefits and alternate treatment options for 1 of 3 residents sampled for the use of psychotropic medications (Resident #4).The findings included: On 6/29/26, a review of Resident #4's medical record was conducted. Resident #4 was admitted to the facility on [DATE] and discharged on 2/16/26. Review of Resident #4's medical history revealed he had diagnoses that included dementia with psychotic disturbances. Physician's orders included Memantine 5 milligrams (mg) dated 2/9/26 (a medication used to treat moderate to severe Alzheimer's disease), Mirtazapine 7.5 mg dated 2/9/26 (a medication used to treat depression), and Rivastigmine 9.5 mg patch dated 2/10/26 (a medication used to treat moderate to severe Alzheimer's disease). Further record review revealed on 2/12/26 Resident #4 became combative and aggressive and a one-time order of Haldol 5 mg (an antipsychotic medication used 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.

    Resident Rights Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · D2025-11-19 · 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 interviews and record review, the facility failed to ensure that staff administered medications ordered to treat a urinary tract infection for 2 of 3 residents reviewed after their return to the facility following hospitalization.(Residents #1 and #3)The findings include:Record reviewsOn 11/18/25, a review of Resident #1's electronic medical record (EMR) showed that this resident was admitted to the hospital on [DATE] for nausea and vomiting and received a diagnosis of urinary tract infection (UTI) and sepsis syndrome. Upon discharge back to facility on 10/9/25, the physician ordered Augmentin 875/125mg with instructions for Resident #1 to take 1 tablet by mouth two times daily until 10/22/25. Upon review of the EMR, no order was found for this medication; therefore, it does not appear that staff administered the medication as ordered.On 11/19/25, a review of Resident #3's EMR revealed that the resident was admitted to the hospital on [DATE] and received a diagnosis of acute cystitis, a type of urinary…

    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 · D2025-08-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 implement the plan of care for 1 of 4 residents sampled for medication administration (Resident #3).The findings include:On 8/26/25 at 10:45 AM, an interview was conducted with Resident #3. He stated he had not received one medication, a Clonidine patch (a medicine used to treat high blood pressure but can also treat Attention Deficit Hyperactivity Disorder), for weeks. Resident #3 further stated nursing had told him the pharmacy delivered a pill instead of a patch. On 8/26/25, a review of Resident #3's medical record was conducted. The resident was admitted to the facility on [DATE] from hospital. Resident #3 had diagnoses that included bipolar disorder. The plan of care included administering medications as ordered related to behavioral problems. Physician's orders included Clonidine HCL tablet 0.2 mg apply transdermally every Wednesday for behavior/mood.The Medication Administration Record (MAR) revealed Resident#3 did 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 · E2025-06-05 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #50 On 6/02/25 at 1:17 PM, an interview was conducted with Resident #50. The resident looked disheveled and had her hair was unbrushed and oily. She stated she had only two showers since she was admitted to the facility. She further stated that both showers happened with Occupational Therapy (OT) staff members. A review of Resident #50's medical record was conducted. This resident was admitted on [DATE] with diagnoses that included needing assistance with Activities of Daily Living (ADL). The plan of care included ADL self-care deficit related to decreased functional mobility and activity tolerance and generalized weakness. Interventions included nursing staff providing ADL care to ensure daily needs. A review of documentation related to bathing indicated Resident #50 was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Bathing documentation revealed OT provided bathing services on 5/1/25 and 5/16/25 and Certified Nursing Assistants (CNAs) provided bathing on 5/16, 5/22 and 5/25. On 6/03/25…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · 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 room [ROOM NUMBER] On 06/02/2025 during the tour of the facility, it was noted that the floor in room [ROOM NUMBER] was sticky and a dried brown substance was noted on the floor and wall of the room in the corner left side of the doorway facing the hallway. (Photographic evidence obtained) On 6/3/26 a follow up observation was made of room [ROOM NUMBER] at approximately 12:00 PM, which revealed the dried brown substance in the left corner of the doorway had been removed from the floor, however remained on the wall. On 6/4/25 at approximately 2:45 PM, another observation was made of room [ROOM NUMBER]. The wall remained with a dried brown substance and the floor remained sticky. An interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), who was responsible for the residents on this hallway. Nurse B confirmed that the floor was sticky and the wall with the dried brown substance needed to be cleaned. Based on observations and interviews, the facility failed to provide a sanitary, orderly, 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interviews, the facility failed to identify and properly code an assessment correctly upon admission to facility. (Resident #27) The findings include: Resident #27 was admitted to the facility on [DATE] with an admitting diagnosis of end stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, Atherosclerotic Heart disease, Chronic ischemic heart disease, Hypertension, Cardiac pacemaker, Cirrhosis of the liver, Heart Failure, AFIB, Osteoarthritis, and Pneumonia. The Minimum Data Set (MDS) assessment with a date of 04/28/25 reveals these diagnoses were not coded on the admission comprehensive assessment. An interview was conducted on 6/4/25 at 10:26 AM with the MDS Coordinator. The MDS Coordinator acknowledged that the admission diagnoses of Resident #27 was not coded correctly on the MDS assessment.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to forward a resident for a level 2 Preadmission Screening and Resident review (PASARR) for 1 of 2 residents residents sampled for PASARR. (Resident #51) The findings include; On 6/3/25, a record review was conducted for Resident #51. The resident had a PASARR form, dated 7/16/20. The formed had depression checked off at that time and had dementia checked off at that time. On the PASARR Completion sections, it was checked the facility needed to request a level 2 screening due to suspicion of serious mental illness. There was no documentation in the record for a level 2 screening. On 06/03/25 at approximately 12:15 PM an interview was conducted with staff development staff, a Registered Nurse (RN) who stated she assists with compliance with the PASARR being accurate and up to date. Stated when she started in 2021 has not updated his PASARR and it should have been done but she will start working on it today. 06/03/25 at approximately 02:40 PM an interview was conducted with the Administration who stated they do not have a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0645 — isolated
    PASARR 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 record reviews and interviews, the facility failed to update the Preadmission Screening and Resident Review (PASARR) for 1 of 2 residents sampled for PASARR. (Resident #51) The findings include: On 6/3/25, a record review was conducted for Resident #51. The resident had a PASARR form dated 7/16/20. The form listed depression and dementia as diagnoses at the time. On the PASARR Completion section, it was recommended that the facility needed to request a level 2 screening due to the suspicion of serious mental illness. There was no documentation in the record for a Level 2 screening. A diagnosis of bipolar disorder was added on 7/21/23. Anxiety disorder was diagnosed on [DATE]. However, no further actions on a Level 2 PASSAR review were noted. On 06/03/25 at approximately 12:15 PM, an interview was conducted with the Staff Development Nurse, who stated she assists with compliance with the PASARR being accurate and up to date. She stated when she started in 2021 and acknowledged the PASARR was not followed…

    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 before2025-06-05 · 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 Resident #27 Resident #27 was admitted to facility on 04/22/25 with admitting diagnoses of End stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, Atherosclerotic Heart disease, Chronic ischemic heart disease, Hypertension, Cardiac pacemaker, Cirrhosis of the liver, Heart Failure, AFIB, Osteoarthritis, and Pneumonia. Resident 27's plan of care revealed he has a risk for falls, complications of anticoagulant medication use, activity involvement, ADL self-care performance, potential for complications related to dialysis, potential for complications related to diabetes, and the potential for complications related to cardiovascular disease with a pacemaker. No goals or interventions are documented for each focus problem identified. An interview with Staff Member Q was conducted on 06/04/25 at 10:26 AM. She revealed that they have 14-21 days to complete a care plan that was initiated from the admission assessment. She acknowledged Resident #27 had incomplete care plans in his medical…

    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 · D2025-06-05 · 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 interview, observation, and record review, the facility failed to consistently perform services to prevent pressure ulcers for 1 of 1 residents observed for pressure ulcers. (Resident #50) The findings include: On 06/02/25 at 1:17 PM, an interview was conducted with Resident #50. During the interview, she stated she had developed a pressure ulcer because staff was not helping her enough during incontinence episodes. A review of Resident #50's medical record was conducted on 6/4/25. The resident was admitted on [DATE]. The plan of care included a risk of skin breakdown due to decreased mobility, incontinence, and fragile skin. Interventions included weekly skin checks. The physician's orders included a skin assessment every week and to notify the physician of any breakdown. The most recent skin assessment was documented on 5/24/25 and stated groin, buttocks and perineal area redden with excoriation. There were no new orders or progress notes indicating resident's skin issues had been addressed. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2025-06-05 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record reviews, observations, and interviews, the facility failed to properly assess and provide services for 1 of 1 residents reviewed for range of mobility care. (Resident #40) The findings include: Observations of Resident #40 on 6/2/25, 6/3/25, and 6/4/25 revealed a contracture to her left upper extremity. Resident #40 was observed with her left arm and hand contracted to her upper chest and abdomen area. Resident #40 stated she has not had any therapy or restorative services since she has been at the facility. Record review on 6/3/25 revealed Resident #40 was admitted to the facility with impairment to left upper and left lower extremities related to contractures. Resident #40 admitting diagnosis to the facility revealed a contracture to her left hand. Her care plan included alteration in musculoskeletal status related to contracture with a goal that Resident #40 will remain free of complications related to contracture and immobility. Further review of the medical record reveals no therapy…

    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 · D2025-06-05 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide care and services for 2 out 2 residents receiving hemodialysis. (Resident #27 and #82) The findings include: Record reviews of Resident #27 and Resident #82 revealed no physician orders for dialysis care, services, and treatments. No physician orders were in place to monitor the Permacath (a special intravenous device that medical professionals insert into a blood vessel that allow less interrupted access to the bloodstream over an extended period) for Resident #27. A physician's order was written on 04/23/25 for Resident #27 to receive dialysis on Monday, Wednesday, and Friday at 8:00 am. However, the physician's order does not reveal where Resident #27 receives dialysis, what time Resident #27 is to be transported to the dialysis center, or to hold medications while the resident is at the dialysis center since his admission to facility on 4/22/25. Resident #82 also has no physician's orders to indicate 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · 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 on observations, interviews and record reviews, the facility failed to provide medications as ordered for 2 of 5 residents observed during medication administration observations. (Resident #79 and #21) The findings include: On 6/3/25 at approximately 9:12 AM, a medication administration observation was conducted with Nurse C, a Licensed Practical Nurse (LPN), for Resident #79. Nurse C indicated that the medication Zoloft (a medication used to treat depression), which was ordered for Resident #79, was not in the cart. After informing the resident that the medication had not come in from the pharmacy, Nurse C went to the facility's emergency medication supply Omnicell to see if the medication was available. The medication Zoloft was not stored in the Omnicell. Nurse C indicated that she would notify the physician, and the pharmacy to have it sent in. On 6/4/25 at approximately 9:25 AM, a medication administration observation was conducted with Nurse D, a Registered Nurse (RN), for Resident #21. During the medication administration observation, it was noted that the 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 · Dcited before2025-06-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and facility policy review, the facility failed to store medications in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 2 of 2 medication carts reviewed for medication storage. The findings include: On 6/4/25 at approximately 1:30 PM, an observation was made of the Northwest 18 hall medication cart with Nurse C, a Registered Nurse (RN). When Nurse C opened the medication cart, in the top drawer, 3 medication cups were sitting in the top drawer with medications inside. The medication cups were noted to have numbers written on the outside of the cups. Nurse C indicated that one of the residents was not in their room when she pulled up their medications to administer them. Nurse C went on to indicate that she then labeled the cup and set it in the cart to administer when the resident returned. Nurse C indicated that the other 2 cups of medications were for 2 other residents that she had pulled up to give as well. When asked Nurse C what the facility policy is for medications…

    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 · D2025-06-05 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to ensure the Quality Assurance and Program Improvement Program (QAPI) identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information and corrective actions addressed gaps in systems, and were evaluated for effectiveness. Specifically the facility failed to provide medications to meet the needs for 2 of 5 residents observed during medication administration observations. (Resident #79, and #21). The findings include: On 5/23/25, a complaint survey conducted at the facility revealed the facility failed to ensure medications were available and administered to two residents. A plan of correction was submitted to the State Agency which stated, .2. In order to identify if there were any other residents affected by the alleged deficient practice, the DON, ADON, and Unit Managers were assigned with reviewing all current resident charts to ensure physicians…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · 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 — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a Influenza immunizations. (Residents #41 and #83) The findings include: A review of Resident #41's medical record provided by the Director of Nursing (DON) indicated that influenza immunization was administered on a future date of 11/06/25. A review of Resident #83's documentation provided by the DON also shows that the influenza immunization was administered on a future date of 11/06/25. An interview with the Director of Nursing (DON) was conducted on 06/05/25 at 12:52 pm inquiring how often the Flu, Pneumonia, and COVID vaccines should be offered. The DON stated they are offered yearly in the fall. The DON was made aware of the issues with the documentation with Residents #41 and #83. Upon exit, the facility was not able to provide current information of the influenza vaccines for these two residents.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · 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 — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to provide documentation that 2 of 5 residents received education and were offered a COVID immunization. (Resident #83 and #44) The findings included: A review of Resident #83's documentation shows that the COVID immunization was refused however no signature of the resident or a responsible party was present. Resident #44's medical record was missing Education and Consent or Declination of COVID immunization. The Director of Nursing (DON) was conducted on 06/05/25 at 12:52 pm inquiring about the COVID vaccine process. The DON stated they are offered yearly in the fall. The DON and Administrator were informed of the missing information for Residents #44 and #83. This information was not presented prior to the exit of the survey.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-15 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, document review, and policy review, the facility failed to maintain a fully functional resident call system in 4 of 8 sampled facility bedrooms. (Rooms 11, 36, 18, and 48) The findings include: An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:24 PM. The bedroom call light system was tested for both A and B bed and found to be not functional. An observation of bedroom [ROOM NUMBER] (A and B beds) was conducted on 4/14/25 at 1:50 PM. The bedroom call light system was tested and found to be not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:18 AM. Resident bedroom [ROOM NUMBER]'s call light system was not functional. An observation of unoccupied resident bedroom [ROOM NUMBER] was conducted on 4/15/25 at 9:22 AM. Both A and B bed were missing call lights cords rendering the call system for room [ROOM NUMBER] not functional. (Photographic evidence obtained.) An interview 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-15 · 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, staff interview, and policy review, the facility failed to follow pharmacy documentation procedures for administration of medications for 2 of 4 sampled residents receiving thyroid medications. (Resident #2 and #3) The findings include: Resident #2 A review of Resident #2's January, February, and March 2025 physician orders and medication administration record (MAR) revealed that Resident #2 was ordered to receive Levothyroxine 125 mcg by mouth daily at 6:00 AM for hypothyroidism through 3/10/25. The MARs for January, February, and March 2025 revealed that the medication was not signed off as administered on 1/10/25, 1/19/25, 1/27/25, 2/2/25, 2/16/25, 3/3/25, 3/7/25, and 3/8/25. A physician order revealed that the Levothyroxine dose was increased to 150 mcg daily on 3/11/25. The March 2025 MAR revealed that the 150 mcg dose was blank and not signed of as administered on 3/30/25. Resident #2's record revealed that the resident was seen by a metabolic physician assistant (PA) on 12/18/24. The note documented by the PA indicated the lab results on 12/11/24 had a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-03-14 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 3/14/24, Resident # 68's Quarterly MDS, dated [DATE], showed in progress, to be completed by 1/1/24, resulting in the plan being 73 days overdue at the time of review. On 3/14/24, Resident # 53's Quarterly MDS, dated [DATE] showed in progress, to be completed by 2/27/24, resulting in the plan being 16 days overdue. An interview was conducted with the MDS Licensed Practical Nurse on 3/13/24 at 4:05 PM concerning all of the above issues. She confirmed the quarterly MDS reviews were not completed. She stated she was the only full-time employee completing MDS and care plans. A review of the undated facility policy for Care Plans revealed the resident assessment must be reviewed no less than once every 3 months. Resident #20 had a quarterly assessment initiated on 12/16/23 that was not completed by survey exit date on 3/14/24. Resident #26 had a quarterly assessment initiated on 3/1/24 that was not completed by survey exit date on 3/14/24. Resident #37 had a quarterly assessment initiated on 12/16/23 that was not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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, staff interview, and policy review, the facility failed to ensure comprehensive assessments (minimum data sets) were completed within 14 days of admission or within 14 days of a significant change of resident status for 3 of 29 sampled residents. (Resident #84, #148, and #150) The findings include: Resident #148 and #150 During a review of Resident #148's electronic medical record, it was discovered that an admission minimum data set (MDS) dated [DATE] was listed as in progress and not complete. A review of Resident #150's electronic medical record revealed a significant change MDS dated [DATE] also showed in progress and was not complete. An interview was conducted with Employee A, the MDS Licensed Practical Nurse, on [DATE] at 4:05 PM. Employee A confirmed the admission MDS for Client #148 was not complete. She stated she was the only full-time person completing MDS and care plans. She stated the significant change MDS for Resident #150 was due to the resident coming off of hospice…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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, staff interview, and policy review, the facility failed to ensure each resident assessment (minimum data set) accurately reflected the resident's status for 2 of 29 sampled residents. (resident numbers 30 and 55) The findings include: A review of Resident #30's electronic medical record revealed a quarterly minimum data set (MDS) dated [DATE], which indicated the resident was taking an anticoagulant. A review of the current and past physician orders revealed the resident had never received an anticoagulant. An interview was conducted with Employee A (licensed practical nurse MDS) on 3/14/24 at 10:06 AM. Employee A stated Resident #30 had not received an anticoagulant and the MDS was not correct. A review of Resident #50's electronic medical record revealed an admission MDS dated [DATE], which indicated the resident was taking an anticoagulant. A review of the current and past physician orders revealed the resident had never received an anticoagulant. An interview was conducted with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · 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 review and interview, the facility failed to develop a comprehensive care plan for 2 of 23 residents sampled. (Resident #32 and #49) The findings include: Resident #32 A review of Resident # 32's medical records was conducted. The physician's orders and Treatment Administration Record revealed the resident was receiving the following wound care treatments: On Left Calf: clean area with normal saline, apply calcium alginate to open area, apply unna boot, after wrap with kerilex and finish with coban, change dressing every Monday and Thursday, and as needed if soiled, start date 1/25/24. On right heel: clean area with normal saline, apply calcium alginate to open area, apply unna boot, after wrap with kerilex and finish with coban, change dressing every Monday and Thursday, and as needed if soiled, start date 1/25/24. However, Resident #32's plan of care did not include any goals and interventions for wound care treatments. On 3/13/24 at 3:30 PM, an interview was conducted with Staff A, the facility's MDS coordinator. She stated she was aware the wound care treatments…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and policy review, the facility failed to develop and implement an effective discharge plan that includes care giver support and referrals to local contact agencies in a timely manner for 1 of 1 residents sampled for discharge planning. (Resident #20) The findings include: On 3/12/24 at approximately 10:00 AM, an interview was conducted with resident #20. He stated the he has lived at the facility for a year. The resident indicated he has been asking to be discharged or go somewhere else the entire time he has been living at the facility. He explained that he used to live with his mother. He indicated that he would like to live with his sister and, if that is not possible, to go to a group home. Resident #20 explained that his sister has been trying for the past year to help him find another place such as a group home. He does not feel at home living in a nursing home at his age. He explained that he goes home with his sister all the time but must be back at the nursing home at night. He always comes back but does not like living…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to store all drugs and biologicals in locked compartments for 2 of 27 observations of medication pass and storage conducted during the survey. The findings include: On 3/13/24 at approximately 8:30 AM, an observation was made of 5 blister cards left unattended on top of a medication cart that was in the hallway near room [ROOM NUMBER]. The medication cart was locked and there was no nurse or other staff members nearby. (photographic evidence obtained) At approximately 8:40 AM. Nurse B, a Licensed Practical Nurse (LPN), came out of the resident room and back to the medication cart. Nurse B quickly picked up the medication blister cards that were on top of the cart. She explained that the medication had been discontinued and she would return the medication cards to the locked medication room now. When asked if the medications should be on top of the cart where any resident has access to them, Nurse B indicated that the medications should be…

    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 · D2023-08-03 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, interviews, and record review, the facility failed to implement appropriate behavioral interventions for 1 of 5 residents sampled. (Resident #2) The findings include: On 8/2/23 at 9:51 AM, Resident #2 was observed wearing a wanderguard device (an elopement prevention system consisting of an anklet/bracelet wore by a resident that contains a sensor that monitors doors and sends safety alerts when a resident approaches a monitored door). A review of the resident's medical record indicated the resident exited the building on 6/10/23. Interventions in the care plan after this included a wanderguard device. However, a review of the resident's Electronical Medical Record (EMR) revealed no orders for a wanderguard. On 8/3/23 at 9:42 AM, an interview with Staff A, a Licensed Practical Nurse and unit manager, was conducted. Staff A reviewed the resident's EMR and stated there should have been an order placed onto the Resident #2's medical record to ensure staff was monitoring placement and functionality of the wanderguard anklet.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · 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 observations, interviews, and record review, the facility failed to follow to consistently document the administration of physician ordered medications for 1 of 5 residents sampled. (Resident #1) The findings include: On 8/1/23 at 4:55 PM, an interview was conducted with Resident #1 via telephone. During the interview, Resident #1 stated she did not receive her hypotensive medication for 3 days. A review of Resident #1's clinical record revealed a physician's order for Midrodine 10 mg, three times a day, for hypotension. The Medication Administration Record (MAR) revealed Midrodine was scheduled to be given at 8:00 am, 2:00 pm and 10:00 pm daily. The MAR was not documented on the following dates: 7/7/23 at 10:00 pm, 7/8/23 at 10:00 pm, 7/9/23 at 8:00 am, 2:00 pm, and 10:00 pm, and 7/10/23 at 8:00 am and 2:00pm. In addition, the most recent blood pressure reading was recorded on 5/8/23. On 8/3/23 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). The DON reviewed the resident's MAR and stated she was unaware that Resident #1 missed 3 days of…

    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 · D2023-08-03 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to provide or facilitate the provision of required therapy services for 1 of 5 residents sampled. (Resident #3) The findings include: A review of an incident reports submitted to the Agency was conducted. According to one report involving Resident #3 dated 6/4/23, Resident #3 sustained an unwitnessed fall that led to a laceration on the right forehead and transfer to an Emergency Department for treatment and evaluation. In this report, there was a reference that the facility would monitor Resident #3 and refer them to therapy upon return. A review of the resident's clinical record showed there were no documentation indicating Resident #3 received therapy services after the incident. The resident's plan of care was reviewed and indicated that the resident was at risk for a fall and had an incident of falling dated 4/26/23. On 8/3/23 at 1:58 PM, an interview was conducted with the facility's Administrator. He stated that the resident had COVID-19 during the time of the accident and the facility could not offer…

    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

“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

$43,264 in federal fines across 1 penalty.

  • $43,264 — penalty dated 2025-06-05

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.

Who owns this facility

Owner / managerTypeRoleSince
KEYCORP REAL ESTATE CAPITAL MARKET, INCOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 11/28/2006
INGRAM, SPENCERIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/03/2020
WATSON, JOANNEIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 05/28/2019
GAINES, ROLANDIndividualCORPORATE DIRECTORsince 07/01/2013

CMS files one row per role, so the 8 rows in the source record cover these 4 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.

1 organizational owner 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.

$11.2M
Net patient revenuemost recent cost report
+10.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 81%Medicare 9%Other / private 10%

About 81% 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.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$276per resident / day
operating cost
$8,405per month
≈ monthly operating cost
$309per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 105810. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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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