Nspire Healthcare Tamarac
5901 NW 79th Avenue, Tamarac, FL 33321 · For profit - Corporation · 141 certified beds · (954) 722-7001 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- 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
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.5% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.3% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.6% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.7% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.4% | 9.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.1% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.0% | 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 table | 5.0% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 4.3% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 2.9% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.86 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.50 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
34.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 21.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 65 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 34.0%CMS range 20.3–56.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.2%CMS range 10.6–18.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 21.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 27.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 89.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 91.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 4.4–14.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 141 beds and averages 124.1 residents a day — about 88% occupied, or roughly 17 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 3.12 hrs/resident/day on weekends vs 3.38 on weekdays — 8% thinner on weekends. RN hours go from 1.05 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
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 · D2025-12-11 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
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 a review of facility records, the facility failed to provide evidence of documented grievances submitted by 1 of 1 sampled resident, Resident #75, regarding delays in the call-light response and concerns related to activities of daily living (ADL) care. The findings included: Clinical record review showed that Resident #75 was admitted on [DATE] with diagnoses including shoulder arthroplasty, brain tumor, anemia, left-sided paralysis, and recent right-shoulder surgery. She was alert, oriented, and verbally responsive. Further documentation listed diagnoses of traumatic arthropathy of the right shoulder, primary osteoarthritis, hemiplegia and hemiparesis following cerebral infarction affecting the left side, and coordination deficits.Review of the ADL [Activities of Daily Living] Plan of Care identified significant self-care deficits related to her medical conditions. Interventions included assistance with bathing, dressing, eating, hygiene, mobility, toileting, transfers, skin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-11 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, record review and interview, the facility failed to obtain physician orders for intravenous (IV) midline catheter and care for 1 of 1 sampled resident observed, Resident #111. The findings included: Review of the facility's policy, titled, Midline Catheter Flushing, Locking, Removal, provided by the Director of Nursing (DON), reviewed/revised 11/07/25 documented in the Policy Statement: It is the policy of this facility to ensure that midline catheters are flushed, locked and removed consistent with current standards of practice. Policy Explanation: Midline catheters are longer peripheral catheters that are placed in peripheral veins.Compliance Guidelines: 1. The nurse will obtain and/or verify the physician's order for the type of Intravenous (IV) solution or medication, dose, rate and length of treatment.10. Midline catheter removal will be performed by the practitioner or nurse in accordance with facility policy and your state's nurse practice act. 11.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their menu for 2 sampled residents on a therapeutic diet, Residents #1 and #45. The census at the time of survey was 121, with 31 residents designated as being on a mechanical soft diet and 7 residents designated as on a CHO (Carbohydrate) Controlled diet. The findings included: 1. Review of the Menu Spread Sheets provided by the Certified Dietary Manager (CDM) specified that the Mechanical Soft Diet was to provide Grd (ground) meats every day for Breakfast, Lunch, and Dinner. Record review revealed Resident #45 was readmitted on [DATE] with diagnoses which included Dysphagia, Type 2 Diabetes Mellitus, Dementia, and Hypertension (HTN). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], section C, documented Resident #45 had a Brief Interview for Mental Status (BIMS) score of 10, on a scale of 0 to 15, indicating the resident's cognition was moderately impaired. On 12/09/25 at 12:16 PM, during a dining room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 follow the prescribed therapeutic diet for 1 of 2 sampled residents reviewed for therapeutic diets, Resident #1.The findings included:Record review revealed Resident #1 was re-admitted to the facility on [DATE] with an initial admission of 08/27/24. Resident #1 had diagnoses that included Type 2 Diabetes Mellitus, End Stage Renal Disease and Acquired Absence of Left Leg Above Knee. He received Hemodialysis three times a week. The resident's Brief Interview for Mental Status (BIMS) score was 15 on the PPS (Prospective Payment System) Part A Discharge Minimum Data Set with an Assessment Reference Date of 11/14/25. This indicated he was cognitively intact.On 12/10/25, a record review was conducted of Resident #1's orders. A review of the diet order revealed an order for CHO (Carbohydrate) Controlled, Hi Pro Renal Diet, Regular texture, thin consistency. An observation was conducted on 12/10/25 at 10:34 AM of Resident #1's breakfast meal. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interviews, the facility failed to ensure that meat prepared and ready to be served to residents was maintained at the proper hot-holding temperature on the steam table. This deficiency had the potential to affect all 12 of 12 sampled residents who received the alternate lunch meal, which included chicken on 12/08/25. The census at the time of survey was 121. The findings included: On 12/08/25 at 11:45 AM, during an observation of food service operations and temperature checks conducted with Food Service Assistant, Employee F, the surveyor observed the temperature of cooked chicken on the steam table. Staff F prepared two plates and placed them on the food cart for distribution to residents. Immediately following this, the surveyor measured the temperature of the chicken in the steamtable pan. The pieces located on the top measured 107 F, while the pieces at the bottom measured 127 F (Fahrenheit). At the request of the surveyor, the chicken was immediately reheated to the proper temperature of 165 degrees before serving it to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interiors for residential rooms, community shower rooms, activity rooms, and common areas) located on First Floor West, Second Floor East, and Second Floor West. The findings included: During the resident screenings conducted by the surveyors on 06/09-10/24 and environment observation tour conducted on 06/11/24 at 9:00 AM, and on 06/12/24, accompanied with the Corporate Nurse Consultant and Corporate Director of Maintenance, the following were noted: 1. First Floor [NAME] Unit: a. 1500 Unit Community Shower Room: One of two hand wash sinks did not have running water and soiled gloves located in the sink basin, large rotting piece of wood (2 X 4 ') located on shower floor, three privacy curtains too short to promote privacy during bathing and toileting, shower stall floor soiled and heavily stained, and broken wall tiles (4). b. room [ROOM NUMBER]:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-12 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to properly remove and dispose of controlled medications for 2 of 3 discharged residents reviewed during medication storage observation, affecting Residents #497 and #496; failed to secure and properly lock 3 of 3 emergency crash carts observed during the initial tour; failed to safely secure prescription and over-the-counter (OTC) medications; failed to properly date stamp an opened insulin bottle observed during medication storage opportunities in the 1-East unit; and failed to discard expired topical medication stored in the wound treatment cart observed during medication storage tour. The findings included: Review of the facility's policy, titled, Storage of Medications, dated [DATE], included, in part, the following: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or standards of the supplier. The medication supply is accessible only to licensed nursing personnel,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-12 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet and to meet the preferences of potentially 117 facility residents. The findings included: During routine interview conducted with the Administrator and Certified Dietary Manager (CDM) on 06/10/24 and 06/11/24, it was noted the facility's Walk-in Refrigerator had stopped working on 05/31/24 and Reach-in Refrigerator had stopped working on 06/04/24. They stated a refrigeration contractor evaluated the issues and parts were ordered to repair the units. They further stated the contractor was contacted for days when the repairs were to be completed but the facility was informed the shipped parts have not been received to complete the repairs. They stated there was not proper refrigerator space (walk-in and reach-in refrigerators) to store and thus prepare and serve foods that require refrigeration. They stated a decision was made by the facility's administration to put into place the Emergency Menu (non-perishable food that require no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-12 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare foods in a manner to maintain the nutritional value of the foods, for potentially 117 residents. The findings included: During the initial kitchen tour, on 06/09/24 at 9:25 AM, accompanied by Staff R, [NAME] and the Dietary Manager, it was noted that the hot holding unit was already set up for the lunch meal that included: chicken and mechanically altered chicken, chicken and dumplings, mashed potatoes, rice, pureed chicken, pureed peas, mechanical soft peas, gravy and carrots. Staff R confirmed that the food was for the lunch meal on this day. When asked when the items that were being 'hot held' for lunch were cooked stated, we finished breakfast at about 8:30 AM and then started cooking for lunch. Staff R further stated that the carrots were canned and took approximately 20 minutes to prepare. When asked about the facility's policy for preparing foods prior to meal being served, Staff R did not provide a response. The Dietary Director acknowledged concerns related to preparing and hot holding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to prepare, store and serve foods in a sanitary manner in accordance with professional standards for food safety. The findings included: 1. During the initial kitchen tour, on 06/09/24 at 9:25 AM, accompanied by Staff S, cook, and the Dietary Director / Certified Dietary Manager (CDM), the following were noted: a. The internal temperature of a full-sized 4-inch deep pan of canned carrots that was being 'hot held' in the steamer was 93 degrees Fahrenheit (F). b. The concentration of the quaternary ammonia based sanitizer in a bucket on the assembly line less than 200 Parts per Million (PPM). c. In the walk in freezer, there was a canned beverage and a bottle of water placed directly on top of a case of milk shakes. The Dietary Director confirmed that the beverages were employees' drinks. d. On the top shelf of the walk in freezer, there was a box of dough that was uncovered and the uncooked dough that was exposed to contamination. e. There was an accumulation of dust on the fan guards in the walk in freezer. f.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · E2024-06-12 · tag F0880 — failed to prevent and control infections — patternProvide 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 2. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Neuromuscular Dysfunction of Bladder, Peripheral Vascular Disease, Hypertension, Multiple Sclerosis, Major Depressive Disorder, Seizures, Polyneuropathy and Muscle Weakness. Resident #8 had a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). During a Peri-care and Foley catheter care observation conducted on 06/11/24 at 10:50 AM by Staff I, Certified Nursing Assistant (CNA), Staff I was observed doing the following: a. while gathering her pre-bagged supplies, she initially dropped the bagged towels and supplies in the garbage can next to Resident #8's bed b. Staff I began to perform Resident #8's pericare, in her same uniform, without first donning a gown. c. Staff I was observed placing Resident #8's Foley catheter on top of her bed above the level of her chest, and she left the Foley bag in that position throughout the entire observation. d. Staff I was then observed using the same…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-12 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and record reviews, the facility failed to make prompt efforts to repair and replace necessary kitchen equipment in order to provide wholesome and palatable food at the appropriate temperatures. The findings included: 1. During the initial kitchen tour, on 06/09/24 at 9:25 AM, accompanied by the Dietary Manager (DM) / Certified Dietary Manager (CDM), it was noted that the walk-in cooler was out of order with a sign on the door. During an interview, the Dietary Manager/CDM stated that the walk-in cooler had not been working since Wednesday of previous week and that the facility was using the disaster emergency menu and products. The Dietary Manager stated that the facility expected to have parts repaired near the end of the week. During a follow up interview, on 06/11/24 at 6:32 AM, with the Dietary Manager/CDM, the Dietary Manager/CDM stated that the walk-in cooler had been down since 05/31/24 and was hoping to be repaired by 06/12/24. 2. During the follow up kitchen tour, on 06/11/24 at 11:45 AM, it was noted that the kitchen staff were not using…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a wheelchair to a resident for mobility and to allow the resident to attend activities, for 1 of 1 sampled resident, Resident #13. The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with the following diagnoses that included COPD (Chronic Obstructive Pulmonary Disease), Chronic Bronchitis, Depression, and Left Below the Knee Amputation (BKA). Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE], Section C revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Section GG of this MDS revealed Resident #13 was dependent on some functional abilities such as toileting, dressing, transferring from bed to wheelchair (vice-versa), and changing positions from lying down flat on his bed to sitting up. Review of Physician's Orders dated 03/21/24 included notes for Resident#13 to participate 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.
- Potential for harm · D2024-06-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, interview and record review, the facility failed to ensure that it provided appropriate personal assistive care and services for 1 of 1 sampled resident observed for Activities of Daily (ADLs), Resident #68. The findings included: Review of the facility policy and procedure on 06/12/24 at 10 AM, titled, Bathing/Showering, provided by the Director of Nursing (DON) revised 09/01/17, documented in the Policy Statement: Assistance with showering and bathing will be provided at least twice a week and PRN (as needed) to cleanse and refresh the resident The resident's frequency and preferences for bathing will be reviewed at least quarterly during care conference. Procedure .Identify resident. Explain procedure to resident .Escort resident to shower room and assure privacy .Document in the medical record. Record review documented Resident #68 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Acute Respiratory Failure with Hypoxia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, interview and record review, the facility failed to follow appropriate care and services for 1 of 1 sampled resident observed during a Foley catheter and peri care observation, Resident #8. The findings included: Review of the facility policy and procedure on 06/11/24 at 1:02 PM, titled, Perineal Care, provided by the Director of Nursing (DON), revised 09/05/17, documented, in part, in the Policy Statement: .provide privacy .Perform hand hygiene . Review of the facility policy and procedure on 06/11/24 at 1:26 PM, titled, Urinary Catheter Care, provided by the Director of Nursing (DON), revised 09/05/17, documented, in part, in the Policy Statement: .Provide privacy .Perform hand hygiene .Put on gloves. Remove catheter securement device while maintaining connection with drainage tube .Reattach catheter securement device .Perform hand hygiene. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Neuromuscular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 record review and interview, the facility failed to ensure residents received ongoing communication and collaboration with the dialysis center, for 1 of 1 sampled resident, Resident #106, reviewed for dialysis, regarding dialysis observation, care and services. The findings included: Record review of Resident #106 on 06/11/24, noted a re-admission date of 04/07/24 to the facility with diagnoses that included Chronic Kidney Disease and Altered Mental Status. It was also noted that the resident receives in-house dialysis three times per week (M/W/F) (Monday, Wednesday, Friday). Review of the current MDS dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and is independent in Activities of Daily Living (ADLs). Review of the Hemodialysis Communication Record noted that the assessment forms did not have the proper documentation on them by the facility (prior to leaving and on return to the facility) and by the dialysis center. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (%) or greater. The medication error rate was 14.70 percent (%), five (5) medication errors were identified while observing a total of 34 opportunities, affecting Resident #499 and Resident #8. The findings included: 1. Record review documented Resident #499 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Malignant Neoplasm of Colon, Type 2 Diabetes Mellitus, Hypertension, Depression, End Stage Renal Disease, Dependence of Renal Dialysis, and Presence of Cardiac Pacemaker. A medication administration observation was conducted on 06/10/24 8:16 AM with Staff A, Registered Nurse (RN), for Resident #499. Staff A was observed preparing 6 medications for Resident #499, including Methocarbamol tablet 500mg used for Muscle Spasm. Review of the Methocarbamol Blister card revealed it was labeled with a different resident's name, Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave 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 it developed and implemented an effective Quality and Performance Improvement Plan (QAPI) that addressed residents' food concern needs, failed to ensure kitchen euipement was repaired timely and failed to make effective efforts to provide meals that were palatable, appealing and at appropriate temperatures. The findings included: Review of the QAPI Committee activities revealed the facility had not addressed and made an effective effort to address, rectify, even temporarily, and develop a plan to address residents' food concerns and repairs for kitchen equipment since August 2023, and, most recently, regarding the broken walk-in cooler that has not been working since May 31, 2024. The facility resorted to serving the emergency food menu unnecessarily. The facility made no other efforts to ensure that the food was palatable (e.g. changes in procedures for hot holding, other means to ensure that the food was an appropriate temperature {per residents}, interview with residents for quality concerns,or to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0919 — failed to provide a working call system — isolatedMake 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, interviews and record reviews, the facility failed to maintain call lights within reach of residents for 3 of 3 sampled residents reviewed, Residents #23, 481 and 13, as evidenced by call lights being out of the residents' reach. The findings included: The facility's policy, titeled, Call Bell System - Inoperable, effective date 11/30/14, with a revision date of 08/22/17, documented, in part, Resident must have, at all times, a system to notify staff when assistance is needed . The facility did not provide a policy for call light placement after being asked for ti. 1. Record review documented Resident #23 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Annual Minimum Data Set (MDS) assessment, dated 03/08/24, documented Resident #23 had a Brief Interview for Mental Status (BIMS) score of 09, indicating a moderate cognitive impairment. The MDS documented the resident required Partial to moderate assist for activities of daily 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.
- Potential for harm · D2023-10-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide care and services as per physician orders for 1 of 3 sampled residents, Resident #3. The findings included: Review of Resident #3's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Fracture of Lateral Malleolus of Left Fibula, closed fracture, Diabetes Mellitus Type 2 with Neuropathy, Legal Blindness, Acute Kidney Failure, and Dependence on Renal Dialysis. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed supervision from the staff to complete the activities of daily living. Review of Resident #3's physician orders dated 06/14/23 documented Efinaconazole External solution 10%, apply to left big toe topically one time a day for fungus for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide dining in a dignified manner during dining observations for 5 of 5 sampled residents (Resident #54, Resident #63, Resident #41, Resident #1, and Resident #9). The findings included: 1. Resident #54 was admitted on [DATE] with diagnoses to include Dysphagia, Altered Metal Status, and Metabolic Encephalopathy. Review of the Minimum Data Set (MDS) dated [DATE] showed severe cognitive impairment; and for eating, the resident needed extensive assistance with one person assist. The physician ordered diet dated 11/10/20 noted soft mechanical texture. Resident #63 was readmitted on [DATE] with diagnoses to include Dementia and Dysphagia. The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score indicating severe cognitive impairment, and for eating, the resident needed total dependence on one person's assistance. Resident #41 was readmitted on [DATE] with diagnoses to include Anemia and Heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow tube feeding orders as per physician's orders for 1 of 1 sampled resident reviewed for tube feeding (Resident #62). The findings included: Resident #62 was admitted on [DATE] with diagnoses to include Dysphagia, Altered mental status, and Muscle Weakness. The physician order, dated 02/16/23, documented for enteral feeding with Jevity 1.5 (tube feeding formulary) at 70 milliliters (ml) an hour for 20 hours off at 10:00 AM and on at 2:00 PM. The order, dated 02/09/21, was noted for regular diet mechanical soft texture. An observation conducted on 03/19/23 from 12/30 PM to 2:00 PM did not show that Resident #62 received any food for lunch. In an observation conducted on 03/20/23 at 9:00 AM, Resident #62 was in his room eating his breakfast tray with Staff B, Certified Nursing Assistant (CNA), feeding him the lunch meal. Closer observation showed the tube feeding was still running with Jevity 1.5 at 70 ml an hour while getting fed by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliation was accurate for 3 of 6 sampled residents reviewed during the controlled substance record review at the facility's 2 [NAME] wing, for Residents #10, #30 and #44. The findings included: Review of the facility's policy, titled, Preparation and General Guidelines-Controlled Substances, revised on 01/2018, documented: .when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the medication administration record (MAR): date and time of administration .initials of the nurse administering the dose, completed after the medication is actually administered . 1. Review of Resident #10's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE], and diagnoses that included Hemiplegia, Obesity, Schizoaffective Disorder, Pain to left shoulder, Non-Traumatic Acute Subdural,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to secure medications at the bedside for 3 of 3 sampled residents, Residents #94, #74 and #25; and failed to secure medications in the unlocked dialysis room. The findings included: 1. During the initial tour of the facility conducted on 03/19/23 at 9:12 AM, the surveyor noted that the door of the dialysis room on the first floor was unlocked. The Dialysis Room was located across the hallway from the main dining room on the 1st floor (where activities were held for the residents during the week of survey) and was on the same hallway as the DON's office and Human Resources. Observations at various times during the 4-day survey revealed residents and staff walking through that area. a. The surveyor toured the dialysis room and found a 7-drawer storage container-sitting on top were ExSept exit site skin and wound cleanser (dated 03/14/23), Alcavis disinfectant (dated 03/15/23), and an open tube of Bacitracin gel (not dated). Inside one of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility needed to follow its menus to meet the nutritional needs of the residents observed during the main kitchen tray line observation. The findings included: A review of the Week 1 Day 3 Dinner Menu showed the following foods and portion sizes: for the regular diet, provide 8 ounces of Turkey [NAME]; for the L 2 mechanical altered diet, provide two #8 (4 ounces) scoops of the Turkey [NAME], and for the L 1 Puree diet provide two #8 scoops of the Turkey [NAME]. An observation of the tray line conducted on 03/21/23 at 4:35 PM showed the following: Staff E, Cook, was observed plating the following: 4 ounces of Turkey (not the 8 ounces as required) for a regular diet plate, one scoop of the #8 Turkey (not the two scoops of the #8 as required) for the L 2 mechanical altered diet, and 1 scoop of the #8 Turkey (not the two scoops of the #8 as required) for the puree diet plate. Continued observation showed that Staff E plated two more of the #8 Turkeys for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility needed to follow its menus to meet the nutritional needs of the residents observed during the main kitchen tray line observation; and failed to provide the correct diet consistency per physician's orders for 4 of 4 sampled residents reviewed during dining observations (Resident #54, Resident #49, Resident #1, and Resident #25). The findings included: 1. A review of the Week 1 Day 3 Dinner Menu showed the following foods and portion sizes: for the regular diet, provide 8 ounces of Turkey [NAME]; for the L 2 mechanical altered diet, provide two #8 (4 ounces) scoops of the Turkey [NAME], and for the L 1 Puree diet provide two #8 scoops of the Turkey [NAME]. An observation of the tray line conducted on 03/21/23 at 4:35 PM showed the following: Staff E, Cook, was observed plating the following: 4 ounces of Turkey (not the 8 ounces as required) for a regular diet plate, one scoop of the #8 Turkey (not the two scoops of the #8 as required) for the L 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to follow physician's orders for Resident #48 during medication administration observation and failed to accurately maintain documentation of medication administration of physician's orders for Resident #107. The findings included: Review of the fac policy, titled, Administering Medications, revised on 04/2019, documented, .the individual administering the medication checks the label THREE (3) times to verify the right .medication .before giving the medication . Review of the facility's policy, titled, Policies and Procedures - Pharmacy Services for Nursing Facilities, with a revised date of January 2018, included the following: Documentation (including electronic) 1) The individual who administers the medication dose records the administration on the resident's Medication Administration Record/electronic Medication Administration Record (MAR/eMAR) directly after the medication is given. At the end of each medication pass, the person…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 2.9 | +1.1 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MLNM MASTER TENANT, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| FC INVESTORS XXI LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| LAVIE HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2021 |
| LV INVESTMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR CARE CENTERS, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR OPERATIONS I, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| NSPR OPERATIONS II, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2018 |
| LEE, BRADLEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/10/2024 |
| NSPRMC, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2026 |
| CAVERO, JAVIER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/16/2025 |
| MENDEZ, OSCAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2019 |
CMS files one row per role, so the 16 rows in the source record cover these 11 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.
8 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.
This home reported $715K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105609. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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 →
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