Elon Manor Nursing And Rehabilitation Center
1203 E 22nd Ave, Tampa, FL 33605 · For profit - Individual · 96 certified beds · (813) 229-6901 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (30% 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 citations for mishandling residents’ money or property (F0568, F0569)
- it has 1 actual-harm citation
- 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
- the CMS record shows $30,989 in federal fines (most recent 2026-02-25)
- 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.
| 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 10.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.8% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.3% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| 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 | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| 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 | 2.0% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.9% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 84.2% | 99.2% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 8.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.1% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.8% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 17.8% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.3% | 9.1% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.65 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.98 | 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.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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
| 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 | not 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 SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 96 beds and averages 75.7 residents a day — about 79% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.479 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.11 hrs/resident/day on weekends vs 3.63 on weekdays — 14% thinner on weekends. RN hours go from 0.94 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%. 3 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 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2026-04-02 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate one (1) of one (1) resident's choice to close the room door at night for privacy and personal comfort (Resident #39); and two (2) of two (2) residents right to use electric wheelchairs to support mobility, independence, and the resident's highest practicable level of functioning (Resident #s 44 and 96). This failure caused Resident #44 frustration, anxiety, mental anguish, and self-isolation, which resulted in psychological harm.The findings include:1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent; muscle weakness; intermittent explosive disorder (added 09/15/2025); and pain in right elbow. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was 15/15, which reflected intact cognition. MDS dated [DATE] revealed the resident was mobile with an electric wheelchair;…
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 · E2026-02-25 · 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 Based on observation and interview, the facility failed to ensure infection control practices were followed related to: 1) staff performing hand hygiene when completing medication administration, 2) cleaning of multi-use equipment, such as blood glucose monitors and blood pressure cuffs, in between uses on residents, and 3) an uncleanable surface in one of two resident shower rooms in the one west unit. Findings included: 1. On 2/23/26 at 9:20 a.m. during medication administration observation Staff A, Registered Nurse (RN) used her fingers to place vitamin D-3, aspirin, Iron, and sodium chloride pills into a medication cup to administer to Resident #62. On 2/23/26 at approximately 9:23 a.m. after preparing medications for Resident #62, Staff A, RN did not perform hand hygiene (HH) and entered room [ROOM NUMBER] put gloves on and resecured ace bandage on the resident's right arm. Staff A, RN removed gloves, did not perform HH, entered Resident #62's room and administered medications to the resident. On 2/23/26 at…
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 · E2026-02-25 · tag F0924 — patternPut firmly secured handrails on each side of hallways.
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, facility record review and staff interviews, the facility failed to ensure handrails were affixed to the wall in a safe and secure manner in two floors (200 and 100) of two floors observed, during three days (2/22/2026, 2/23/2026, and 2/24/2026) of four days observed. Findings included: During a facility wide tour on 2/22/2026 at 9:15 a.m., at 2:00 p.m. and on 9/23/2026 at 8:30 a.m., the following was observed: 1. The 2nd floor hallway handrail located before the shower room was not affixed tightly to the wall. 2. The 2nd floor hallway handrail located across from the nurse station and below the mirror and clock was not affixed tightly to the wall. 3. The 2nd floor hallway handrail located on the right side of the nurse's station door was not affixed tightly to the wall. 4. The 2nd floor hallway handrail located between resident rooms [ROOM NUMBERS] was not affixed tightly to the wall. 5. The 2nd floor hallway handrail located on the left side of resident room [ROOM NUMBER] was not affixed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-25 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to notify the Power of Attorney (POA) of a change in condition related to weight loss for one resident (#41) out of five residents reviewed for nutrition. Findings included: Review of the admission record revealed Resident #41 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the advance directives revealed Resident #41had a medical and financial decisionmaker/ Power of Attorney (POA) to make his decisions. The medical diagnosis sheet revealed diagnoses to included but not limited to muscle weakness, quadriplegia, contracture of muscle unspecified on upper arm, need for assistance with personal care, contracture lower leg, disorder of bone density, and structure, dysphagia, protein calorie malnutrition, and gastrostomy.Review of the physician's orders for the month of 2/2026 revealed; Diet Order - NPO (nothing by mouth); Enteral feeding Jevity 1.5 75 ml (milliliters) per hour for 1500 liters bid (twice daily)…
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 before2026-02-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure a clean and home-like environment in two resident rooms (103 and 201) out of 25 rooms observed, and in one shower room (West Unit) of two observed.Findings included: On 2/22/26 at 9:38 a.m., an observation of the floor in room [ROOM NUMBER], by the resident's bed and bedside table, revealed a cockroach crawling next to the call light located on the floor. On 2/22/26 at 12:18 p.m., an observation of room [ROOM NUMBER] revealed the floor, between the resident's bed and dresser, had a large hole with wood and unidentifiable material exposed, as well as pieces of tile missing. Further observations of room [ROOM NUMBER] revealed the area under the sink had a large hole, that exposed pipes and wood, and cracked tile pieces. The area under the sink revealed multiple pieces of painter's tape that separated from the wall and a clear, thin sheet of plastic material was covering approximately half of the hole. The room further revealed a white dresser located…
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 before2026-02-25 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#5) of 52 residents reviewed for PASARRsFindings included:Review of the admission record showed Resident #5 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included Parkinsonism, mood disorder, depression, psychosis and cognitive communication deficit.Review of a level I PASARR for Resident #5 dated 9/11/25 revealed a completed Level I PASARR with qualifying diagnoses. The review showed the Level I PASARR was complete, and a level II was not submitted for consideration following qualifying diagnoses.During an interview on 2/25/26 at 12:46 p.m. Staff A, Social Service Director (SSD) said Resident #5 did not need a Level II PASARR because the resident is functioning, able to explain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-25 · 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
Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) related to nail care were provided for one resident (#9) out of three residents sampled.Findings included:On 02/22/2026 at 12:55 PM, Resident #9 was observed to have brown and red substances underneath the fingernails. Resident #9's fingernails were about half an inch past the fingertips.Review of Resident #9's medical record revealed diagnoses of cerebral infarction, unspecified, muscle weakness (generalized), hereditary and idiopathic neuropathy, unspecified, other lack of coordination, and acquired absence of left and right legs above knees.Review of Resident #9's medical record revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitive function was intact with little to no memory or thinking impairment.A review of Resident #9's ADL sheets did not show documented refusals of personal hygiene care for the month of January 2026. The ADL sheets for the month of February 2026 were not provided for review.A review of Resident #9's shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation record review and interview, the facility failed to ensure physician orders for oxygen were followed for one resident (#24) out of two residents sampled and failed to ensure the resident had physician orders for oxygen use for one resident (#54) out of two residents sampled.Findings included: 1. On 02/22/2026 at 12:00 PM, Resident #24 was observed to have an oxygen concentrator set to a four-liter (L) flow rate. Resident #24 said the concentrator was set to a flow rate of four or five.A review of Resident #24's medical diagnoses revealed chronic obstructive pulmonary disease (COPD), unspecified, COPD with (acute) exacerbation, acute and chronic respiratory failure with hypoxia, centrilobular emphysema.A review of Resident #24's order summary report revealed an order to check oxygen saturation levels as needed and oxygen at 2L (liters) per minute via nasal cannula every shift related to COPD with (acute) exacerbation.An interview with Staff N, Registered Nurse (RN) on 02/24/2026 at 12:43 PM revealed Resident #24 had orders for oxygen via nasal cannula set at a 2L…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-25 · 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
Based on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Thirty-three medication administration opportunities were observed, and two errors identified for two (#49 and #92) of five residents observed. These errors constituted a 6.06% medication error rate.Findings Include:On 2/24/2026 at 11:15 a.m. an observation of medication administration with Staff B, Licensed Practical Nurse (LPN) conducted with Resident #49. Staff B, LPN performed HH, removed an Novolog FlexPen injector pen from the medications cart. She verified the insulin type/expiration, attach a new needle and turned the dosage dial to administer 4 units. Cleaned the insertion site with alcohol and let it dry and administered the medication.Review of Resident #49 medication orders revealed an order for Novolog FlexPen 100 unit/ml inject as per sliding scale: if 150-199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units ; 350 - 399 = 10 units, subcutaneously with meals for Diabetes Mellitus (DM) greater than 400, please notify…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-19 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to implement an accurate and up to date system for the accounting of residents' personal funds entrusted to the facility for three (#3, #5, and #6) of three residents sampled for resident funds review. Findings included: Review of accounts records for Resident's #3, #5 and #6 showed the residents' cost of care being withdrawn from their personal funds account did not consistently match what the Medicaid Access eligibility had determined, and Social Security direct deposits for January and February 2025 were not reflected in the accounts. On 02/19/2025 at 10:23 a.m. Resident #6 was observed in her room and she agreed to an interview. During the interview, she stated she had a concern with her resident trust fund, the monies held by the facility. She said, I am not sure if my balance is accurate. A couple of months ago they took a two-month payment at one time and then no payment for my room and board bill. I worry if I have enough money there. On 02/19/2025 at 1:30 p.m. a telephone 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.
- Potential for harm · E2025-02-19 · tag F0569 — patternNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure personal funds deposited with the facility were conveyed to the resident or resident representative within thirty days after discharge or death for three (#4, #7, #8) of three residents sampled for return of funds in a timely manner. Findings included: On 02/19/2025, the facility provided a list of residents with personal trust fund accounts. During the review of the list provided, three residents were sampled for conveyance of funds, Resident #4, #7, and #8. Review of the facility's Resident Fund Management Services (RFMS), listing the following residents and resident fund balances as of 02/19/2025: Resident #4, with a balance of $3, 814.35. Resident #7, with a balance of $1,470.59. Resident #8, with a balance of $340.54 Review of Resident #4's clinical chart the admission record, documented an initial admission of 04/17/2020, readmission of 11/01/2024; and a discharge to the community on 12/17/2024. Review of Resident #7's clinical chart, the admission record, documented an admission of 12/09/2021, and discharge…
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 16 citations
- Potential for harm · E2025-02-19 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation record review and interviews, the facility failed to ensure adequate management of tube feeding services for two (#1 and #9) of two sampled tube fed residents out of a total of nine sampled residents related to inaccurate dating of enteral product, non-labeling of product type, rate and time of administration. Findings included: 1. Review of Resident #1's admission record documented an admission of 04/02/2022 and readmission of 06/12/2024. The diagnosis list included but not limited to: Cerebral infarction; chronic atrial fibrillation; aphasia following cerebral infarction; unspecified dementia, unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance; lack of coordination. Review of Resident #1's Care Plan documented a focus - Resident is dependent upon a feeding tube to meet nutritional and fluid needs due to (d/t) dysphagia. The interventions included: Provide feeding and H20 flushes per orders. Review of Resident #1's Tube Feeding & Flushes Flow Record for 02/2025 reflected the following physician orders: -Between 10am &…
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 · D2025-02-19 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a prompt resolution to a grievance for one (#3) of nine sampled residents. Findings included: An interview was conducted on 02/19/2025 at 12:27 p.m. with the Social Service Director (SSD). A review of three grievances for Resident #3 was conducted. The SSD stated, one grievance, received on 11/18/2024, the (resident's representative) wanted the phone bill paid for Resident #3. The (resident's representative) was upset that the bill was not paid. The representative communicated to the business office who said they were going to pay the bill. The representative tracked the phone bill, and it was not paid. Further review of the grievance form reflected the former Nursing Home Administrator (NHA) had signed that the bill had been paid and the grievance resolved on 11/26/2024. The SSD stated, the next grievance received on 12/16/2024, the (resident's representative) was upset because the phone bill was not completely paid. Review of the grievance form reflected the former NHA signed the grievance as completed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-21 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure the Dietary Manager met the mandatory minimum qualifications for the Dietary Manager position. Findings included: Review of the Dietary Manager's qualifications revealed the Dietary Manager (DM) was not [Food Certification Service] qualified and was not certified as a dietary or food service manager. During an interview on 12/20/23 at 11:09 a.m., The Dietary Manager (DM) stated I have been working as the Dietary Supervisor for three months now. The DM stated prior to being DM, I was a cook here since 2016. The DM stated she did not have an associate degree in food service or hospitality, and was not certified in food management but was working on obtaining the [Food Certification Service] certification. The DM stated she had a lot of experience working in dietary. The DM stated she attempted the [Food Certification Service] when she first started the DM job on 09/01/23, but did not pass it the first time and took the exam again a week later and was unable pass it again. The DM stated the online site would not allow…
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 before2023-12-21 · 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
Based on observations and interviews the facility failed to ensure the environment was clean and free from bio-growth for one Hopper Room (East Hallway on the 1st Floor) of four Hopper Rooms observed in the facility. Findings included: An observation on 12/18/23 at 4:00 p.m., revealed a musty like smell in the air on the first floor East Hallway of the facility. An observation on 12/18/23 at 4:25 p.m., revealed a room designated as the Hopper Room on first floor East Hallway. The musty smell was stronger in this area. The Hopper Room was observed to have bio-growth up the walls of the room and also had a big patch of bio-growth on the ceiling. (Photographic Evidence Obtained). During an interview on 12/18/23 at 4:35 p.m. the Maintenance Director (MD) stated he had issues with bio-growth on East Hallway at the First floor Nurses Station before but it was fixed. The MD stated he was unaware of any bio-growth in the facility right now. The Hopper Room East Hallway on the First Floor door was opened and MD stated, I never look in there and then stated there must be a leak to cause 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 · Ecited before2023-12-21 · 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, record reviews, and interviews the facility failed to ensure food was held at a safe and appropriate holding temperatures prior to food tray distribution. The failed practice had the potential to affect 67 of 69 residents in the facility: Findings included: During an interview on 12/19/23 at 11:45 a.m. Staff B, [NAME] stated hot foods should be held above 150 degrees Fahrenheit and cold foods should be held under 41 degrees Fahrenheit. Staff B, [NAME] proceeded to check the temperatures of the food to be served for lunch. An observation on 12/19/23 11:45 p.m., showed Staff B, [NAME] completed a temperature check on all the food being served to residents. The food items/temperatures included: Hamburger- 150 degrees Fahrenheit French Fries- 154 degrees Fahrenheit Puree Broccoli- 140 degrees Fahrenheit Puree Beef- 140 degrees Fahrenheit Puree bread- 140 degrees Fahrenheit Mush- 150 degrees Fahrenheit Brown Gravy- 160 degrees Fahrenheit Broccoli Salad- 78 degrees Fahrenheit Tuna Salad- 60 degrees Fahrenheit During an interview on 12/19/23 at 11:55 a.m. Staff B,…
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 · D2023-12-21 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure one resident (#8) out of one resident sampled was properly assessed and monitored for self-administration of an inhaler. Findings included: During an interview on 12/19/2023 at 9:30 a.m. Resident # 8 was observed removing an inhaler from her pocketbook and she proceeded to take a puff on the inhaler, she waited approximately five minutes and then took another puff. She then replaced the inhaler into her pocketbook. She stated her Primary Care Physician (PCP) gave an order for self-administration, however the staff could not get the order correct, so the nurse told her the next time she brings the inhaler for her to keep it. During an interview on 12/20/23 at 3:30 p.m. Resident # 8 revealed she still had the inhaler in her pocketbook. She stated she does not remember which nurse gave it to her, or how long she has had the inhaler. The box the inhaler was in revealed the date was worn off. She stated she has days she does not use…
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 · D2023-12-21 · tag F0641 — isolatedEnsure 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 reviews and interview the facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for two residents (#49 and #67) out of two sampled for resident assessments. Findings included: A review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, cerebral Infarction affecting left side, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), hypertension, and repeated falls. The admission Record revealed Resident #49 was discharged from the facility on 08/21/2023. A review of the MDS assessments for Resident #49 revealed a completed entry assessment dated [DATE] and a completed admission assessment dated [DATE]. No discharge MDS assessment was located in the record. A review of the medical record for Resident #67 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, osteomyelitis, Type 2 Diabetes Mellitus, respiratory…
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 · D2023-12-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to develop a patient-centered care plan for one resident (#30) out of thirty-three sampled residents related to behavioral monitoring with the use of psychotropic medications. Findings included: Review of Resident #30's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified nontraumatic subarachnoid hemorrhage, other seizures, most recent episode depressed in partial remission bipolar disorder, bipolar-type schizoaffective disorder, generalized anxiety disorder, metabolic encephalopathy, and alcohol abuse in remission. During an interview, on 12/18/23 at 11:35 a.m., Resident #30 reported abuse occurs All the time, employees are very sadistic and there was bad drug abuse with staff. The resident stated the Nursing Home Administrator (NHA) had been notified of the allegations. The resident did not use the same first name of NHA as the current administrator. The resident reported 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.
- Potential for harm · D2023-12-21 · 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 conduct an accurate smoking assessment for one resident (#32) out of three residents sampled for smoking. Finding Included: On 12/18/23 at 11:55 a.m., Resident #32 was observed outside in the designated smoking area smoking a cigarette without supervision. The resident was observed with a band aid and burn marks on his left fingers. The resident said when his cigarette burns, he is not able to feel it because he has neuropathy so that's why he has burn marks on his fingers. Review of admission Record, dated 12/19/2023, showed Resident # 32 was originally admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus, Atherosclerotic heart disease of native coronary artery without Angina Pectoris, and unspecified lack of coordination. Review of a Hospice Comprehensive Assessment, dated 10/24/2023, showed Resident #32 was admitted to hospice on 10/24/2023 with diagnoses to include but not limited to severe…
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 · D2023-12-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews the facility failed to ensure wound care for one resident (#17) was provided care per assessment and orders were clarified with the provider out of one resident sampled for pressure ulcer care. Findings included: During an interview on 12/20/23 at 6:57 a.m., Staff D, Registered Nurse (RN) and Staff K, RN stated Resident #17's buttock wound was healed. Staff K reported changing the dressing on Monday (12/18/23), the night before last, it (dressing) did not need to be changed today, it was healed. Staff K stated nurses continue to apply dressing until the Wound Advanced Practitioner Registered Nurse (APRN) comes to the facility and says the wound is healed. An observation was conducted with the Director of Nursing (DON) on 12/20/23 at 7:11 a.m., of Resident #17 lying in bed. The DON requested to observe the resident's wound located on the right buttock. The DON removed a pink foam dressing with a silver/gray patch from the resident's right buttock. The area under the dressing was an area approximately 1.5 centimeter (cm) x 0.3 cm…
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 · D2023-12-21 · 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 record reviews and interviews the facility failed to provide appropriate care and services to one resident (#21) out of one resident sampled for bladder and bowel management related to inaccuracy and incomplete documentation of bowel movements and transfer to an acute care facility with a diagnosis of bowel impaction. Findings included: Review of Resident #21's admission Record revealed the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified constipation, overactive bladder, and unspecified other psychoactive substance use with psychoactive substance-induced persisting dementia. A review of Resident #21's nurse's notes revealed the Director of Nursing (DON) wrote on 11/7/23 at 9:00 a.m. of the resident's physician giving a verbal order to transfer the resident per family request to an acute care facility for a critical Hemoglobin (Hgb) value of 6.9 (according to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-21 · 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 review the facility failed to ensure 1) medications were stored and labeled properly in two (1 West-East and 2 West) of three medication carts and three of three nursing stations, and 2) medications were inaccessible to residents, visitors, and unauthorized personnel in three of three nursing station/medication rooms and two of three medication carts. Findings included: On 12/19/23 at 8:43 a.m., an observation was conducted at the 2 [NAME] nursing station. The medications at the nursing station were accessible through an unlocked door, the observation revealed nursing staff were engaged elsewhere and the area was unlocked and unattended. On 12/19/23 at 9:02 a.m., an observation of the 2 [NAME] nursing station revealed the following: -In an upper cupboard was a pink basin containing two 50 usp/5 ml (United States Pharmacopeia (usp) per 5 milliliter) prefilled Heparin syringes. -The basin also contained several tablets of denture cleanser and a hairbrush. -One tablet…
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 · E2021-09-16 · 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 observation and interview, the facility failed to maintain kitchen equipment in a safe, operating condition, related to one burner on the stove. The stove was used to provide meals for residents on two of two floors of the facility. Findings included: On 09/13/21 at 09:57 a.m., during the initial kitchen tour, the stove was being used to prepare lunch. The Certified Dietary Manager (CDM) was asked to ignite the back left burner. On the first attempt, the knob was turned to the on position, the burner failed to ignite. A second attempt was made, which was also unsuccessful. The CDM walked away and returned with a handheld, multipurpose lighter. He turned the knob, allowing gas to flow, struck the lighter, pointed it towards the burner, at which time the burner ignited. Following the observation, an interview was conducted with the Cook, Staff A, she stated that the burners are always pre-lit, but she has had to blow on the burner to make the fire come on. On 09/16/21 at 1:09 p.m., an interview was conducted with the CDM, he stated that he noticed the pilot light was out…
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 before2021-09-16 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that each resident was accurately assessed for their Preadmission Screening and Resident Review (PASRR) needs for one (Resident #36) of 29 sampled residents. Findings include: A review of Resident #36's record revealed that he was admitted to the facility on [DATE], with diagnoses that included depression; bipolar; and hallucinations. Further review of the record, revealed that a PASRR Level I Screen was completed at the hospital on 5/13/19. The PASRR Level I screen revealed that Section I: PASRR Screen Decision-Making was left blank, with no documentation of any mental illness or Intellectual disabilities. A review of the Psychiatric Periodic Evaluation with a date of service of 5/30/19, revealed that this resident had diagnoses that included Bipolar disorder, current episode depressed, moderate; chronic schizoaffective disorder; and generalized anxiety disorder. An interview on 9/14/21 at 1:21 p.m., with the Social Service Director revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-09-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, policy review, and interviews, the facility failed to, (1) discard medications in an appropriate manner on one (2 East) of four units, (2) ensure Schedule IV medications were stored within a double-lock system in two of two medication refrigerators, (3) label medications with an open date and discard medications within the shortened shelf life on two (1 East and 2 West) of three medication carts, and (4) ensure one of three medication carts and one treatment cart were locked while unattended. Findings included: (1) On 9/14/21 at 1:41 p.m., a medication storage observation was conducted on the 2 East unit of the medication room/nursing station and medication cart with Staff D, Licensed Practical Nurse (LPN). In a locked upper cupboard in the left corner of the medication room/nursing station were six gallon-sized clear plastic bags which contained individual blister packages containing a tablet or capsule of medication. The plastic bags were labeled and contained the following: - Two of the bags labeled A, B, C, D, E, F, G, H contained an assortment 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.
- Potential for harm · Dcited before2021-09-16 · 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 and interview, the facility failed to ensure that food was prepared in a clean and sanitary manner in the kitchen related to 1) Food left uncovered and exposed to contaminates and 2) Non dietary staff in the kitchen without a hairnet. The kitchen was used to prepare meals for residents on two of two floors of the facility. Findings Included: On 09/13/21 at 09:57 a.m. an initial tour of the kitchen with the Certified Dietary Manager (CDM) was conducted. During the tour, dough that had been formed into rolls was observed, uncovered, sitting on top of an oven. The dough was observed to be sitting, uncovered, underneath a stained, greasy substance, and peeling rust. The CDM confirmed that the rolls were placed there by the cook for proofing (to allow the dough to rise) and would be used for lunch. The observation of peeling rust and the greasy substance was shown to the CDM. Following the observation, the CDM stated that he would not serve the rolls, he would just throw them out. On 09/13/21 at 10:05 a.m., a staff member was observed in the kitchen without 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.
“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
$30,989 in federal fines across 3 penalties.
- $20,910 — penalty dated 2026-02-25
- $3,728 — penalty dated 2023-12-21
- $6,351 — penalty dated 2023-12-11
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 / manager | Type | Role | Since |
|---|---|---|---|
| THA TAMPA PROPCO LLC | Organization | DIRECT OWNERSHIP INTEREST | since 10/01/2023 |
| MCGAULEY, ROSE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2023 |
| PETTY, LAURENCE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 10/01/2023 |
| FREIFELD, STEVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2023 |
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.
About 82% 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 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 105725. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, 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.