Rehabilitation And Healthcare Center Of Tampa
4411 N Habana Ave, Tampa, FL 33614 · Non profit - Corporation · 174 certified beds · (813) 872-2771 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has a citation for mishandling residents’ money or property (F0565)
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $231,152 in federal fines (most recent 2024-08-20)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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 | 1 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 3 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 | 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 2025-09 to 2026-06, this home’s CMS overall rating held steady at 1 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 | 4.6% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.0% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.2% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.9% | 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 | 2.8% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.7% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.1% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.3% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 1.5% | 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 | 5.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.3% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.09 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.73 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.9% 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 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.1% 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 89 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 49.9%CMS range 40.2–64.3 | 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 | 12.4%CMS range 9.5–15.8 | 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 | 46.1% | 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 | 48.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.0% | 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 | 96.5% | 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 | 95.3% | 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 | 100.0% | 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 | 3.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 5.3–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 174 beds and averages 163.2 residents a day — about 94% occupied, or roughly 11 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.15 hrs/resident/day on weekends vs 3.54 on weekdays — 11% thinner on weekends. RN hours go from 1.12 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
32 citations, most serious first. The 15 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · L2023-12-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to ensure sufficient staff with the appropriate competencies and skills-sets to perform the functions of the food and nutrition service, taking into consideration resident assessments and individual plans of care related to dietary staff not properly implementing adequate kitchen hygiene, proper sanitation practices, proper food labeling and storage, and appropriate serving of meals affecting 158 out of 168 residents in the facility. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on 12/13/23. The findings of Immediate Jeopardy were determined to be removed on 12/14/23 and the severity and scope was reduced to a D. Findings included: On 11/28/23 starting at 9:30 a.m. a tour of the facility's kitchen was conducted which revealed: An observation was made 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.
- Immediate jeopardy · L2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchens observed, and three of three nutrition rooms observed, as evidenced by improper dish washing, unsanitary kitchen area, undated food, expired food, inappropriate food temperatures, unlabeled food, unsanitary preparation of food, food with evidence of bio-growth, and residents not being served according to their prescribed diet orders. This failure created a situation that resulted in the likelihood of serious injury and/or death to 158 residents and resulted in the determination of Immediate Jeopardy on 12/13/23. The findings of Immediate Jeopardy were determined to be removed on 12/14/23 and the severity and scope was reduced to a D. Findings Included: On 11/28/23 starting at 9:30 a.m. a tour of the facility's kitchen was conducted which revealed: An observation was made 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.
- Immediate jeopardy · L2023-12-14 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchen observed, and three of three nutrition rooms observed. The facility failed to ensure the safety of 158 residents in the facility as a result of the failure. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on 12/13/23. The findings of Immediate Jeopardy were determined to be removed on 12/14/23 and the severity and scope was reduced to a D. Findings included: During a survey on 11/28/23 to 11/29/23 and 12/11/23 to 12/14/23 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.
- Actual harm · Gcited before2024-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to prevent falls/accidents resulting in an injury to one resident (#1) out of three residents sampled for falls. Resident #1 sustained a scalp hematoma and clavicle fracture with a transfer to a higher level of care. Findings included: Review of the admission Record showed Resident #1 was originally admitted to the facility in 2017 and discharged to a local hospital on [DATE]. The admission Record showed diagnoses to include: other sequelae following unspecified cerebrovascular disease, muscle wasting and atrophy, dementia, weakness, lack of coordination, and need for assistance with personal care. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 3 showing severe cognitive impairment. The resident had no mood or behaviors identified, and no falls since the prior MDS assessment dated [DATE]. The resident required substantial/maximal assistance 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.
- Actual harm · H2023-12-14 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and policy review, the facility failed to ensure pain medication was administered and pain was managed for three residents (#20, #14, and #9) of four reviewed for pain management. Findings included: 1. An interview was conducted on 11/29/23 at 3:18 p.m. with Resident #14. The resident stated her pain level was an 8 out of 10 on the pain scale and was located in her shoulders and lower back. The resident was lying in bed with the head of her bed elevated. She winced (shrinking movement of the body in anticipation of pain or distress) with pain when she tried to reposition herself. The resident said she has Morphine scheduled every 6 hours as needed and she routinely takes it two to three times a day. Resident #14 said it had been a couple of days since the facility had any available. She said she asked her nurse for pain medication two times that day and had been told her pain medication had not been delivered to the facility. The resident said she is worried…
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 · D2026-04-21 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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, record review and interview, the facility failed to provide social services supports for one resident (#6) of fourteen sampled residents.Findings included: On 04/20/2026 at 10:21 a.m., a telephone interview was conducted with Resident #6's family member. She stated (Resident #6) only received $30.00 per month.An interview conducted on 04/20/2026 at 1:40 p.m. with Resident #6. He was observed in bed. He stated he had no money coming to the facility.On 04/21/2026 at 2:26 p.m. an interview was conducted with the Social Services Director (SSD). When asked if she had received any complaints regarding Resident #6, she stated she had not. The SSD stated for Resident #6, she was not sure whether a complaint had been received from the resident. She said she had not gone and spoke with him.On 04/21/2026 at 2:35 p.m., Resident #6 was re-interviewed. When asked about his income, he stated before he came to the facility, he was receiving $800.00 per month. He said, then the check from social security…
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 before2025-04-02 · 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, record review and interview, the facility failed to ensure residents on two of three floors (2nd and 3rd floors) had an environment free from heavy foul and offensive odors during four of four days observed (3/30/25, 3/31/25, 4/1/25, and 4/2/25). It was found heavy odors emitted from two of thirty-four sampled residents (#163 and #80) and their rooms. Findings included: On 3/30/2025 at 9:58 a.m., the elevator doors opened on the second floor and there was immediately a heavy foul urine and offensive odor. After walking past the unit station and to Resident #163's room, it was observed the room door was closed. After knocking on the door and opening it, a very heavy foul urine and offensive odor emitted from this room. The odor was overpowering and leached throughout out areas to include the activity/dining room, hall near the shower room, the nurse station and down both halls approximately thirty feet away from Resident #163's room. Upon entering Resident #163's room, she was observed lying…
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 · E2025-04-02 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — 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 1. Call light cords and buttons were placed within reach while residents were in bed in five of ninety-six resident rooms, on two of three floors, (Rooms 214a, 216p, 234a, 302a 310a, and 310b, ; and 2. Did not ensure bathroom call light cords were free hanging and not tied to hand rails for resident bathrooms 220, 226, 228, 234, and 310, during three of four days observed (3/30/25, 3/31/25, 4/1/25). Findings included: During various tour observations on 3/30/2025 at 10:00 a.m., 1:30 p.m., 3:00 p.m.; 3/31/2025 at 9:30 a.m., 2:00 p.m.; and on 4/1/2025 at 10:30 a.m. the following was observed: 1. Resident room [ROOM NUMBER]a was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind the head of the bed. 2. Resident room [ROOM NUMBER]p was observed with the resident lying in bed and with the call light button and cord out from reach, lying on the floor back behind…
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 · D2025-04-02 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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, record review, and interview, the facility failed to provide two of thirty-four sampled residents, (#107, and #36) with a homelike eating experience during two of three meals observed on 3/30/2025 and 3/31/2025. Findings included: On 3/30/2025 at 12:15 p.m., the third floor dining/activity room was observed during lunch service. It was observed with one long table and with seven residents seated at it in either wheelchairs or regular chairs. Resident #107, who was seated in his wheelchair at the end of the table, was observed without his meal. All the other six residents seated at the table had been served, set up with their meals, and were eating. However, Resident #107 was observed just watching the others eat, and without a meal tray of his own. Staff K, Certified Nursing Assistant (CNA) was the only staff member in the dining/activity room. She said she was assisting another resident with eating assistance and they had not got out Resident #107's meal yet. She said there were two other…
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 · D2025-04-02 · 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 observation, interview, and record review, the facility failed to ensure care plan interventions were implemented related to call light placement when residents were in bed for three (#163, #80, and #113) of thirty-four sampled residents. Finding included: 1. During observations on 3/30/2025 at 9:58 a.m., 3/31/2025 at 11:20 a.m., 12:25 p.m., 1:11 p.m., and on 4/1/2025 at 7:40 a.m., Resident #163 was seen in her room lying flat in bed and on top of the covers. She was noted looking up and at the wall with no affect. Resident #163 had cognitive impairment and was not able to answer questions related to her day, medical care and services. During each observed time, Resident #163 was found with the call light cord and button not on her bed, and not within reach. The call light was located on the floor back behind the head of the bed, and out of her reach. Photographic evidence obtained. On 4/1/2025 at 1:25 p.m., Staff G, Certified Nursing Assistant (CNA) confirmed the call light was on the floor and out 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 before2025-04-02 · 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, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice related to physician orders for pain parameters and administration of pain medications for one (Resident #147), and nebulizer treatments for one (Resident #132) of 34 residents reviewed for physician orders. Findings included: 1. On 3/30/25 at 9:52 a.m. during an interview and observation, Resident #132 said at the end of his of a breathing treatment he removed the nebulizer mask because staff took a long time to return. In the top drawer of Resident #132's bedside table were three plastic unopen ampules. Resident #132 said the ampules contained medication for his breathing treatment. Resident #132 twisted the cap off of one ampule and poured the clear liquid contents in the top opening of the connection between the mask and the medicine cup part of the nebulizer mask. Review of Resident #132's Minimum Data Set (MDS), dated [DATE], section c, showed 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 before2025-04-02 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide suctioning for one (Resident #70) with a Tracheostomy out of 34 residents sampled. Findings Included: During an observation on 03/30/2025 at 10:12 a.m., Resident #70 was observed sitting in bed dressed in a hospital gown and was observed to have a Tracheostomy with no suction. During an observation on 03/30/2025 at 12:15 p.m., the Risk Manager was observed bring a Suctioning machine onto the 3rd floor and putting into resident #70's room. During an observation on 03/30/2025 at 12:26 p.m., a suctioning machine was observed on the dresser in Resident #70's room. Review of Resident #70's admission record revealed a re-admission date of 03/29/2025 and initial admission date of 11/25/2024. Resident #70 was admitted to the facility with diagnosis including Pneumonitis Due to Inhalation Of Food And Vomit, Chronic Respiratory Failure, Unspecified Whether With Hypoxia Or Hypercapnia, Encounter For Attention To Tracheostomy, Chronic…
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 before2025-04-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1) availability of personal protective equipment (PPE) for four out of five bins on hallway 4 Long, 2) proper storage of respiratory equipment for one (Resident #132) of two residents, and 3) proper Contact Precautions were followed for one (Resident #155) of two residents on transmission-based precautions. Findings included: 1. On 3/30/2025 at 9:01 a.m., an observation was made of the 4 Long hallways of four out of five PPE bins missing gowns and/or gloves. Bin Five was located at the end of 4 Long hallways close to 4 Short hallway and had two gowns observed in the bottom drawer. On 3/30/2024 at 9:24 a.m., an observation was made in front of room [ROOM NUMBER] with a Contact Isolation Precaution sign on the front door with no PPE in the bin on the outside of the immediate room entrance. An unidentified Certified Nurse Assistant went down to the 4 Long hallways where bin 5 was and pulled the remainder of the two gowns there, offered…
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 before2024-10-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a process was in place for smoking safety for three (#8, #29, #164) out of 19 residents sampled. Findings Included: 1. During an interview on 10/28/2024 at 10:00 a.m., Resident #8 was observed lying in bed dressed for the day. To the right of her bed was a bedside table with a green and white box of cigarettes. Next to the box was a lighter. Resident #8 stated she was a smoker but only smoked occasionally when she was having a bad day. She stated she usually signed out at the front desk and went in front of the building to smoke. She stated she did not use the facilities smoking section because the smoking area was disgusting and the times available were not convenient for her. She stated, no one cleans the smoking area, and it smells out there. She stated she bought cigarettes from the store in front of the building and two packs last her up to six months. She stated all of the other residents in the facility knew they could come…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · 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 observation, record review, and interviews, the facility failed to ensure a accurate comprehensive care plan for one (#141) of eight sampled residents. Findings included: On 10/29/24 at 9:15 AM observed Resident #141 was not in room. The housekeeper in the room emptying trash can stated he already left for dialysis, referencing Resident #141. Observed white cup half filled with clear liquid with straw in cup, marked with 10/29/24. Review of resident #141 medical record showed an initial admission to facility on 08/20/2024 and readmission on [DATE] with diagnoses including acute respiratory failure, and end stage renal disease. Review of physician orders revealed: - Enhanced Barrier Precautions: C-Auris, Dialysis Catheter and wounds. - Resident to have Dialysis on days: T TH S [name of dialysis center]. Catheter site: right subclavian, Bag meal/snack to go with resident to Dialysis yes or No:yes, Fluid Restriction yes or No:Yes. - 1200 cc Fluid Restriction- Dietary to give 900 cc nursing to give up 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.
Show the remaining 17 citations
- Potential for harm · D2024-10-31 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility did not ensure accuracy of Preadmission Screening and Resident Review (PASRR) for two (#67 and #75) of 16 sampled residents. Findings include: 1. Review of Resident #67's medical record showed an initial admission to facility on 09/22/2022 and readmission on [DATE] with diagnoses including unspecified dementia, other specified depressive episodes, schizophrenia and unspecified psychosis. Review of care plan dated 02/27/24 revealed: - A focus of BEHAVIORAL: The resident has been noted with the following behaviors: throwing things at staff, refusing care and services at times, combative at times, noncompliant with safety suggestions, refuses weights Date Initiated: 03/12/2024 Revision on: 05/29/2024. With interventions including Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician) Date Initiated: 03/12/2024 Observe/document for side effects and effectiveness. Date Initiated:…
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 · D2024-10-31 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one resident (#142) out of eight residents observed. Findings included: On 10/28/2024 at 10:45 a.m., an observation and interview was conducted in Resident #142's room. Resident #142 was in a private room with thick yellow sputum on his hospital gown from his tracheostomy. A young man was sitting in a chair in the corner of Resident #142's room. The young man (Sitter #1) identified himself as a private sitter hired by the family. Sitter #1 stated he would assist the nursing staff with Resident #142's ADL (Activity of Daily Living) care during the day. On 10/29/2024 at 8:28 a.m., an observation and interview was conducted with Resident #142's private sitter (Sitter #2). Sitter #2 stated she was familiar with Resident #142 and stated she had been taking care of the resident since he had been at this facility. Sitter #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 · D2024-10-31 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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, staff interview, and record review, the facility failed to provide an ongoing activity program that provided one on one activities as scheduled and met the individual interests and needs to enhance the quality of life for two (#154 and #472) of two sampled residents. Findings Included: During an interview on 10/28/24 at 11:00 A.M., Resident #154 said he preferred to stay in bed, he felt weak due to recent cancer treatments. He wanted to participate in activities but the facility staff had not offered or provided bedside activities. Review of Resident #154's admission record, showed admission date of 6/28/24. Review of Resident #154's order summary report active orders as of 10/28/24, showed monitor and record pain every shift, restorative nursing as needed, Tramadol 50 mg every 6 hours as needed for pain. Review of Resident #154's care plan focus on pain, initiated 7/1/24, showed resident has pain or a potential for pain related to chronic knee pain and other comorbidities [and] muscle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide emergency tracheostomy supplies for three residents (#142, #25, and #156) of three residents observed. Findings included: 1. On 10/28/2024 at 1:48 p.m., an observation and interview was conducted in Resident #142's room with Staff E, Registered Nurse/Unit Manager (RN/UM). Resident #142 did not have the same size and a smaller size tracheostomy set in his room. Staff H, RN/UM agreed resident did not have this equipment. A record review of Resident #142's admission Record showed an initial admit date of 4/25/2024 with a readmission date of 7/18/2024. Resident #142 has a diagnosis of chronic respiratory failure unspecified whether with hypoxia or hypercapnia and tracheostomy status. A review of Resident #142's Minimal Data Set (MDS) dated [DATE] Section O- Special Treatments, Procedures and Programs, area under Respiratory Treatments C1 -Oxygen therapy, D1-Suctioning and E1- Tracheostomy care was each checked off as present. A review…
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 before2024-05-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for two patient floors (3rd and 4th) out of three patient floors in the facility. Findings included: During an observation of room [ROOM NUMBER] on 05/13/24 at 11:42 AM at the side of the resident bed located closest to the window, the flooring was noted to be lifting. (Photographic Evidence Obtained). A review of the facilities electronic maintenance system report for the past month revealed no concerns related to the floor lifting in room [ROOM NUMBER]. A review of the Concierge rounds report for the month of May 2024 revealed no concerns related to the floor lifting in room [ROOM NUMBER]. During an interview on 05/16/24 at 10:10 AM with the Nursing Home Administrator (NHA), he stated the facility utilizes a concierge rounds system and all concerns are documented on the rounds form. He stated if it is a serious concern it is placed on the electronic maintenance system and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-16 · tag F0641 — patternEnsure 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 interviews and record review, the facility failed to ensure accuracy of resident comprehensive assessment for three residents (#64, #81, and #158) out of fifty-two sampled residents. Findings included: A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, anxiety disorder, and need for assistance with personal care. An observation was conducted on 5/13/2024 at 10:49 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. Resident #64's representative was observed in the room and was interviewed. Resident #64's representative stated Resident #64 has bed rails to her bed because They keep her in the bed. A review of Resident #64's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/15/2024, revealed under Section P-Restraints and Alarms, Bed Rails: Not used. An observation was conducted on 5/14/2024 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 · E2024-05-16 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure informed consent for the use of bedrails was obtained prior to installation of bedrails and failed to ensure residents were assessed properly for the use of bedrails prior to installation for three residents (64, #81, and #311) of three residents sampled for bedrail use. Findings included: 1. A review of Resident #64's medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, anxiety disorder, and need for assistance with personal care. An observation was conducted on 5/13/2024 at 10:49 AM of Resident #64 in the resident's room. Resident #64 was observed resting in bed with bilateral, one quarter length bed rails up. Resident #64's representative was observed in the room and was interviewed. Resident #64's representative stated Resident #64 has had bed rails to her bed because, They keep her in the bed. Resident #64's representative stated Resident #64 was not informed of the risk of bed…
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 · D2024-05-16 · 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 an accommodation of resident needs related to mobility devices for one resident (#39) out of fifty-two sampled residents. Findings included: A review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (MS), obesity, and Lupus Erythematosus. An interview was conducted on 5/14/2024 at 9:55 AM with Resident #39 in the resident's room. Resident #39 was observed resting in bed during the interview. Resident #39 stated she wanted to plan some outings for the upcoming summer season, but the facility had taken her wheelchair and left her without one. A tour of Residents #39's room and bathroom was conducted, and a wheelchair was not observed in the resident's room. Resident #39 stated she required use of a high back wheelchair due to having Lupus. A review of Resident #39's care plan revealed the following: Focus, last revised 2/3/2023, Resident #39 had an…
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 · D2024-05-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to resolve a resident grievance, to their satisfaction, in a timely manner for one resident (#143) out of the fifty-one sampled residents. Findings included: A review of the admission Record for Resident #143 showed he was initially admitted to the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. A review of the Minimum Data Set (MDS), dated [DATE], in Section C-Cognitive Patterns Resident #143 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. On 05/13/24 at 9:30 a.m., Resident #143 reported he had concerns regarding missing clothes. The resident stated he had to wear other residents' clothes because the facility had been unable to locate his clothes. He stated he reported this concern to staff from the laundry and to the social services department, and they still could not find his clothing. The resident stated the clothing went down to the laundry in a bag with his…
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 · D2024-05-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the accuracy of Level I Pre-admission Screening and Resident Review (PASRR) assessments for three residents (#24, #38, and #81) out of eight residents sampled for PASRR's. Findings included: 1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with diagnoses including: -ALZHEIMER'S DISEASE, UNSPECIFIED-9/15/22 primary -BIPOLAR DISORDER, UNSPECIFIED-12/30/20 -DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY-9/15/22-Secondary. -OTHER SPECIFIED DEPRESSIVE EPISODES-9/8/22 -SCHIZOAFFECTIVE DISORDER, UNSPECIFIED-9/15/22 Review of the Level I PASRR, completion date 5/7/24, revealed in Section IA of the form identified the resident as having diagnosis of Bipolar Disorder, Depressive Disorder and Schizoaffective Disorder. A review of Section II of the form revealed the resident had a primary diagnosis 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 · D2024-05-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise the care plan for one resident (#63) out of two residents reviewed for rehabilitation and restorative services. Findings included: An observation on 05/13/24 at 10:49 a.m., revealed Resident #63 sitting in a wheelchair beside her bed. Resident #63 had no socks or shoes on her right foot. Resident #63 stated her shoe for her right foot was in the dresser drawer, she opened the drawer and showed her shoe that laid in the drawer. Resident #63 stated she did not want her shoe on at the time of interview. A review of the admission Record showed Resident #63 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting right dominate side, contracture of muscle, multiple sites, muscle wasting and atrophy, lack of coordination and multiple sclerosis. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #63 had a Brief Interview 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 · D2024-05-16 · 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 observations, interviews, and record review, the facility failed to provide nail care for one resident (#100), who was unable to carry out Activities of Daily Living (ADLs), out of one sampled resident. Findings included: On 05/13/24 at 9:30 a.m., Resident #100 stated she needed her nails cut. The resident stated the staff does not offer to cut her nails and she wants them cut. On 05/15/24 at 1:40 p.m., Resident #100 was observed with elongated, uneven, jagged, nails with visible dirt underneath her nails. She stated she had asked a Certified Nursing Assistant (CNA) to cut her nails and was told the staff member did not have a nail clipper. The resident stated she told the CNA she had nail clippers she could use, but she had not gotten them cut yet. A review of the admission Record revealed Resident #100 was initially admitted to the facility on [DATE] with muscle wasting and atrophy, not elsewhere classified, and multiple sites. A review of the Minimum Data Set (MDS), dated [DATE], Section C-Cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-16 · 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 ensure active and ongoing communication was received between the facility and hospice providers for two residents (#18 and #24) out of four residents reviewed for hospice services. Findings included: 1. During an interview on 05/13/24 at 11:33 a.m., Resident #18 stated hospice comes to the facility for her and assists with her care. Resident #18 stated, When I first got put on hospice I cried because I thought I was dying, but I am still here. A review of Resident #18's medical record revealed no hospice notes or communication forms from Resident #18's hospice program. A review of the admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus of lung, abnormal posture, cognitive communication deficit, major depressive disorder, anxiety disorder, and other seizures. A review of the quarterly Minimum Data Set (MDS), dated…
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 · D2024-05-16 · 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 maintain a medication error rate of less than 5%. A total of 27 medication administration opportunities were observed with two medication errors for two residents (#56 and #4) of four residents sampled for medication administration, which resulted in a medication administration error rate of 7.41%. Findings included: A review of Resident #56's medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy and polyosteoarthritis. A review of Resident #56's physician orders revealed the following orders: - An order dated 11/8/2023 for Docusate sodium 100 milligrams (mg) by mouth every morning and at bedtime. - An order dated 11/9/2023 for Folic acid 1 mg by mouth one time a day. - An order dated 3/25/2024 for Gabapentin 100 mg 2 capsules by mouth every 12 hours. - An order dated 11/8/2023 for Acetaminophen 325 mg 2 tablets by mouth every four hours as needed. An observation 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 · E2023-12-14 · tag F0565 — failed to support the resident council — patternHonor 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
Based on interviews and record review, the facility did not ensure grievances were addressed in a timely manner for resident council members with potential to affect a census of 168. Findings included: Review of Resident council meeting minutes revealed residents had voiced on-going concerns related to food. Review of grievances showed: -on 11/8/23 food portions are small. -on 11/7/23 Dialysis resident did not receive breakfast and lunch. -on 11/2/23 No hot plates on meals, cold food. -on 11/2/23 dinner last night was terrible, breakfast is cold, and portions are not enough. -on 11/01/23 Oatmeal is cold most of the time. -on 10/17/23 Food is not enough. Food is always cold. -on 10/4/23 Plate was just mashed potatoes and baked beans. The review showed similar grievances submitted weekly for the last six months with on-going concerns related to food service, timeliness, food temperatures and food availability. On 11/28/23 at 3:49 p.m. An interview was conducted with the Activities Director (AD) She stated she held resident council meetings every month and had an attendance of 10-12…
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 · D2023-12-14 · 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, interviews, record review and review of facility policies, the facility failed to: 1) ensure dialysis residents received a meal to go during dialysis for three residents (#15, #16 and #17) out of eight residents on dialysis; 2) failed to ensure residents were provided with snacks between meals for three residents (#15, #16 and #17) out of eight residents; and 3) failed to ensure one resident (#19) out of ten with a food allergy received an appropriate meal. Finding included: 1. On 11/28/23 at 4:30 p.m. an interview was conducted Resident #15, a dialysis patient. He stated he went to dialysis 3 times a week on Monday, Wednesday, and Friday. He stated he left the facility at 9 a.m. and returned around 3 p.m. He stated the staff did not give him a snack or lunch to take with him. He stated he did not receive a drink either. He stated he had to buy something to eat when out. He stated the facility used to give him a PBJ (Peanut butter and Jelly) sandwich every day, when he complained about it,…
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 before2023-12-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to ensure infection control practices we utilized on one of three units, related to hand washing and the use of personal protective equipment (PPE) in contact isolation rooms. Findings included: An observation was made on 11/28/23 at 3:05 p.m. of an aide coming out of a resident room. The aide did not perform hand hygiene, then walked to the nurses' station and touched items on the desk, then proceeded to another resident room, came out of that room, and did not perform hand hygiene at any point. An observation was made on 11/29/23 at 9:56 a.m. of Staff K, Registered Nurse (RN) entering a resident room with a contact precaution sign displayed on the door. Staff K, RN went to the window bed and administered medication. She did not don PPE on entering in the room, and did not perform hand hygiene upon exiting the room. Staff K, RN returned to the mediation cart and began preparing medication and typing on the computer. An interview was conducted on 11/29/23 at 10:03 a.m. with Staff K, RN. She stated the 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.
“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
$231,152 in federal fines across 2 penalties.
- $12,035 — penalty dated 2024-08-20
- $219,117 — penalty dated 2023-12-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 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 | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 1.9 | -0.9 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 4.1 | ≈ chain avg |
The other 16 homes this chain runs (chain average 2.2★, 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 | Share | Since |
|---|---|---|---|---|
| FI-TAMPA, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/23/2002 |
| FLORIDA INSTITUTE FOR LONG TERM CARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 12/23/2002 |
| JAFFE, HOWARD | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| KATZ-HALL, KATHY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| MULLARKEY, JAMES | Individual | CORPORATE OFFICER | — | since 07/01/2016 |
| RICHMOND, PENNY | Individual | CORPORATE OFFICER | — | since 07/01/2014 |
| AEGIR HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| CONSULTING SUPPORT SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| FACILITY SUPPORT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| KANE FINANCIAL SERVICES, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/21/2025 |
| AFTANAS, JACKIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/19/2018 |
| CAPUTO, JEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2018 |
| SELECT REHABILITATION, LLC | Organization | ADP OF THE SNF | — | since 08/19/2016 |
CMS files one row per role, so the 19 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $231K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 105234. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-02, 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.