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Vivo Healthcare Gandy

4610 S Manhattan Ave, Tampa, FL 33611 · For profit - Limited Liability company · 160 certified beds · (813) 839-5311 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 20261 immediate-jeopardy citation
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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)
  • about 22% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4543 S Manhattan Ave · (813) 837-2461 · Call to confirm hours
Pharmacy
4401 W Gandy Blvd · (813) 837-8382 · Call to confirm hours
Grocery
4315 W Gandy Blvd · (813) 831-6890 · Call to confirm hours
Park
4700 S Clark Ave · (813) 832-1243 · Typically dawn to dusk

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

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

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.1%8.7%15.4%better
Long-stay residents who lose too much weight7.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.1%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.4%2.5%3.3%better
Long-stay residents whose ability to walk worsened5.1%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.2%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers3.4%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control8.8%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 table3.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.4%94.7%79.4%better
Short-stay residents rehospitalized after admission37.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit3.8%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.022.131.67better
Long-stay outpatient ER visits per 1,000 resident days0.131.151.80better

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

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

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

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

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

42.3% 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 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.3%U.S. median 51.5%
Got home and stayed home
12.9%U.S. median 10.7%
Went back to hospital
50.4%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.10hours / resident / day
Speech therapy

Met the expected recovery: 50.4% 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 119 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.3%CMS range 32.5–54.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.9%CMS range 9.1–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge47.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge38.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.9%100.0%Oct 2024–Sep 2025CMS 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 discharge97.8%98.7%Oct 2024–Sep 2025CMS 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 stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.4–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.58
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.31
Aide hours/ resident / day
3.67
Total nurse hours/ resident / day
0.37
RN hoursweekends
39.7%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 160 beds and averages 143.9 residents a day — about 90% occupied, or roughly 16 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.32 hrs/resident/day on weekends vs 3.82 on weekdays — 13% thinner on weekends. RN hours go from 0.66 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

7
deficiencies at the latest standard inspection (2025-01-16)
4
at the previous standard inspection (2022-11-03)

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

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · J2026-03-27 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 resident rights were honored, related to advance directives and code status, for one resident (#1) out of three residents sampled.On [DATE], facility staff initiated cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury), on Resident #1 when the resident was found unresponsive for approximately twelve minutes. Failure to honor the resident's wishes for Do Not Resuscitate (DNR) caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE]…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-30 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    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 with the facility's nursing and administrative staff, record review and review of the facility policies, the facility administration failed to utilize their resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for five residents (#3, #4, #5, #6 and #8) out of five residents sampled for abuse and neglect, putting all the residents of the facility at risk for ongoing abuse and neglect. [Cross reference F609 and F610].Findings included: Review of a job description signed by the Nursing Home Administrator on [DATE] revealed - the primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times.Duties and responsibilities included:Resident Rights: Ensure that the resident's rights to fair…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure infection control practices were consistently followed to notify visitors of an influenza outbreak and/or offer personal protective equipment (PPE) such as masks prior to entering the resident care area and in nebulizer masks were not stored in a manner to prevent infection in two of four units (100 and 300).Findings Include: On 1/28/26 at 9:10 a.m. during the initial tour of the facility, all staff members observed in the resident care area were wearing masks. When asked, staff stated that mask use was required due to an influenza (flu) outbreak. Upon further review of the lobby area, no signage was posted to notify visitors of the outbreak or to recommend appropriate personal protective equipment (PPE) and the receptionist did provide information or instructions about the influenza outbreak. On 1/28 /26 at 10:25 a.m. an interview was conducted with Family Member #1 visiting room [ROOM NUMBER]. The visitor stated he had been 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-30 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to provide staff with adequate training on issues regarding language barriers reported through grievances via the resident council and residents in seven of seven grievances sampled for review.Findings include: On 1/28/26 at 2:20 pm, an interview with Resident #7 revealed language is still a big barrier at the facility. Resident #7 stated Resident Council has been discussing this issue for months, and no resolution has been made. Resident #7 stated staff will just shove their phone in the resident's faces and try to make them use a translator application. Resident #7 refuses to use the translator for communication. Resident #7 believes they should be able to communicate with staff without having to use a translator. Resident #7 said they hear staff speak Spanish while caring for other residents who are also only English speaking. A review of Resident #7's admission record revealed an original admission date of 11/28/22, with a readmission date of 1/14/25, with diagnoses to includer respiratory failure,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-30 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and review of the facility policy, the facility failed to ensure allegations of abuse and neglect were reported in a timely manner for four (#3, #4, #5 and #6) of five residents reviewed.Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/2026, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.VII. Reporting/ResponseA. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-30 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse and neglect in a timely manner for four residents (#3, #4, #5 and #8) of five residents reviewed.Findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/2026, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: . Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. V. Investigation…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility did not ensure one of two community shower rooms were maintained in a clean and sanitary condition. Findings included: On 01/14/2025 at 9:15 AM the following observations were made of the community shower room located on Unit 4: - Shower curtains on the two showers in the room had a black substance on the lower part of both the out-facing and in-facing portions of the curtain. - A caked black substance was observed on the tile floor behind the toilet and the floor in front of and around the toilet was also caked with black substance. - The rim under the toilet seat had a yellow liquid substance on it. The inside of the toilet bowl had a rust-colored stain in the portion where the water drains when flushed. - There were two shower stalls in the room. In the second shower stall closest to the far wall, the floor of the shower, the drain, and the shower head all had a yellow substance on them. There were areas of cement-like porous, uncleanable spots where the tiles were missing on the floor. - The wall vent fan for the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure resident's with diagnosed mental illness or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) screenings for four residents (#47, #79, #19, and #73) out of 29 residents sampled. Findings included: 1. Review of Resident #47's admission Record revealed an admission date of 12/30/24 and an initial admission date of 07/01/23. Resident #47 was admitted to the facility with diagnoses of paranoid schizophrenia, schizoaffective disorder, depressive type, major depressive disorder, recurrent, and anxiety disorder Review of the Level I PASRR screen dated 07/01/24 showed the following: Section I, Part A - MI (Mental Illness) or suspected MI: Anxiety Disorder, Depressive Disorder, Schizoaffective Disorder, and Schizophrenia were checked. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to develop and implement care plan interventions for four residents (#19, #24, #32, and #133) of thirty-nine sampled residents, related to; 1. Fluid restrictions, 2. Self-administration of oxygen, 3. Discharge planning, and 4. Fall interventions. Findings included: 1. On 1/14/25 at 3:40 p.m., Resident #19 was observed lying in bed. A 16 ounce (oz) foam cup and a wine-colored coffee cup was observed on the over-bed table. The resident picked the foam cup up and reported there was a little bit of fluid in it. On 1/15/25 at 1:31 p.m., Resident #19 was observed lying in bed, wearing street clothes and shoes with her eyes closed. A 16-oz foam cup was observed sitting on the resident's over-bed table next to the bed. Review of Resident #19's admission Record revealed the resident was admitted on [DATE] with diagnoses including but not limited to hypo-osmolality and hyponatremia and essential (primary) hypertension. Review of Resident #19's care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one resident (#118) of two residents sampled for non-pressure related skin conditions received wound care as prescribed by the physician. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The left lower extremity of the resident had been amputated below the knee and four to five steri-strips were covering the surgical incision. A brown/tan color elastic bandage was observed sitting on the resident's dresser wrapped up and not within reach of the resident. The right ankle was wrapped with white rolled gauze from the toes to above the ankle and secured with paper tape. The right ankle gauze was not dated as to when the dressing had been applied. Resident #118 stated staff changed it every couple of days. On 1/13/25 at 9:21 a.m., Resident #118's dressings were observed with Staff T, Registered Nurse/Unit Manager (RN/UM). The staff member lifted the resident's right ankle and confirmed the dressing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure the intravenous (IV) access of one resident (#5) of three residents with IV access was maintained in accordance with professional standards. Findings included: On 1/13/25 at 10:35 a.m., Resident #5 was observed with a single lumen peripherally inserted central catheter (PICC) inserted into the right upper arm. The dressing was dated 1/9/(25) and not fully attached to the skin of the resident. Resident #5 reported having an infection in the spinal cord. Review of Resident #5's admission Record showed the resident was admitted on [DATE] and diagnoses included but was not limited to pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of disease classified elsewhere and unspecified gram-negative sepsis. Review of Resident #5's Admission/readmission Nursing Evaluation, effective 12/27/24, revealed the admitting diagnosis was bacteremia and had a right upper extremity (RUE) midline. The evaluation did not include 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2025-01-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure effective communication with the Dialysis center that provides treatment services for one resident (#119) of three sampled residents. It was determined review of fourteen Dialysis service visits, the Dialysis nursing staff failed to collaborate with the nursing facility by not providing and documenting post weights, vital signs, Dialysis vascular access site status, and what Dialysis treatment was provided. Findings included: On 1/13/2025 at 8:50 a.m., Resident #119 was observed seated on the side of his bed in his room. The resident was alert and able to speak about his medical care and daily decision making. Resident #119 confirmed he goes to an End Stage Renal Disease (ESRD) Dialysis center three times a week for Dialysis treatment and he was getting ready to go to his chair treatment appointment today, which was at 12:00 p.m. Resident #119 confirmed he goes to the Dialysis center on Mondays, Wednesdays, and Fridays. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions and don Personal Protective Equipment in accordance with facility policy for one resident (#118) of thirty-nine sampled residents. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The observation revealed a surgical incision with four to five steri-strips to a left below knee amputation and rolled gauze covering the right ankle from toes to above the ankle. The resident was wearing a nasal cannula delivering three liters per minute (lpm) of oxygen. The observation also revealed the room was not posted for Enhanced Barrier Precautions. On 1/13/25 at 12:28 p.m., Staff U, Certified Nursing Assistant (CNA) asked Staff V, CNA to assist in repositioning Resident #118 in bed for the noon meal. The observation showed the staff members repositioned the resident while wearing gloves, but neither staff member was observed donning a protective gown prior to lifting the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-03 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, and the facility did not respond to grievances in a timely manner for one (Resident #131) of 51 sampled residents. Findings included: Resident #131 was a [AGE] year old female admitted to the facility from an acute care hospital after experiencing a fall at home. She was living independently prior to her fall. The Resident's Brief Interview for Mental Status score was 15 which indicated intact cognition. An interview with Resident #131, on 10/31/2022 at 9:43 a.m., revealed she filed a grievance with the Social Worker on 10/19/2022 and the grievance was taken care of today, 10/31/22. Resident #131 stated the grievance was about the frequency of her dressing changes and she was not receiving some of her psych meds. A follow up interview was conducted on 11/01/22 at 2:53 p.m. and Resident #131 stated, I filed a grievance on the 19th [October 2022] and yesterday when you [surveyor] arrived they came and wanted me to sign saying I agreed with what they wrote. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-11-03 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to implement the care plan related to interventions to manage resident wounds for one (Resident #55) of two residents sampled for wounds. Findings included: Review of Resident #55's record revealed the resident was re-admitted to the facility on [DATE], with diagnoses that included Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis Following Cerebral Infraction Affecting Right Dominant Side and, Arterial fibrillation. Observations on 11/03/22 at 8:23 a.m., revealed the resident lying in bed. He was noted to have a left foot wound dressing and no Podus boot. Closer observation of the room revealed the Podus boot was lying in the residents reclining chair by the window. In an interview with the resident at this time, he denied taking the boot off and denied having the boot on during the night. In an interview with Staff B, Certified Nursing Assistant (CNA) who entered the resident room with his meal tray, she reported…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-03 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure the administration of enteral nutrition was completed according to physician orders and facility policy for one (Resident #88) of one resident sampled for the administration of liquid nutrition via a percutaneous endoscopic gastrostomy (PEG). Findings included: An observation was conducted on 11/2/22 at 2:04 p.m. with Staff F, Licensed Practical Nurse (LPN) of the administration of liquid nutrition for Resident #88. Staff F removed a 60 cubic centimeter (cc) syringe from the package, picked up the end of the PEG where it lay near the side of the bed, inserted the syringe into the tube, flushed the tube with 30 cc's of water, then inserted the end of nutrition tubing into the PEG, and turned on pump. The pump was programmed to deliver the liquid nutrition at 75 milliliter (mL) per hour and a water flush at 150 mL/hr. Staff F pulled back the residents blanket and observed the PEG's insertion site. The staff member confirmed that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-11-03 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 observation, interview, and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-eight medications were observed administered and four errors were identified for three (Resident #13, #113 and #597) of four residents observed. These errors constituted a medication error rate of 14.29 percent. Findings included: On 11/02/2022 at 8:56 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse, (LPN)-Agency, was conducted with Resident #597. Staff D, LPN was observed administering the following medication: -Oxcarbazepine Extended Release (ER) Tablet (Oxtellar XR), 150 Milligrams Orally twice a day for diagnosis of mood disorder. Staff D placed the medications in a clear envelop and then crushed the medications with a pill crusher. The medication had a pharmacy label instruction which indicated to not Chew or crush the medication. A record review of Resident #597's active physician orders dated 10/26/2022 read May crush medications and combine unless contradicted. A facility provided policy titled,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-05-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure three (#88, #124, #102) of 54 residents sampled were provided services to maintain grooming, and personal and oral hygiene. Findings included: 1) On 5/17/21 at 2:55 p.m. Resident #88 was observed self-propelling his wheelchair in the hallway of his unit. He was wearing a pair of white shorts and presented with a dark yellow colored stain just below his waistline and on both sides of his groin. A staff member was in the hallway and was asked about his soiled clothing. She looked at the resident and stated, you need to go to your room and get your shorts changed before you go outside. She then turned his wheelchair around and transported him to his bedroom. At 3:35 p.m. Resident #88 remained in his bedroom when Staff Member B, Certified Nursing Assistant entered the bedroom with a blood pressure cuff, and temperature probe. She was observed as she was performing his blood pressure check. She was overheard telling the resident he needed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-05-20 · tag F0694 — pattern
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observations, and interviews the facility did not ensure appropriate treatment and services were in place for a central line and did not ensure that practice standards were followed related to the a central intravenous catheter for one resident (#83) of three residents with central lines. Findings included: Resident #83 was admitted to the facility most recently on 4/23/2021 with a diagnosis of UTI (urinary tract infection), according to the face sheet in the admission record. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (AHCA form 3008), dated 4/19/21 reflected a left Mid line IV (intravenous) access inserted 4/22/21. Review of the physician's order dated 4/23/21 revealed Resident #83 was receiving Ertepenem Sodium solution reconstituted 1 Gm use 1 gram intravenously one time a day for UTI for 3 days. The order status reflected it was completed on 4/25/21. A review of the physician's orders in the electronic medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-05-20 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in regards to not following appropriate infection control related use of PPE (personal protective equipment) for rooms under contact and droplet precautions, failure to ensure that a cleaning and disinfecting process was utilized after use of a multiuse glucometer device for 4 (#27, #9, #12, #77) residents, and failure to practice hand hygiene prior to donning and after doffing gloves. Findings included: 1. Observation of the 200 hall on 05/17/21 at 10:10 AM revealed that every room door on this unit had a pink laminated sign which indicated Please see nurse before entering room Before entering you must apply: The following items were checked for each room: Apply gloves; Apply Face Mask; Apply gown; Apply goggles. Observations 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 observation, interview and record review the facility failed to honor residents' right to smoke for 2 of 14 (#11, #86) residents who smoke. Findings included: Interview on 05/18/21 at 10:59 AM with Resident #86 revealed that she is allowed to smoke at night only when there is no one around, but that she is not allowed to smoke during the day and that she is dying for a cigarette right now. She reported that she will be off of isolation in 4 days and will be able to smoke during the day. Review of Resident #86's record revealed that this resident was admitted to the facility on [DATE], has a current physician order dated 4/7/21 for droplet precautions and has a Brief Interview for Mental Status (BIMS) score of 13 (Cognitively intact). The resident was assessed to be able to smoke safely and independently on 4/7/21 and was care planned to be able to smoke independently on 4/9/21. The resident signed a smoking policy on 4/9/21. The residents record did not contain any documentation that would indicate that…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-05-20 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to appropriately investigate the concerns of the resident council group and keep them apprised of the resolution of the concern bought up by the resident council group. Findings included: Review of the Resident Council meeting minutes for the months of March, April, and May 2021 identified concerns related to rude staff on the 11:00 PM-7:00 AM shift. Review of grievance dated 3/1/21 revealed that the activities director received a grievance from the Resident Council group related to Residents state the 11-7 staff are rude to them. The form indicated that the action that was taken to resolve the issue was In-serviced staff on customer service. Review of the facility education revealed that staff were in-serviced on 3/2/21 and 3/3/21 related to customer service and treating resident with respect and dignity. The grievance form indicated that the concern was resolved on 3/3/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-05-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, medical record review, and manufacture's directions the facility failed to ensure three (400 unit cart #1, 100 unit cart #1, and 300 unit cart #2) of four sampled medications carts had medication and biologicals stored not past the expiration date, and/or failed to document an open on date. Findings Included: 1. On 5/17/2021 at 1:00 p.m. medication cart #1 on the 400 unit was observed with the following: An oral inhaler Combivent. The inhaler did not contain an open on date. The instructions on the inhaler read to discard three months after opening. A second oral inhaler labeled Breo-ellipta did not contain an open on date. The label indicated to discard 6 weeks after opening. A bottle was labeled assure platinum strips. The bottle did not contain an open on date. vial labeled NovoLog contained an open on date 4/8/2021. The labeled on the bottle read expired 28 days after opened. Indicated last day on 5/6/2021. An insulin vial labeled Lantus was identified and did not have an open on date. Prescription Lantus is a long-acting insulin used to treat…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to VIVO HEALTHCARE — 12 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 →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 1 of 51.9-0.9 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 11 homes this chain runs (chain average 2.4★, 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 / managerTypeRoleShareSince
GANDY HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2025
JEK IRRV TR IIOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 07/01/2025
NMJ IRRV TR IIOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 07/01/2025
SF TRUST HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF20%since 07/01/2025
GLUCK, BENJAMINIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF9%since 07/01/2025
5 MOSHES REALTY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
AML CAROLINA LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
AYC INVESTMENTS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
ELEF INVESTMENTS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
ELIEMAN HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MCFC CAPITAL LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MIDTOWN CAPITAL GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MIRIAM & EDWIN ZAGHI JOINT REVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
ML SOBEL LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MPG HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
PAY HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
RADAR HOLDINGS INCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
RKB HOLDINGSOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
SIMBA THE ALCOHOLIC LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
SJ EQUITY INVESTMENTSOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
TZVI AND STEPHAN IE RATNER-STAUBER REVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
ZOLEX GROUP ONE LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 07/01/2025
BECKER, YITZCHOKIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
COMPTON, MORDECHAIIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
CUKIER, AVROHOMIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
DAVID, MIRIAMIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
DAVID, TOVAIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
DIEGUEZ, JESSICAIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
JAKOBOVITS, ELIEIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
JAKOBOVITS, NATHANIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
KAGAN, JEFFREYIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
LANDSMAN, DVORAIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
LEVY, ELIEIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
LIBROWICZ, EMANUELIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MARK, ARIIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MELAMED, HEDIIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
MELAMED, SHMUELIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
RAND, YOELIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
STERNBUCH, SARAHIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
WILNER, BENIndividualINDIRECT OWNERSHIP INTERESTsince 07/01/2025
KIRBY, IVANAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2025
RABAGO-REYES, CASSANDRAIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 07/01/2025
CUKIER, JOSEFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2025
FRIEDLAND, SHALOMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2025
CNS HOLDINGS LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 07/01/2025
KANNER, SHLOMOIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/09/2026
GANDY PROPCO LLCOrganizationADP OF THE SNFsince 07/01/2025
JEK HOLDINGS LLCOrganizationADP OF THE SNFsince 07/01/2025
NMJ HOLDINGS LLCOrganizationADP OF THE SNFsince 07/01/2025
TAMPA 5 PROPCO GP LLCOrganizationADP OF THE SNFsince 07/01/2025
TAMPA 5 PROPCO HOLDCO LLCOrganizationADP OF THE SNFsince 07/01/2025
TAMPA 5 PROPCO HOLDCO LPOrganizationADP OF THE SNFsince 07/01/2025
TAMPA 5 PROPCO HOLDCO MEZZ BORROWER LLCOrganizationADP OF THE SNFsince 07/01/2025

CMS files one row per role, so the 62 rows in the source record cover these 53 parties — each is shown once here with every role it holds. Nothing is omitted.

29 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.

$16.2M
Net patient revenuemost recent cost report
-6.1%
Operating marginrevenue minus expenses
$3.8M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 10%Other / private 14%

About 75% 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 $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$335per resident / day
operating cost
$10,175per month
≈ monthly operating cost
$315per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105491. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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