Ybor City Center For Rehabilitation And Healing
1709 Taliaferro Ave, Tampa, FL 33602 · For profit - Limited Liability company · 80 certified beds · (813) 223-4623 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $43,050 in federal fines (most recent 2025-10-21)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.0% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 16.5% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 2.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 0.0% | 9.5% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 3.0% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 75.4% | 94.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 31.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 1.5% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.42 | 2.13 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.82 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.8% 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 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.2% 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 52 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 48.8%CMS range 36.0–66.2 | 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 | 12.5%CMS range 9.3–17.0 | 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 | 44.2% | 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 | 50.0% | 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 | 42.3% | 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 | 84.8% | 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 | 92.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.8%CMS range 5.1–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 80 beds and averages 62.4 residents a day — about 78% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.42 hrs/resident/day on weekends vs 3.92 on weekdays — 13% thinner on weekends. RN hours go from 0.46 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-12-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure the prevention and development of pressure wounds for one resident (#1) out of three residents reviewed.Fundings included: Review of Resident #1's admission history and physical, dated 11/26/25 showed under chief complaint: R (right) foot infection. History of present illness: [Resident #1] is an [AGE] year-old patient with Alzheimer's, dementia, hx. (history of CVA (Cerebrovascular Accident) with R lower and upper contracture, RLE (right Lower Extremity) osteomyelitis, . who presents for worsening right foot wound. Pt. unable to contribute to history due to underlying dementia and fatigue. History obtained from [family member] over the phone. Reportedly patient was put in an ALF (adult Living Facility) on 11/18 as [family member} was out of state. When she returned yesterday she visited [Resident #1]. she noted an infected R foot with open wounds on R foot, R heel and R knee. Prior to the ALF, Pt. reportedly had no ulcers…
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 · D2026-03-03 · 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 interviews and record review, the facility failed to address a change in condition in a timely manner for one Resident (#1) out of three residents sampled. Findings included: On 03/03/2026 at 12:53 PM an interview was conducted with Resident #1's Resident Representative (RR). The RR stated after the initial X-ray the facility called him letting him know the Xray came back clear, so he was thinking everything was fine. The RR stated after a week or so he went to visit the resident and noticed swelling on her arm and her hand looked to be hanging in a weird position, like hanging down, so he reached to feel the arm to see if it was warm because he was concerned about a possible blood clot. The RR stated when he barely touched the arm right above the wrist Resident #1 screamed out in pain. He stated he notified the nurse and they said they would address it. The RR stated he called the facility 4 or 5 times, asking for the Director of Nurses (DON) to see what the plan was for Resident #1. He stated he 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.
- Potential for harm · D2025-10-21 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an effective pest control program related to live pests found in two rooms (210 and 350) located in two halls (200 and 300) out of 4 halls observed.Findings included: An observation of room [ROOM NUMBER] on 10/21/2025 at 9:40 A.M. revealed several roaches on the wall behind Bed 2's nightstand and under and around the floor of Bed 3's armoire/closet. An observation of the outside of the maintenance area on 10/21/2025 at 11:20 A.M. revealed a resident nightstand. The Housekeeping Supervisor (HS) was spraying the nightstand with a red can of ant and roach pesticide. The nightstand had three drawers that were partially pulled out and each drawer contained personal resident items. A record review of the pest sighting logbooks on each nursing station revealed an entry dated 10/20/2025 and read, 200 Nurse Cart Roach. The entry was made by the Nursing Home Administrator (NHA). A record review of the exterminators invoice 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 · D2025-06-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to honor a residents right to refuse medications for one resident (#2) out of four residents sampled. Findings included: During an observation on 06/09/2025 at 10:40 a.m., Resident #2 was observed dressed for the day sitting in a wheelchair on the back patio. Review of Resident #2's admission record revealed an admission date of 03/25/2025. Resident #2 was admitted to the facility with diagnoses to include vascular dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder, recurrent, moderate. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15, indicating severe cognitive impairment. Review of Resident #2's Care Plan, dated 04/01/2025, revealed the following: Focus: The resident has a behavior problem related to refusing to allow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect a residents right to be free from abuse for one resident (#2) out of four residents sampled. Findings included: During an observation on 06/09/2025 at 10:40 a.m., Resident #2 was observed dressed for the day sitting in a wheelchair on the back patio. Review of Resident #2's admission record revealed an admission date of 03/25/2025. Resident #2 was admitted to the facility with diagnoses to include vascular dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder, recurrent, moderate. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 03 out of 15, indicating severe cognitive impairment. Review of Resident #2's Care Plan, dated 04/01/2025, revealed the following: Focus: The resident has a behavior problem related to refusing to allow…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure medications were properly stored and secured on two units (300 and 400) out of four units in the facility. Findings included: An observation was conducted on 6/9/25 at 9:25 a.m. at the 400-unit nurses' station. The door to the nurses' station was open, no staff were in sight, and the medication refrigerator in the station was observed to be unlocked. There were floor to ceiling cabinets next to the refrigerator that were also unlocked, and the top cabinet was full of over-the-counter (OTC) medications. The medications were accessible to residents, visitors, or unlicensed staff. An observation was conducted on 6/9/25 at 9:32 a.m. in the 300-unit common area. There was a treatment cart sitting in the resident common area unlocked. No staff were in sight at the time. The treatment cart was observed to contain prescription medications and wound care supplies. A follow-up observation was conducted on 6/9/25 at 12:46 at the 400-unit nurses' station. The medication refrigerator and cabinet with the OTC…
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 before2024-11-07 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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, interview, and record review. the facility failed to provide Activities of Daily Living (ADLs) related to showering for two (#2, #4) of three residents sampled and related to incontinence care for two (#2, #3) of three residents sampled. Findings included: 1. Review of Resident #2's admission Record showed diagnoses included but not limited to acute respiratory failure with hypoxia, Urinary Tract Infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), anemia, diabetes, hypertension, myocardium infarction sleep apnea, and muscle weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Under Section GG - Functional Abilities showed the resident needed moderate assistance for toileting hygiene and maximal assistance for toilet transfer. Section O, Special Treatments, Procedures and Programs showed Occupational Therapy (OT) started on 10/14/2024 and Physical Therapy (PT) started…
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 before2024-11-07 · 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
Based on observations, record reviews, and interviews the facility failed to ensure four (#5, #6, #9, and #10) residents of seventy-three had access to the call light system as evidence by call light pull strings were not within their reach. Findings included: On 11/7/24 at 9:30 a.m. Resident #5 was observed lying in bed wearing a hospital gown. The resident's head of bed was raised greater than 45 degrees. The observation revealed the resident's call light pull string was lying on the bedside dresser, which was pushed up against the wall behind and next to the resident's bed, the end of the cord was observed under boxes sitting on top of dresser. Photographic evidence was obtained. On 11/7/24 at 9:30 a.m. Resident #6 was observed lying in bed, curled up and facing the door. The resident's call light pull string was at the resident's head of bed and dropped through the mattress holder onto the floor. The resident would have had to reach behind and above him to reach the cord/string. An interview and observation was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/7/24 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 · D2024-11-07 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a 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 interview and record review, the facility failed to provide therapy services in a timely manner for one (#2) of three sampled residents. Findings included: 1. Review of the admission Record for Resident #2 showed she was admitted to the facility on 107/2024 with diagnoses included but not limited to acute respiratory failure with hypoxia, Urinary Tract Infection, Chronic Obstructive Pulmonary Disease (COPD), myocardial infarction, and muscle weakness. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Section GG Functional Abilities showed she needed moderate assistance for toileting hygiene and maximal assistance for toilet transfer. Section O, Special Treatments, Procedures and Programs showed Occupational Therapy (OT) started on 10/14/2024 and Physical Therapy (PT) started on 10/12/2024. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 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 · D2024-11-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review. and interview. the facility failed to maintain the medical record of one (#3) of three residents sampled in an appropriate manner related to complete and accuracy of the records. Findings included: Review of the admission Record for Resident #3 showed the resident was admitted on [DATE] following a hospital stay. The admission Record revealed diagnoses not limited to presence of left artificial knee joint, unilateral primary osteoarthritis of left knee, difficulty in walking not elsewhere classified, unspecified anxiety disorder, and recurrent unspecified major depressive disorder. The record revealed the resident's primary language was English. Review of the Nursing Admission/ readmission Screening/ History, effective 11/1/2024 at 12:04 p.m. for Resident #3 revealed the other language spoken by resident #4 was Spanish. The screening did not reveal the resident spoke English. Review of the Continence Evaluation for Resident #3 showed the resident was oriented x 3 (person,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-28 · 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 provide a safe, clean, and homelike environment for four (250, 310, 330, and 350) of eight rooms observed during four (03/25/2024, 03/26/2024, 03/27/2024, and 03/28/2024) of four days. Findings included: On 3/25/24 at 09:35 a.m., during the initial tour, an observation was made of room [ROOM NUMBER]. Loose wires were noted between two residents' beds (photographic evidence obtained). Continuing with the initial tour at 10:00 a.m. on the 300 hallway, room [ROOM NUMBER] had privacy curtains with brown and red spots and black streaks at the bottom of one set of curtains, and a dirty floor (photographic evidence obtained). In room [ROOM NUMBER] loose wires we observed between residents' beds, a dirty and dusty AC (air conditioning) Vent, cluttered furniture without access to light cord for resident and/or staff to reach, and the hot water knob for the sink would not turn off (photographic evidence obtained). The main shower room for the 300…
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 11 citations
- Potential for harm · Dcited before2024-03-28 · 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
Based on observations, interviews, and record review the facility failed to ensure reasonable accommodations were met for one (#19) of thirty-nine residents on four (03/25/2024, 03/26/2024, 03/27/2024 and 03/28/2024) of four days. Findings included: On 3/25/24 at 11:32 a.m. an observation was made of Resident #19 in her room. The resident was lying in her bed with the lights off, requesting to have her overhead light turned on. Resident #19's voice was extremely soft and reading her lips was difficult. The resident cord to pull her overhead light switch on was hanging behind her bed from the light on the wall out of her reach. The pathway to get to the wall behind her bed to reach this cable was blocked with furniture. Resident #19 said no one can get to it. Resident #19 stated she could not use the call light provided to her because her hands can not squeeze tight enough around the yellow cord to call for assistance. Resident #19 was in a room with three other residents on Droplet precautions. An interview was conducted on 3/25/23 at 11:45 a.m., with Staff D, Licensed Practical…
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 · D2024-03-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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, record review and interviews, the facility failed to ensure a code status was provided upon admission for one resident ( # 228 ) out of 10 residents sampled. Finding Include: Review of the electronic and paper medical record revealed Resident #228 did not have an advanced directive related to the resident code status for six days after being admitted to the facility. Review of Resident # 228 admission Record dated 03/27/2024 showed the resident was admitted on [DATE] with diagnoses to included but not limited to Acute Kidney Failure, unspecified, hyperosmolality and hypernatremia, major depressive disorder, recurrent, moderate. During an interview on 03/27/2024 at 10:00 AM., with Resident # 228's responsible party. He said that he received a phone call yesterday from someone at the facility to ask him if he wanted his mother to be a full code or a do not resuscitate (DNR). He said he told the person at the facility that he wants his mother to be an DNR because she is [AGE] years old, 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 · D2024-03-28 · 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 interview and record review, the facility failed to ensure the accuracy of the Level I Pre-admission Screening and Resident Review (PASSAR) for four (#56, #7, #10 and #32) of eleven residents reviewed. Findings Included: 1. Electronic Medical Record (EMR) review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses that included but not limited to Bipolar Disorder, Alzheimer's, Other Schizophrenia, Major Depressive Disorder, Unspecified Mood Disorder, Anxiety Disorder according to the Face Sheet. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: -Section C: Brief Interview for Mental Status (BIMS) score 99, indicating resident unable to complete interview. -Section I: Active Diagnosis - Alzheimer's. Anxiety, Depression, Bipolar, Schizophrenia checked. -Section N: Medications administered - Antidepressant and Antianxiety. Review of the Medication Administration Record (MAR) for March 2024 showed: -Lorazepam Tablet 0.5 milligrams (mg) - Give 1 tablet via G-Tube…
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 before2024-03-28 · 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, record reviews, and interviews, the facility failed to ensure one resident (# 24) was provided with Activity of Daily Living, (ADL's) assistance out of 10 residents sampled. Findings Included: During an observation on 3/25/2024 at 3: 30 PM., Resident # 24 was observed laying down in his bed with his hair disheveled and facial hair. Resident # 24 said he would like to be shaved but staff won't assist him. During an observation on 03/26/2024 at 10:00 AM., Resident # 24 was observed laying down in bed and appeared with no signs of distress. Review of Resident #24's admission Record dated 03/27/2024 showed he was initially admitted on [DATE] with diagnoses to included but not limited to hereditary and idiopathic neuropathy, unspecified, unspecified osteoarthritis, unspecified site, chronic kidney disease, stage 3 unspecified. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 13, which indicated cognitively intact. Review 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 · D2024-03-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility failed to ensure oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen, was provided for one resident (#66) out of thirty-nine residents sampled. Findings include: On 3/25/24 at 1:15 p.m. an observation was made of Resident #66 in his room with his nasal cannula hanging from his side rail next to a urinal, which had thick brown liquid inside. The nasal cannula was unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/26/24 at 10:45 a.m. an observation was made of Resident #66 in his room with his nasal cannula at the bottom of a garbage can unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. On 3/27/24 at 11:50 a.m. an observation was made of Resident #66 in his room with his nasal cannula on the ground unlabeled and connected to a powered-on concentrator [photographic evidence obtained]. Resident #66 stated he uses oxygen on and off. On 3/28/24 at 10:30 a.m. an observation was made of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0700 — isolatedTry 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 observations, record review and interviews, the facility failed to ensure Side Rail evaluation were conducted prior to installation for two residents (# 10, 24) out of 10 residents sampled Findings Included: 1 During an observation on 03/25/2024 at 03:26 PM Resident # 10 was observed laying down in bed fully dressed, well groomed, with no signs of distress. Resident # 10 was observed with two different types of ¼ side rails on his bed. During an observation on 03/27/2024 at 10: 00 AM., Resident #10 was observed laying down in bed with 1/4 side rails up on both sides of his bed. Resident # 10 said he did not know why he had side rails on his bed. Residents were observed with no signs of distress. Review of a admission Record showed Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Parkinson's disease without dyskinesia, without mention of fluctuation, need for assistance with personal 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.
- Potential for harm · Dcited before2024-03-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and 3 errors were identified for two residents (#9 and #32) of five residents observed. These errors constituted a 9.38% medication error rate. Findings Include: On 3/26/24 at 8:50 a.m. an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted for Resident #9. Staff C, LPN dispensed the following medications: -Clonazepam 0.5 milligrams (mg) one tablet -Plavix 75 mg one tablet -Haldol 5 mg one tablet -Paroxetine 40 mg one tablet -D3 50 mg/2,000 International units (IU) one tablet Staff C, LPN was observed continuing medication administration for Resident # 32 with the following medications: -Aspirin 81 mg chewable one tablet -Losartan 50 mg two tablets -Metoprolol 50 mg one tablet -Doxazosin 4 mg one tablet -Spironolactone 25 mg one tablet -B12 100 micrograms (mcg) one tablet -Incruse 62.5 mcg inhaler 1 puff A review of the physician orders 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 · D2021-12-22 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility did not ensure hearing aides were provided for one (Resident #55) of one resident sampled for assistive devices. Findings included: On 12/20/21 at 09:39 AM, Resident #55 was observed to be hard of hearing during an attempted interview. Resident #55 stated she was unable to hear the questions. Resident #55 stated she did not have hearing aids in place. A review of the facility's Grievance/Concerns Summary Log for October 2021 revealed a grievance reported on 10/27/21 by Resident #55's responsible party related to missing hearing aids. Findings were documented as reported to the responsible party on 10/28/21. A review of the resident's admission Record revealed the resident was admitted on [DATE]. Resident #55 had medical diagnoses of need for assistance with personal care, cognitive communication deficit, and dementia. The resident's family member was listed as the responsible party. A review of the resident's Minimum Data Set [MDS] dated 11/19/21…
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 · D2021-12-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure care and services were provided for a dialysis resident, related to ensuring medications were administered prior to dialysis appointments and ensuring post dialysis orders were followed for one (Resident #58) out of six dialysis residents sampled. Findings included: A review of the admission Record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including: encounter for orthopedic aftercare following surgical amputation, end stage renal disease (ESRD), dependence on renal dialysis, Type 1 Diabetes Mellitus with other specified complications, essential primary hypertension, Type 2 Diabetes Mellitus with unspecified diabetic retinopathy without macular edema, Type 1 Diabetes Mellitus with foot ulcer, and acquired absence of other left toe(s). Review of an admission Minimum Data Set (MDS) dated [DATE] for Resident #58 Section C-Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) of 14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-22 · 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 observations, interviews, and medical record review the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and six errors were identified for three (Resident #24, Resident #54, and Resident #31) out of five residents observed. These errors constituted a 24% medication error rate. Findings Included: On 12/21/21 at 9:25 a.m. an observation of medication administration was conducted alongside Staff Member D, Registered Nurse (RND) for Resident #24. He prepared Acetaminophen 325 milligrams (mg) two tablets, Amlodipine 50 mg one tablet, Lotensin HCL 20-25 mg one tablet, Clopidogrel 75 mg one, Potassium 20 milliequivalents ([NAME]) ER on e tablet, Multivitamin with mineral one tablet, Senokot one tablet, and Zinc 50 mg one tablet. He confirmed a total of nine medications as he placed all the medications into a plastic sleeve. He crushed the medications he stated, she likes her pills crushed and given in applesauce.…
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 · E2020-10-02 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and medical record review, the facility failed to honor the choice and desire for showers for four (Residents # 22, 36, 7, and 41) of five residents sampled for activities of daily living (ADLs) out of a total sample of 29 residents. Findings included: 1. Record review revealed Resident #22 was re-admitted to the facility on [DATE] with diagnoses that included COVID -19, pneumonia, generalized muscle weakness and epilepsy. The Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 13 (indicating cognitively intact). Review of Section E: Behavior: revealed that Resident #22 did not exhibit physical or verbal behavioral symptoms or rejection of care. Section F: Interview for Daily Preferences: was coded with the numeral 1, which indicated it was very important to the resident to choose between a tub bath, shower, bed bath or sponge bath. Section G: Functional Status: indicated the resident needed one person physical help with part…
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
$43,050 in federal fines across 1 penalty.
- $43,050 — penalty dated 2025-10-21
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 SUMMIT CARE — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.3 | -0.3 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.3 | +0.7 vs chain |
The other 21 homes this chain runs (chain average 3.3★, 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 |
|---|---|---|---|---|
| YBOR CITY SNF OPERATIONS HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2020 |
| DREBIN, EZRIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 02/01/2020 |
| SUMMIT CARE II INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2020 |
| KLEIN, SOLOMON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2020 |
2 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 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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.
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 105891. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-28, 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.