Club Healthcare And Rehabilitation Center At The V
16529 SE 86th Belle Meade Circle, The Villages, FL 32162 · For profit - Limited Liability company · 68 certified beds · (352) 385-8200 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.5% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 10.0% | 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 | 7.9% | 2.5% | 3.3% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 5.7% | 14.4% | 18.9% | better |
| Long-stay residents with pressure ulcers | 13.0% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.3% | 10.5% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 8.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.6% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 16.6% | 9.1% | 12.0% | worse |
* 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.
62.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 379 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.6% 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 255 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 1.07 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 62.8%CMS range 57.3–66.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.8–13.9 | 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 | 59.6% | 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 | 54.1% | 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 | 54.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.7% | 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 | 94.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 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 | 0.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 5.4–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 68 beds and averages 65.3 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.33 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above 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 3.82 hrs/resident/day on weekends vs 4.54 on weekdays — 16% thinner on weekends. RN hours go from 0.77 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed (Residents #11 and #90).Findings include: 1) Review of Resident #90 physician order dated 6/3/2026 read, Flomax Capsule 0.4 MG [milligram] give 1 capsule by mouth one time a day for benign prostatic hyperplasia. Review of Resident #90 Minimum Data Set titled Medicare 5 Day dated 6/4/2026 Section I Active Diagnoses did not document Benign Prostatic Hyperplasia. During an interview on 6/17/2026 at 10:56 AM with MDS Coordinator stated, [Resident #90's name] MDS needs to be corrected to add Benign Prostatic Hyperplasia he was ordered Flomax for that diagnosis. 2) Review of Resident #11 progress note dated 5/30/2026 read, cervical collar to be worn at all times every shift when this writer arrived on shift and completed rounds, I observed resident without his collar on, I woke resident up and asked if i [sic] could put his collar back on resident stated no and went back to sleep. Review of Resident #11 MDS titled Modification 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 · D2026-06-18 · 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 a Preadmission Screening and Resident Review (PASRR) was completed when a mental illness was identified for 1 of 3 residents, Resident #20, review for PASRR screening.Findings include:During an interview on 06/17/2026 at 1:42 PM the Social Services Director (SSD) with the Social Services Assistant (SSA) the SSD said she had started working for the facility three weeks ago. We need to assist with ensuring PASRRs (Preadmission Screening and Resident Review) are up to date moving forward during the psychiatry meeting we have once a week to discuss GDR's [gradual dose reductions]. During an interview on 06/18/2026 at 9:42 AM the Director of Nursing stated, It is a joint effort between the social services and clinical team to ensure they [PASRRs] are updated. We have a PASRR performance improvement plan that was started on 3/13/2026. It was for the newly admitted residents' PASRRs to be reviewed, it did not include updating the PASRRs to reflect the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 5 residents, Resident #59, reviewed for ADL (Activities of Daily Living) care. Findings include:During an observation on 06/15/2026 at 09:35 AM Resident #59 was reclining in bed with her hands resting on her lap. The resident's nails on both hands were jagged and had dark matter under the length of the nails. The nails were approximately 5 to 8 millimeters in length and all the nails on both hands had jagged edges.During an observation on 06/16/2026 at 10:25 AM Resident #59 was sitting in a wheelchair in the resident's room conversing with her spouse. The resident's nails on both hands had been filed and no longer continued to have jagged edges. The nails on both hands continued to have a dark matter substance under the length of the resident's nails.During an interview on 06/16/2026 at 10:30 AM Resident #59 stated, They do not give me wipes or a washcloth to wipe my hands before I eat or after I go to the bathroom.During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure blood pressure medication administration per the physician's ordered parameters for 1 of 6 residents, Resident #46, reviewed for medication management. Findings include:Review of Resident #46 physician order dated 3/9/2026 read, Clonidine HCl [Hydrochloride] Oral Tablet 0.1 MG [milligram] (Clonidine HCl) Give 1 tablet by mouth every 6 hours as needed for BP [blood pressure] systolic greater than 150 or diastolic over 90.Review of Resident #46 Weight and Vital Summary for the month of June 2026 documented on 6/13/2026 at 07:44 [7:44 AM] blood pressure was 174/93.Review of Resident #46's Medication Administration Record for the month of June 2026 did not document Clonidine 0.1 mg was administered.Review of Resident #46 Weight and Vital Summary for the month of May 2026 documented on 5/1/2026 at 09:02 [9:02 AM] blood pressure was 161/105, on 5/2/2026 at 07:38 [7:38 AM] blood pressure was 174/85, on 5/3/2026 at 07:21 [7:21 AM] blood pressure was 162/92, on 5/3/2026 at 17:26 [5:26 PM] blood pressure was 156/92, on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-18 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide laboratory and diagnostic testing as ordered for 2 of 6 residents reviewed for laboratory services (Resident #11 and #74).Finding including:1) Review of Resident #11's physician order dated 6/8/2026 read, UA [urine analysis] & culture take sample on 06/11/2026.Review of Resident #11's laboratory documentation did not document a urinalysis and culture and sensitivity dated 6/11/2026.During an interview on 6/17/2026 at 9:33 AM Staff C, Licensed Practical Nurse stated, I spoke to the provider yesterday [6/16/2026]. I saw the order and asked the patient [Resident #11] he had no signs and symptoms and I called the provider. I didn't see any results in the system. Generally, we collect the sample the same day. During an interview on 6/17/2026 at 9:48 AM the Advance Practice Registered Nurse #3 stated, I spoke to [Staff C's name] yesterday and I said the patient was stable and the UA could be discontinued. I would say there is no set time for collection some patients will not void on demand. I would logically have to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to prevent the possible spread of infection by not donning personal protective equipment when providing direct care for 1 of 3 residents, Resident #37, reviewed for enhanced barrier precautions and failing to performed hand hygiene during mealtime for Residents #55 and #42. Finding including: 1) During an observation on 6/16/2026 at 8:15 AM on the outside of Resident #37's room door there was an Enhanced Barrier Precaution sign. Staff E, Certified Nursing Assistant (CNA) entered with Resident #37's breakfast tray and placed it on the bedside table. Without wearing gloves or a gown Staff E began to reposition Resident #37 in bed. Staff E reposition Resident #37's pillow and proceeded to readjust the resident's head on the pillow. 2) During an observation on 6/16/2026 at 12:31 PM Staff E, CNA entered Resident #55's room and removed the lunch tray from the room. Staff E return to the tray cart and placed Resident #55's tray inside the cart. Without performing hand hygiene Staff E walked over to Resident #42's room.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to submit accurate direct care staffing information to CMS for the fourth quarter of 2024. Findings include: Review of the Payroll Based Journal (PBJ) for the fourth quarter of 2024 (July 1 - September 30) showed low weekend registered nurse (RN) staffing for Saturday and Sunday on September 7-8, 2024. During an interview on 1/28/2025 at 2:00 PM, the Administrator stated, The PBJ staffing trigger of low weekend staffing for nurses was because an RN who was covering for the RN Supervisor on the weekend of September 7th and 8th, while the weekend supervisor was on vacation was coded for another sister facility and not here at this facility. Upon request, the Administrator did not provide a policy and procedure on PBJ submission. During an interview on 1/29/2025 at 8:16 AM, Staff D, RN, stated, I worked at the Club back in September, the first weekend to cover for the weekend supervisor. My hours worked were coded for the facility I normally work in and not for the Club.
- Potential for harm · Ecited before2025-01-30 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
Review of Resident #1's physician order dated 12/25/2024 showed it read, House Nutritional Supplement two times a day for Nutritional Supplement, risk of malnutrition, Offer 240 ml and document amount consumed. Review of Resident #1's physician order dated 12/25/2024 showed it read, House Protein two times a day for risk of malnutrition, Offer 30 ml and document amount consumed. Review of Resident #1's medication administration record for January 2025 showed no entries documented for the amount of House Protein consumed or the amount of House Nutritional Supplement consumed from 1/1/2025 through 1/27/2025. Review of Resident #38's physician order dated 1/1/2025 showed it read, House Nutritional Supplement two times a day for Nutritional supplement, risk of malnutrition, Offer 240 ml and document amount consumed. Review of Resident #38's physician order dated 1/2/2025 showed it read, House Protein two times a day for risk of malnutrition, offer 30 ml and document amount consumed. Review of Resident #38's medication administration record for January 2025 showed no entries documented…
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 · D2025-01-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident's physician was notified of a change in condition for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of Resident #38's dietary profile dated 1/2/2025 showed it read, New admit. Nutrition Evaluation and recommendations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 5 residents reviewed for nutrition, Resident #17. Findings include: Review of Resident #17's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified protein-calorie malnutrition, anemia, gastro-esophageal reflux disease without esophagitis, and acute kidney failure. Review of Resident #17's quarterly Minimum Data Set, dated [DATE] showed it read, Section K- Swallowing/Nutritional Status . K0310. Weight Gain: Gain of 5% or more in the last month or gain of 10% or more in last 6 months . 2. Yes, not on physician-prescribed weight-gain regiment. Section K did not indicate the resident was on therapeutic diet. Review of Resident #17's progress note dated 12/27/2024 showed it read, Weight Note. 12/18: 118.8# [pounds], 7/30/2024: 134.6#. Weight loss of 11.7% in 6 months. Review of Resident #17's physician order dated 12/2/2024 showed…
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 14 citations
- Potential for harm · D2025-01-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to reassess the effectiveness of the interventions, review and revise the resident's care plan when necessary for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of the Intradisciplinary Plan of Care review meeting summary 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 · Dcited before2025-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received adequate nutrition for 1 of 3 residents reviewed for significant weight loss, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, unspecified dementia, acute kidney failure and adult failure to thrive. Review of Resident #38's Weights and Vitals Summary showed the resident weighed 76.4 lbs. (pounds) on 12/30/2024, and 71.2 lbs. on 1/4/2025, which indicates -6.44% loss. The resident's weight on 1/11/2025 was 66.9 lbs., which indicates -12.09% loss compared to the weight on 12/30/2024, and the resident's weight on 1/25/2025 was 62.2 lbs., which indicates -18.59% loss compared to the weight on 12/30/2024. Review of Resident #38's physician order dated 12/30/2024 showed it read, Regular diet, Mechanical soft texture, nectar thick consistency. Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · 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 observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 31 observations of medication administration. The facility had a medication error rate of 6.45%. Findings include: 1) During an observation on 1/28/2025 at 8:25 AM, Staff E, Licensed Practical Nurse (LPN), began pouring Resident #159's medications into individual cups. Staff E removed Guaifenesin ER (Extended Release) tablet from her medication cart and placed the medication in a medication cup. Staff E finished placing all medications into individual cups and then proceeded to crush each medication. Staff E donned personal protective equipment and entered Resident #159's room. Staff E was about to begin to administer the medication via Resident #159's gastric tube. The surveyor asked Staff E to stop the medication administration process and notified Staff E that she had crushed an extended-release medication to administer enterally. During an interview on 1/28/2025 at 8:30 AM, Staff E, LPN, stated, I know she has an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · 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 observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: During an observation on 1/26/2025 at 10:06 AM, Resident #160 was lying in bed. There was one bottle of Tylenol tablets on top of the resident's drawer. During an interview on 1/26/2025 at 10:06 AM, Resident #160 stated, I had a headache and my daughter brought the Tylenol for me. I took the medication, and it has been there ever since. During an observation on 1/26/2025 at 10:18 AM, Resident #1 was lying in bed. There was one tube of 1% Silver Sulfadiazine Cream on top of the bedside table next to the resident's bed. During an interview on 1/26/2025 at 10:18 AM, Resident #1 stated, The nurses will apply the cream to my wound when I ask them too. During an observation on 1/26/2025 at 10:41 AM, Resident #32 was lying in bed. There was one tube of Goodsense extra strength itch relief cream on top of the resident's bedside table.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing direct contact care for 2 of 10 residents reviewed for enhanced-barrier precautions (EBP), Residents #1 and #161, and 1 of 4 residents reviewed for transmission-based precautions, Resident #158, to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 1/26/2025 at 12:23 PM, Staff C, Activities Assistant, donned gloves and grabbed a pillow from Resident #1's chair in the residents' room. Staff C assisted Resident #1 to turn to his right side. Staff C placed the pillow on the resident's back, tucking the pillow in the left side of the resident's back to assist with repositioning and offloading the resident. Resident #1's room door had an enhanced barrier precaution sign and a plastic bin outside of Resident #1's room with personal protective equipment. Review of Resident #1's physician order dated 1/24/2025 showed it read, Requires enhanced barrier precautions R/T [related…
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 · D2024-04-23 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food items were stored in a safe and sanitary manner in bistro of the facility. Findings include: During an observation on 4/23/2024 at 9:13 AM, while conducting a tour of the facility's bistro with the Certified Dietary Manager, there were four undated and unlabeled individual containers of pureed fruit stored in the cabinet, one of which was opened; one uncovered sherbet cup of granulated sugar stored on top of the counter; one container of whipped topping with an open date of 3/3/2024 stored in the cabinet; spillage on the bottom edge of Cooler #1; one undated and unlabeled cut lemon wrapped in plastic wrap stored in Cooler #2; two top cabinet drawers containing speckled black and brown debris; one gallon of dill pickles stored in the sink, with the top of the pickle jar with inscribed warning to refrigerate after opening; no thermometer in the ice cream storage bin; and black and brown speckled debris in the ice cream scoop bin. During an interview on 4/23/2024 at 9:13 AM, the Certified Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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 initial weights were obtained for 4 of 6 residents, Residents #93, #28, #196, and #198, upon admission to the facility. Findings include: 1) Review of Resident #93's record documented Resident #93 was admitted to the facility on [DATE]. Review of Resident #93's care plan, read Resident #93 was at risk for alteration in nutrition and/or hydration related to variable intake, depressive mood, anemia, hypoparathyroidism and macular degeneration. Review of Resident #93's dietary profile, dated 10/15/23, read List Other Dietary Interventions: None (Hospital wt [weight] used for assessment d/t [due to] no facility wt [weight] at time assessment completed). During an interview on 10/18/23 at 10:12 AM, the Director of Nursing stated We weigh residents upon admission. If they refuse, we try again, and go back within hours. Someone should have asked again. She [staff that weighs the residents] comes in on Mondays and does my weights. She [Resident #93]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-19 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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
Based on observation, interview, and record review the facility failed to ensure residents' medical records were complete and accurately documented for 2 of 7 residents, Residents #4, and #198 reviewed for care treatments. Findings include: 1) During an interview on 10/18/2023 at 8:50 AM, Resident #4 stated, The nurse came yesterday and did wound care for me, they changed my dressings. During an observation on 10/18/2023 at 9:33 AM of Resident #4 it showed the wound dressing to his coccyx and left lower buttock was dated 10/17/2023. Review of Resident #4's Treatment Administration Record (TAR) for the month of October 2023, read, Wound Care Right Lower Abdomen Surgical Site. Cleanse with soap and water pat dry. Then apply skin prep, hydrogel, and cover with bordered foam, every day shift for wound care start date 9/26/2023 d/c [discontinue] 10/3/2023. The TAR had a blank entry, no staff initials to document the care was provided on 10/02/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care coccyx clean with n/s [normal saline], apply medi honey, calcium…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide a bed hold notice to the resident or the resident's representative when the resident was transferred to the hospital for 1 of 4 residents, Resident #195, reviewed for discharge. Findings include: Review of Resident #195's medical record revealed Resident #195's was most recently admitted on [DATE] with diagnoses including, but not limited to, acute respiratory failure with hypoxia, sarcoidosis of lung, type 2 diabetes, acute on chronic systolic heart failure, lobar pneumonia, cardiomegaly, major depressive disorder, chronic obstructive pulmonary disease, acute kidney failure, essential hypertension, morbid obesity due to excess calories, dysphagia, altered mental status, and anemia. Review of Resident #195's Nursing Home to Hospital Transfer Form read, Sent to: [name of local hospital]. Date of Transfer 6/19/2023. Reason for Transfer. Shortness of Breath (bronchitis, pneumonia). Review of Resident #195's medical record did not reveal a bed hold…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure care plan fall precautions were fully implemented for 1 of 4 residents, Resident #18, reviewed for accidents. Findings include: Review of Resident #18's census record documented Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's care plan, initiated 7/19/2023, read Resident #18 was at risk for falls and/or fall related injury related to impaired balance and a history of falls. Resident #18's care plan documented fall prevention interventions that included Keep bed in lowest position acceptable to resident. Review of Resident #18's progress notes revealed Resident #18 had fallen on 6/17/2023 with resulting complaints of back pain, had fallen on 6/20/2023 with no resulting discomfort, had fallen on 6/23/23 with resulting pain in his right hip/groin area, had fallen on 8/27/2023 with no resulting discomfort, had fallen on 8/28/2023 with no injury documented and had fallen on 9/30/2023 with no resulting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · 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 observation, record review, and interview the facility failed to ensure residents received treatment care and services in accordance with professional standards for 1 of 1 resident, Resident #198, with a central venous line catheter, and 1 of 6 residents, Resident #29 reviewed for pressure ulcers. Findings include: 1. During an observation on 10/16/2023 at approximately 10:00 AM, Resident #198 was lying in bed. A signal lumen PICC (peripherally inserted central catheter) line with a transparent dressing dated 10/8/2023 was observed to the resident's right upper arm. There was dried blood observed at the insertion site. During an interview on 10/16/2023 at approximately 10:00 AM, Resident #198 stated, I came from the hospital with this IV [intravenous catheter], it has not been changed here at the facility. Review of the medical record for Resident #198 revealed Resident #198 was most recently admitted into the facility on [DATE] with diagnoses including metabolic encephalopathy, enterocolitis due to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents' environment was free of accident hazards for 1 of 4 residents, Resident #18, reviewed for accidents. Findings include: Review of Resident #18's medical record documented Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's care plan, initiated 7/19/2023, read Resident #18 was at risk for falls and/or fall related injury related to impaired balance and a history of falls. Resident #18's care plan documented fall prevention interventions that included Keep bed in lowest position acceptable to resident. Review of Resident #18's progress notes revealed Resident #18 had fallen on 6/17/2023 with resulting complaints of back pain, had fallen on 6/20/2023 with no resulting discomfort, had fallen on 6/23/23 with resulting pain in his right hip/groin area, had fallen on 8/27/2023 with no resulting discomfort, had fallen on 8/28/2023 with no injury documented and had fallen on 9/30/2023 with no resulting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts, and failed to ensure medications were secure when unattended in 1 of 2 units, the POLO unit. Findings include: During an observation on [DATE] at 9:10 AM, of Medication Cart 1 with Staff A, License Practical Nurse (LPN), there was one expired bottle of Calcium Carbonate with an expiration date of 8/23 and one open Trelegy Ellipta inhaler with no open or expiration date. During an interview on [DATE] at 9:28 AM, Staff A, LPN, stated Expired medication should be thrown out. Normally the inhaler is stored in aluminum tin foil and that is where I write the open date. I am not sure where the aluminum tin foil is. During an observation on [DATE] at 9:30 AM of Medication Cart 2 with Staff B, LPN there was one expired Humalog Kwik pen labeled with an open date of [DATE], one open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when not performing hand hygiene and following infection control standards during wound care, and failed to ensure transmission-based precautions were followed. Findings include: 1) During an observation on 10/17/2023 at 8:36 AM Staff C, License Practical Nurse (LPN) entered Resident #143's room without donning personal protective equipment [PPE]. Resident #143's room had a sign outside of the room on the door that read Contact Isolation. During an interview on 10/17/2023 at 8:40 AM, Staff C, LPN, stated, I did not see the sign on the door. I entered the room and gave Resident #143 her medication. I should have used proper PPE to enter the room. Review of Resident #143's physician order, dated 10/8/2023, showed the order read, Contact isolation ESBL [Extended Spectrum Beta-Lactamase] urine. Review of Resident #143's care plan, initiated 10/8/2023, read, Resident requires isolation precautions because of an infectious disease. Interventions: On strict isolation, all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to GOLD FL TRUST II — 36 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 | 3.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 35 homes this chain runs (chain average 3.4★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THE CLUB SNF HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/23/2022 |
| FL MASTER OPCO HOLDCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/27/2022 |
| PALMER, DEVON | Individual | W-2 MANAGING EMPLOYEE | — | since 07/27/2022 |
| SHELBY, JACK | Individual | CORPORATE OFFICER | — | since 07/27/2022 |
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.
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 2024. 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, FY2024). 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 106095. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-18, 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 →
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