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Titusville Rehabilitation & Nursing Center

1705 Jess Parrish Ct, Titusville, FL 32796 · For profit - Limited Liability company · 157 certified beds · (321) 269-5720 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 2024Resident-funds citation (F0565)1 immediate-jeopardy citation$17,369 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,369 in federal fines (most recent 2024-06-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (63%) runs well above the national median (45%)

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

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

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

Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
875 Century Medical Dr · (321) 269-0748 · Call to confirm hours
Pharmacy
695 N Washington Ave 101 · (321) 747-0600 · Call to confirm hours
Grocery
1450 N Washington Ave
Park
Typically dawn to dusk
Place of worship

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 5 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.0%8.7%15.4%better
Long-stay residents who lose too much weight4.9%5.5%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.3%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.0%2.5%3.3%worse
Long-stay residents whose ability to walk worsened11.6%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.0%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers6.1%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control11.4%10.5%21.2%typical for the state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table5.6%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication4.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine99.0%94.7%79.4%better
Short-stay residents rehospitalized after admission30.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit2.1%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.362.131.67better
Long-stay outpatient ER visits per 1,000 resident days2.001.151.80worse

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.

58.8% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.8%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
69.4%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 69.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 36 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.8%CMS range 48.7–70.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 7.8–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge61.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge41.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge90.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.4%CMS range 4.0–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.66
RN hours/ resident / day
0.43
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.02
Total nurse hours/ resident / day
0.46
RN hoursweekends
63.4%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 157 beds and averages 93.5 residents a day — about 60% occupied, or roughly 64 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 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 2.78 hrs/resident/day on weekends vs 3.11 on weekdays — 11% thinner on weekends. RN hours go from 0.74 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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

9
deficiencies at the latest standard inspection (2026-03-05)
11
at the previous standard inspection (2024-06-07)

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.

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2024-06-07 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 follow policy and procedure related to Full Code status leading to a delay in initiating Cardiopulmonary Resuscitation (CPR) for 1 of 5 residents reviewed for Advance Directives of a total sample of 68 residents, (#100). Resident #100 a-[AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included anemia, type II diabetes, occlusion and stenosis of the carotid artery. The resident was admitted to Hospice services on [DATE] with diagnosis of moderate protein-calorie malnutrition. The resident's physician's order dated [DATE] noted full resuscitation. Progress note dated [DATE] at 6:30 AM, documented by Licensed Practical Nurse (LPN) A read, Patient has expired Hospice notified MD (Medical Doctor) notified. Resident #100 died at the hospital on [DATE]. The facility's failure to provide CPR in a timely manner as per resident #100's wishes and physician's order placed all residents in the facility at risk, and could lead to potential…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient nursing staff was available on 1 of 3 units to meet residents' needs related to the timely administration of scheduled medications, (Unit 2).Findings: Cross Reference F755 1. During a medication pass observation with Licensed Practical Nurse (LPN) A on 6/03/26 at 10:05 AM, eight residents listed on the electronic Medication Administration Record (MAR) appeared in red, indicating their scheduled morning medications had not yet been administered. When asked why the residents' names appeared in red, LPN A stated the morning medications were past due. She explained nurses were expected to administer 9:00 AM medications between 8:00 AM and 10:00 AM. LPN A prepared and administered medications for resident #4 at 10:33 AM. Upon completion of the medication administration at approximately 10:40 AM, LPN A stated medication administration required significant time to complete because residents could not be rushed, often required…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 pharmaceutical services in accordance with professional standards of practice by: failing to appropriately dispose of medications during medication administration for 1 of 2 residents reviewed during medication pass observations (#4); failing to accurately account for and document controlled substance administration and maintain security of medications for 1 of 4 residents reviewed for narcotic administration, (#11); and failing to administer medications according to physician orders and the facility's established medication administration schedule for 10 residents on 1 of 3 units reviewed, out of 19 sampled residents, (#1, #3, #5, #13, #14, #15, #16, #17, #18, and #19). Findings: Cross Reference F725, F867 1. During a medication pass observation with Licensed Practical Nurse (LPN) A on 6/03/26 at 10:05 AM, she indicated nurses were expected to administer 9:00 AM medications between 8:00 AM and 10:00 AM. While preparing…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 interview, and record review, the facility failed to maintain a complete and accurate medical record for one of one residents sampled for wound treatments, of a total sample of 19 residents, (#3).Findings:Medical record review revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included colostomy, pressure ulcers to his left heel, right and left buttock and left hip.A colostomy is a surgical opening in the abdomen to allow stool to exit the body when it cannot pass through the rectum. It connect the large intestine to the outside of the body and stool is collected in a pouch worn on the outside, (retrieved on 6/17/26 from www.hopkinsmedicine.org).Review of current physician orders revealed resident #3 had physician orders for colostomy care every shift starting 6/18/25; wound care orders every day and night shift for right great thumb on 2/16/26, wound care every night shift for a left plantar callus dated 4/20/26, wound care every night shift for sacrum and right and left…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-04 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee implemented, monitored, evaluated, and revised a Performance Improvement Plan (PIP) to address identified concerns related to narcotic accountability and diversion prevention. The facility failed to ensure corrective actions were sustained after identifying repeated narcotic management concerns, resulting in continued deficiencies related to narcotic accountability, documentation, and medication management practices.Findings: Cross Reference F755 Review of a report submitted to the Agency for Health Care Administration (AHCA) on 4/14/26 for alleged misappropriation of property revealed the facility identified 28 missing Oxycodone tablets pertaining to resident #1. Following completion of the investigation, the facility determined there was a discrepancy between the number of narcotic cards received by a nurse and the number documented on the narcotic accountability records, resulting in the potential for a one-card discrepancy. In a joint interview…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-05 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the policy and procedure, QAPI Facility Plan dated 10/19/25, revealed the QAPI committee monitored progress to ensure that interventions or actions were implemented and were effective in making and sustaining improvements.The facility had a deficiency cited at F842 for complete and accurate medical records during the previous recertification survey conducted 6/03/24 through 6/07/24. During this survey, the facility was found to again be in noncompliance with F842. As a result of this repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation.On 3/06/26 at 5:10 PM, the Administrator stated the facility had a QAPI committee that met monthly. He explained that the committee reviewed several areas which included information obtained during rounds 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide 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 observation, interview, and record review, the facility failed to provide care and services to maintain the highest practicable physical well-being by failing to prevent a facility acquired pressure ulcer, implement revisions to the pressure ulcer care plan after a change in wound status, and failing to implement physician orders for existing pressure ulcers for 2 out of 2 residents reviewed for pressure ulcers, of a total sample of 44, (#7, & #107).Findings: 1.Resident #7 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, peg tube (feeding tube in stomach), type two diabetes, and brain damage from low oxygen. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed resident #7 was severely impaired cognitively, he was dependent for all activities of daily living (ADL) and had no pressure injury. The MDS assessment revealed the resident was dependent on the helper for all functional abilities and the resident did none of the effort to complete.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-05 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure frying pans, refrigerated foods, and spices were stored under clean and sanitary conditions, dry food was stored at the appropriate temperature; prepare, distribute and serve food in a manner to prevent food borne illness, by failing to maintain potentially hazardous pureed and regular foods at the correct hot holding temperature for four residents on a puree diet, and 57 residents on regular house diet, of a total population of 93 residents.Findings:On 3/02/26 at 10:25 AM, the initial kitchen tour was conducted with the Certified Dietary Manager (CDM). In the walk-in refrigerator there was visible food debris and residue along the baseboards and corners. The CDM stated there was a weekly deep clean schedule but could not say when the last time a deep clean was done. In the food preparation area, two spice bins had a visibly sticky residue and debris in the bottom of the container. (photo evidence obtained) The CDM acknowledged 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 observation, interview, and record review, the facility failed to honor resident rights in regard to self-determination for 1 of 7 residents reviewed for reviewed for choices, of total sample of 44 residents, (#63). Findings: On 3/02/26 at 10:14 AM, resident #63 said she was unhappy at the facility, didn't feel like she belonged, and had requested a transfer. She expressed she preferred to be outside as much as possible, and this facility only allowed residents to exit the building if they smoked. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed resident #63 had a Brief Interview for Mental Status of 13/15, indicating she was mostly cognitively intact, was dependent on staff for all activities of daily living and was unable to move from the waist down. The assessment indicated she had a history of traumatic brain injury, was able to use the internet, hold a conversation, and recall events. Review of resident #63's medical record indicated she sought assistance on 12/05/25 from…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 out of 2 residents reviewed for care plans, of a total sample of 44 residents, (#99). Findings: Resident #99 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, morbid obesity, and muscle wasting. The hospital transfer form indicated the resident was blind. On 3/02/26 at 1:11 PM, resident #99 remarked she was mostly blind, and needed cataract surgery. She explained the facility had her sign financial paperwork without explaining it to her. The Minimum Data Set (MDS) assessment dated [DATE] revealed resident #99 had severely impaired vision but was cognitively intact and required moderate assistance from staff. Review of resident #99's care plan revealed no interventions related to her blindness or impaired vision. Review of the Electronic Medical Record (EMR) revealed a nurse progress note dated 2/08/26 which indicated resident #99 was legally…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, interview, and record review, the facility failed to revise the comprehensive care plan to include wound management for 1 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 44 residents, (#36).Findings:Review of the medical record revealed resident #36, an [AGE] year-old female was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 9/19/25. The resident's diagnoses included type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma (skin cancer).The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 12/03/25 noted resident #1 scored 13 out of 15 on the Brief Interview for Mental Status that indicated intact cognition. The skin and wound assessment documented there were no surgical wounds or care during the look-back period.On 3/03/26 at 9:05 AM, resident #36 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2026-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care consistent with professional standards of practice, and treatment to promote healing of other skin conditions for 1 of 4 residents reviewed for skin conditions, of a total sample of 44 residents, (#107).Findings:Resident #27 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, flaccid hemiplegia (one-sided paralysis, where muscles are weak), affecting the dominant right side and bladder dysfunction. Review of the Annual Minimum Data Set (MDS) assessment with reference date of 11/22/25 revealed the resident was cognitively intact. The assessment revealed resident #27 was at risk for developing pressure ulcers with treatments that included the application of ointments or medications other than to the feet. Review of physician orders dated 7/30/25 instructed nurses to apply Bacitracin 500 UNIT/GRAM (GM) (Bacitracin (Topical) to buttock excoriation topically every shift 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor supplemental oxygen therapy for 1 of 2 residents reviewed for respiratory care, of a total sample of 44 residents, (#1).Findings:Review of the medical record revealed resident #1, a [AGE] year-old male was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 1/19/26. The resident's active diagnoses included respiratory failure, pneumonia, Chronic Obstructive Pulmonary Disease (COPD), sepsis, presence of gastrostomy (feeding tube), atrial fibrillation (abnormal heart rhythm), and type 2 diabetes mellitus.The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 1/26/26 revealed resident #1 scored 10 out of 15 on the Brief Interview for Mental Status that indicated moderate cognitive impairment. Active diagnoses included pneumonia, Multidrug-Resistant Organism (MDRO), dementia, traumatic brain injury, asthma, respiratory failure with hypoxia (tissue oxygen deficiency),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 44 residents, (#36).Findings:Review of the medical record revealed resident #36, an [AGE] year-old female was admitted to the facility on [DATE] and re-admitted from an acute care hospital on 9/19/25. The resident's diagnoses included type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma (skin cancer).The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 12/03/25 noted resident #1 scored 13 out of 15 on the Brief Interview for Mental Status that indicated intact cognition. The skin and wound assessment documented there were no surgical wounds or care during the look-back period.On 3/03/26 at 9:05 AM, resident #36 was observed in her room eating…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-30 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a homelike environment for residents on 2 of 3 units, (100 unit and 200 unit).Findings: During an initial tour of the facility on 12/29/25 at 9:38 AM, it was observed that the wall paint over the Packaged Terminal Air Conditioner (PTAC) at the entrance to the 100-unit was bubbled and chipped; the sheetrock was broken off and the baseboard was missing on an area of the wall next to the sink in room [ROOM NUMBER]; a hole in the wall outside the door to room [ROOM NUMBER] was covered by the baseboard; the wall was repaired around the PTAC in room [ROOM NUMBER] but was not painted to match the surrounding area; ceramic tile was off the wall behind the toilet and missing from the top of the shower stall in room [ROOM NUMBER]; the paint on the wall next to the window in room [ROOM NUMBER] was bubbled and peeling; the wall area close to the baseboard next to the window in room [ROOM NUMBER] had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the provision of care for blood pressure monitoring for 1 resident, (#2), reviewed for Quality of Care, and failed to ensure staff implemented physician orders to ensure residents received treatment and care in accordance with professional standards of practice, (#5), of a total sample of 7 residents.Findings: 1. Review of the medical record revealed resident #2, an [AGE] year-old male was admitted to the facility from on acute care hospital on 9/16/25 with diagnoses that included Alzheimer's Disease, altered mental status, history of transient ischemic attack (stroke), and essential primary hypertension (high blood pressure). The most recent Comprehensive admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/22/2025 noted resident #2 scored 8/15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The assessment indicated a diagnosis of hypertension, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 out of 7 sampled residents, (#7). Findings:Resident #7 was readmitted to the facility on [DATE] with diagnoses which included quadriplegia, neuromuscular dysfunction of the bladder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE], resident # 7 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A review of the physician's orders revealed that resident # 7 had orders for Midodrine HCl Oral Tablet 10 milligrams (mg), give one tablet by mouth three times a day for low blood pressure. The order directed nurses to hold the medication if the systolic blood pressure (the first number) was greater than 120. On 11/13/25 at 12:10 PM, the Medication Administration Record (MAR) indicated the assigned nurse Registered Nurse (RN) B, administered Midodrine 10 mg at 9:00 AM. The MAR had a check mark with the nurse's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-07 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews from the Resident Group Meeting and record reviews, the facility did not promote an environment for residents to voice grievances about care and treatment without fear of discrimination, and/or reprisal. Findings include: During an interview with the Resident Council President on 06/05/24 at 11:15 AM, they said usually 5-6 people attended the Resident Council meetings. They suggested Thursday, 6/06/24 at 9:30 am would be a good time to meet with the residents. The Resident Council President said there was no place to meet privately with a group of residents except in his room. The regular meetings were held in the atrium on the back of the 200 hall closest to his room, but he explained it wasn't private, with staff standing around listening to what was said. During an interview with the Activity Director on 6/05/24 at 11:35 AM, he stated, There is no private area for the Resident Group meeting to be held, so we will hold it at the back of the 200-hall atrium as that is the only place available. The Resident Council Group Meeting was held on the 200-hall atrium,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-07 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Resident Group interview, and record review, the facility failed to properly and promptly respond to Resident Council concerns and grievances. Findings: During a record review of the June 2023 to June 2024 Resident Council minutes provided by the Activity Director revealed documentation the Council did not believe their previously initiated concerns/grievances were addressed or resolved for the following dates: June 2023, August 2023, December 2023, April 2024, May 2024 and June 2024. The minutes indicated a new Administrator was introduced on 4/16/24 and told the Council that all concerns were being taken care of and the facility was working on them, but the minutes for May and June 2024 indicated the Council continued to feel their concerns were not addressed by the facility. On 6/05/24 at 11:35 AM, the Activity Director stated they worked alone in the Activity Department from Monday through Friday. The Activity Director explained the Activity Department had no volunteers so when they had been out sick in the hospital for a week, there were no activities in the facility…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-07 · tag F0572 — pattern
    Give residents a notice of rights, rules, services and charges.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Resident Group meeting, review of Resident Council Minutes, and interview, the facility staff failed to review and inform residents of their rights in the facility. Findings include: The Resident Group meeting was held on the 200-hall atrium, on 06/06/24 beginning at 9:30 AM, in an open area that was 15 feet away from the nurse's station. At the time of the meeting, there were 5 staff members sitting and standing around the nurse's station that was centrally located in the middle of the atrium. The meeting was held in this large open common area. During the Resident Group meeting, held on 06/06/24 beginning at 9:30 AM, seven residents and family representatives responded they did not know what their resident rights were, were not provided a copy of their rights either at admission or during their stay, and that resident rights were not reviewed during the Resident Council meeting. Even the Resident Council President said resident rights had not been reviewed in the Resident Council meetings. In review of the Resident Council minutes for a year from June 2023 to June 2024,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-07 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide ongoing program of activities designed to meet the interests, and physical, mental, and psychosocial well-being of the residents for 3 out of 3 residents sampled for activities, of a total sample of 68 residents, (#10, #39, and #80). Findings: 1. Resident #10 was observed in bed on 6/03/24 and 6/04/24. On 06/05/24 at 12:53 PM, resident #10 was again observed in bed. The Activity Director was observed to look in the room from the door way and went into the room for less than 3 minutes. On 06/06/24 at 2:08 PM, The Activity Director started the group activity bingo in the 200-hall atrium, where resident #10 lived, but resident #10 was not at the bingo game. During an interview with the Activity Director on 06/06/24 at 3:57 PM, the Activity Director was unable to show any participation by resident #10 in either small group or independent 1:1 programming. The Activity Director confirmed resident #10 spent all his time in bed. When 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-07 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient nursing staff was available to ensure residents received the nursing care and related services required to timely administer medication and failed to provide sufficient nursing staff to meet the residents' individualized care needs on all shifts on 2 of 3 Wings, (100, 200). Findings: Cross Reference F 755 1. Medication administration observations conducted with Registered Nurse (RN) K, and Licensed Practical Nurse (LPN) H on the 100 Wing on 6/03/24, showed scheduled 9 AM medications were prepared to be administered at 11:46 AM, and at 11:54 AM for residents # 20, and #3a, approximately three hours after the scheduled time, and not according to established medication administration principles of within one hour before or one hour after the scheduled time. On 6/03/24 at 12:21 PM, LPN H stated she was on the split assignment, and had residents on the 100, and 200 Wings. She stated medication administration was going very slowly and said it was a lot, but due to the facility's census, they were…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-07 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 scheduled medications were administered within parameters on the 7 AM to 3 PM shift for 31 residents on the 100 Wing, of a total sample of 68 residents, (#3a #20, #77, #354, #3b #16, #33, #26 #68 #84, #5, #59, #56,#88, #34, #50, #95, #47, #19, #58, #651 #52 #55 #37, #38, #91,#89, #35,#23,#64, and, #14). Findings: On 6/03/24 at 11:37 AM, Registered Nurse (RN) K stated she was still doing scheduled 9 AM medication administration and was giving the priority medications first. On 6/03/24 at 11:46 AM, medication administration observation was conducted for resident #20 with RN K. Review of the Medication Admin (Administration) Audit report revealed documentation to indicate resident #20 received his scheduled 9 AM medications on 6/03/24 at 11:52 AM. The resident's administered medications included Coreg 3.125 milligram (mg) twice daily, Norvasc 10 mg daily for high blood pressure, Gabapentin 300 mg twice daily for pain, and Aldactone 25 mg daily for congestive heart failure (CHF). On 6/03/24 at 11:54 AM,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-07 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's QAPI Plan revealed each Performance Improvement Project (PIP) subcommittee would identify areas for improvement. The subcommittee would collect and analyze data to determine the effectiveness of change. The PIP subcommittee would provide the QAA Committee with a summary report, analysis of activities and recommendations. The QAA Committee would monitor progress to ensure interventions or actions were implemented and effective in making and sustaining improvements. The facility had a deficiency cited at F 609, for failing to report during the previous recertification survey conducted 6/13/22 through 6/16/22. During this survey, the facility was found again to be in noncompliance with F 609 for failing to report. As a result of the repeat deficiency, it was identified there 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-07 · tag F0644 — isolated
    Coordinate 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 refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination and failed to request a Level 1 PASARR evaluation for resident with new mental disorder diagnosis for 2 of 6 residents reviewed for PASARR, (#1, & #72), of a total sample of 68 residents. Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, encephalopathy and cognitive communication deficit. Review of the Minimum Data Set (MDS) significant change in status assessment with assessment reference date (ARD) of 4/25/24 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 which indicated he had severe cognitive impairment. The document indicated his active diagnoses included anxiety disorder and depression. Review of resident #1's care plan revealed a psychotropic medication use care plan…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-07 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASARR) evaluation was accurate upon admission for 1 of 1 residents reviewed for PASARR accuracy, of a total of 68 residents, (#93). Findings: Review of the medical record revealed Resident #93 was admitted to the facility from the hospital on 4/23/24 with a discharging diagnosis of schizophrenia. Record review of the Level 1 PASARR completed on 3/29/24 by the hospital social worker inaccurately omitted the diagnosis of schizophrenia. On 06/04/24 at 5:29 PM, the interim Administrator said Social Services was responsible for completing PASARRs. The Social Service Director on 6/06/24 at 2:22 PM, related the Director of Nursing (DON) was responsible for the review and accuracy of the PASARRs. The Interim DON on 6/06/24 at 3:22 PM, said she was surprised resident #93 was admitted on [DATE] with a diagnosis of schizophrenia which would require a level 1 PASARR. She confirmed the Level 1 PASARR was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-07 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 2. Resident #25 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, chronic atrial fibrillation, cardiac arrhythmia, unspecified glaucoma, hypertension and generalized anxiety disorder. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of [DATE] revealed resident #25 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. She did not exhibit any behavioral symptoms and did not reject care that was necessary to achieve her goals for health and well-being. The document revealed resident #25 had a diagnosis of unspecified glaucoma. A care plan for potential for impaired visual function related to history of glaucoma was initiated on [DATE] and revised [DATE]. Interventions included, Administer medication as ordered. Review of resident #25's EMR revealed a physician order dated [DATE] for 1 drop of Combigan Ophthalmic solution 0.2-0.5% (Brimonidine Tartrate-Timolol Maleate) to be instilled in both…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 documentation of education, proof of consent, or medical contraindication for both influenza and pneumococcal vaccines for 4 of 5 residents reviewed for influenza and pneumococcal immunizations, of a total sample of 68 residents, (#5, #10, #44, and #55). Findings: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, obstructive sleep apnea, dementia, type II diabetes, and heart failure. Review of resident #5's immunization report revealed no documentation of education, consent, refusal or medical contraindication for pneumococcal vaccine. 2. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included metabolic encephalopathy, acute and chronic respiratory failure with hypoxia, encounter for attention to gastrostomy, and dementia. Review of resident #10's immunization report revealed he received the influenza vaccine on 10/09/2023, but…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-07 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report potential abuse and/or neglect violations with respect to a delay in cardio-pulmonary resuscitation (CPR) due to inaccurate and incomplete investigation, for 1 of 1 resident reviewed for reporting of alleged abuse and/or neglect, of a total sample of 68 residents, (#100). Findings: Resident #100 admitted to the facility on [DATE] with diagnoses including anemia, diabetes type II and muscle wasting. Review of the Minimum Data Set, dated [DATE], the resident scored a 13 out of 15 on the Brief Interview for Mental Status, indicating his cognition was intact. There was no evidence resident #100 could not make his own health care decisions. Resident #100 was placed on hospice care on [DATE] with a terminal diagnosis of moderate protein calorie malnutrition. A progress note dated [DATE] revealed a care plan meeting was held to discuss the resident's Advanced Directives/code status. The resident chose to be a Full Code which meant he wanted to be…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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, record review and interview, the facility failed to maintain kitchen equipment, cookware and refrigerators, in a clean, sanitary, and functional condition. The kitchen staff also failed to ensure milk was returned to the vendor or discarded after the expiration date. Findings: During the initial kitchen inspection on 6/13/22 at 10:37 AM: 1. The 3-compartment sink was observed with pots and pans sticking out of the sanitizer solution in the third sink compartment. The Certified Dietary Manager (CDM) used a 10-second test strip to determine the sanitizer solution's strength/parts per million (ppm). After submerging the test strip in the sanitizer mixture for 10 seconds, the CDM referred to the test strip and said, it was barley readable, that indicated the sanitizer strength could not be determined. Review of the sanitizer solution manufacturer's instructions noted it was effective against commonly identified sources of food contamination such as Escherichia Coli, Staphylococcus Aureas, Campylobactor Jejuni, Listeria Monocytogenes, Salmonella and Shigella, when…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an alleged violation of abuse for 1 of 1 resident reviewed for abuse of a total sample of 45 residents (#50). Findings: Resident #50's medical records revealed she was admitted to the facility on [DATE] with diagnoses that included Corona Virus Disease 2019, chronic obstructive lung disease, depression, and hypothyroidism. Reesident #50's quarterly Minimum Data Set (MDS) assessment, dated 4/27/22, revealed she had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS revealed resident #50 demonstrated no behaviors, no rejection of care, and required the assistance of 2 staff for bed mobility, toileting and dressing. On 6/13/22 at 12:57 PM, resident #50 said she had an issue with 2 Certified Nursing Assistants (CNAs). She explained the second shift CNAs, B and C, forcibly pushed her down about 3 weeks ago and she reported it to a nurse. Resident #50 indicated she waited until the morning to report the incident…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$17,369 in federal fines across 1 penalty.

  • $17,369 — penalty dated 2024-06-07

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to FLORIDA INSTITUTE FOR LONG-TERM CARE — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.2-0.2 vs chain
Health inspection 1 of 51.9-0.9 vs chain
Staffing 2 of 53.2-1.2 vs chain
Quality measures 5 of 54.1+0.9 vs chain
The other 16 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
FLORIDA INSTITUTE FOR LONG TERM CARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 04/15/2025
OMEGA HEALTHCARE INVESTORS, INCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 07/01/2003
JAFFE, HOWARDIndividualCORPORATE OFFICERsince 01/01/2012
KATZ-HALL, KATHYIndividualCORPORATE OFFICERsince 01/01/2012
MULLARKEY, JAMESIndividualCORPORATE OFFICERsince 01/01/2012
RICHMOND, PENNYIndividualCORPORATE OFFICERsince 01/01/2012
CONSULTING SUPPORT SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
ELEUS HEALTH MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
FACILITY SUPPORT COMPANY, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
KANE FINANCIAL SERVICES, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/24/2025
COLE, KATHLEENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/13/2016
HAMIL, COREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/31/2018
SELECT REHABILITATION, LLCOrganizationADP OF THE SNFsince 08/19/2016

CMS files one row per role, so the 21 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.3M
Net patient revenuemost recent cost report
-21.4%
Operating marginrevenue minus expenses
$208K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 7%Other / private 19%

About 74% 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 $208K paid to related parties (affiliated landlords or management companies) in its most recent 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 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

$389per resident / day
operating cost
$11,831per month
≈ monthly operating cost
$321per day
avg. revenue, all payers

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

What families pay in FL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105448. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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