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Advinia Care At Venice

950 Pinebrook Road, Venice, FL 34285 · For profit - Corporation · 45 certified beds · (941) 484-8801 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Jul 20234 immediate-jeopardy citations
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2023
  • 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
  • inspectors cited 4 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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 (1/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

Worth a closer look. This home's quality-measure rating runs 2 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1370 E Venice Ave · (941) 480-0500 · Call to confirm hours
Pharmacy
1405 E Venice Ave · (941) 488-8122 · Call to confirm hours
Grocery
Publix0.2 mi
1445 E Venice Ave · (941) 480-0779 · Call to confirm hours
Park
1360 Ridgewood Ave · (941) 316-1172 · Typically dawn to dusk
Place of worship
1000 Pinebrook Rd · (941) 484-9543

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 3 of 5
Long-stay residentspeople who live here 1 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 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased18.6%8.7%15.4%worse
Long-stay residents who lose too much weight6.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder1.8%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection6.3%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.2%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 injury5.2%2.5%3.3%worse
Long-stay residents whose ability to walk worsened40.3%9.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.7%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers11.7%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control12.2%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 table6.9%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.2%94.7%79.4%better
Short-stay residents rehospitalized after admission29.0%26.1%22.6%worse
Short-stay residents with an outpatient ER visit9.3%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.882.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.711.151.80better

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

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

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

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

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

61.2% 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 227 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

61.2%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
47.8%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 47.8% 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 46 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% 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 SNF61.2%CMS range 55.9–67.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.4–15.210.7%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 discharge47.8%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 discharge63.0%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 discharge50.0%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 identified85.5%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%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 stay1.3%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 worsened2.6%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 hospitalization8.2%CMS range 5.0–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

0.49
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.72
Total nurse hours/ resident / day
0.31
RN hoursweekends
45.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 45 beds and averages 40.5 residents a day — about 90% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 3.85 on weekdays — 12% thinner on weekends. RN hours go from 0.56 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

8
deficiencies at the latest standard inspection (2024-07-11)
17
at the previous standard inspection (2023-07-16)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · J2023-07-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of facility's policies and procedures, and staff interview the facility failed to protect residents' rights to be free from neglect. The facility neglected to develop a care plan and ensure adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #386) of 5 sampled cognitively impaired residents with active exit seeking behaviors. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood…

    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
  • Immediate jeopardy · Jcited before2023-07-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, record review, and staff interviews, the facility failed to implement processes to ensure adequate supervision of 1 (Resident #386) of 5 cognitively impaired residents at risk for elopement to prevent unsafe wandering and elopement. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was a vulnerable cognitively impaired, wheelchair bound resident with known wandering behavior was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 wore a wander alarm and triggered the alarm of two doors without staff response. Resident #386 left through the front door of the Assisted Living Facility, and traveled in her wheelchair, approximately three tenths of a mile, and crossed two streets. Resident #386 was missing for approximately one hour and 30 minutes without staff knowledge. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing…

    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
  • Immediate jeopardy · J2023-07-16 · tag F0835 — failed to run the facility competently — isolated
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to ensure a safe environment, including adequate supervision of cognitively impaired residents with known exit seeking behaviors to prevent unsafe wandering and elopement. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 5:45 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk for serious injury from a fall, getting lost or…

    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
  • Immediate jeopardy · J2023-07-16 · tag F0867 — failed to act on quality-improvement findings — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's policies and procedures, and staff interviews the facility failed to develop and implement appropriate corrective actions related to adequate supervision of cognitively impaired residents at risk for unsafe wandering, elopement and exit seeking behaviors. On 4/1/23 at approximately 4:30 p.m., Resident #386 who was vulnerable, cognitively impaired, and wheelchair bound was not adequately supervised. The resident wheeled herself through an unsecured door of the skilled nursing facility into a hallway leading to the adjoining Assisted Living Facility. Resident #386 left through the front door of the Assisted Living Facility, setting off a wander alarm, and traveled unsupervised in her wheelchair, approximately three tenths of a mile, and crossed two streets. On 4/1/23 at 6:00 p.m., a staff member from a neighboring skilled nursing facility found Resident #386 wandering the streets. Resident #386 had a likelihood for serious harm, injury, or death due to the risk 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-08 · tag F0691 — failed to provide colostomy / ostomy care — isolated
    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and procedure, and staff interviews, the facility failed to provide nursing care and services consistent with professional standards of practice for 1 (Resident #1) of 2 residents reviewed for ostomy (part of the intestine surgically brought outside the abdominal wall to collect stool into a pouch) .The findings included:The findings include: Review of the facility Ostomy Care (Colostomy [surgical opening bringing the a section of the large intestine to the surface], Jejunostomy [a surgical opening into the mid-section of the small intestine through the abdominal wall], Ileostomy [a surgical opening connecting the small intestine through a new opening through the abdominal wall]) policy (last revised 1/2023) states it is the policy of this facility to provide ostomy care to residents in a manner that promotes dignity and resident health by maintaining cleanliness and skin integrity, preventing odors and preventing infections . apply appliance per manufacturers…

    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 plan of correction
  • Potential for harm · Fcited before2024-07-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, review of facility policy and procedure and staff interviews, the facility failed to prepare, and store food in a sanitary manner by failing to cover and date food in 1 reach-in refrigerator, failed to use proper hand hygiene during dish washing procedure, and failed to ensure hair restraints were used to cover facial hair. Additionally, the facility failed to properly assist residents during meals to prevent cross contamination. The lack of sanitation in the kitchen and dining services had the potential to affect all residents and staff. The findings included: The facility policy Food Safety and Sanitation initiated 2021 documented Beard nets are required when facial hair is visible are we cried when facial hair is visible. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching their face, hair, other people or surfaces or items with potential for contamination. All time and temperature control for safety foods including leftovers…

    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 · Ecited before2024-07-11 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, review of the clinical record and resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents # 11 and #16) of 2 residents reviewed for ADLs (activities of daily living). The findings included: 1. The facility policy CA-12 ADL Support initiated 7/2019 (revised 10/2022) documented Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). Review of the clinical record revealed Resident #11 had a readmission date of 6/13/24 with diagnoses including falls, acute respiratory…

    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 before2024-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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, record review and staff and family interview the facility failed to document a thorough investigation including root cause analysis to prevent future falls for 1 (Resident #16) of 2 residents reviewed for falls. The facility also failed to coordinate care and implement interventions to minimize the risk of avoidable fall and fall related injuries for Resident #16 with a history of multiple falls. The findings included: Review of a facility policy titled, Falls Management Program, dated 2/7/21 indicates that the fall response steps are a comprehensive approach that forms the backbone of the falls Management Program (FMP). It includes the following eight steps: 1. Evaluate and monitor resident for 72 hours after the fall. 2. Investigate fall circumstances. 3. Record circumstances, resident outcome, and staff response. 4. Fax alert to primary care provider. 5. Implement immediate intervention within the first 24 hours. 6. Complete falls assessment. 7. Develop plan of care. 8. Monitor staff…

    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 before2024-07-11 · 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, staff and family interview, and record review, the facility failed to revise and update the plan of care for 1 (Resident #16) of 2 residents reviewed for fall. Reviewing and updating of a resident's plan of care by the interdisciplinary team ensured the residents reached and maintained the highest practical safety measures and wellbeing. The findings included: Review of a facility policy titled, Falls Management Program, dated 2/7/21 indicates that the fall response steps are a comprehensive approach that forms the backbone of the falls Management Program (FMP). It includes the following eight steps: 1. Evaluate and monitor resident for 72 hours after the fall. 2. Investigate fall circumstances. 3. Record circumstances, resident outcome, and staff response. 4. Fax alert to primary care provider. 5. Implement immediate intervention within the first 24 hours. 6. Complete falls assessment. 7. Develop plan of care. 8. Monitor staff compliance and resident response. During an interview 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · tag F0679 — failed to provide activities — isolated
    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, review of facility policy and procedure, record review and resident and staff interview, the facility failed to ensure they provided an ongoing program to support the residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 2 (residents #11, and #190) of 3 residents reviewed for involvement in activities. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. The findings included: The facility policy Activities effective 7/1/18 (revised 2/3/21) documented Activities refer to any endeavor, other than routine ADL's in which a resident participates that is intended to enhance her/his sense of well-being and to promote self-esteem, pleasure, comfort, education, creativity, success and independence. The facility shall provide, based on the comprehensive assessment and care plan and the preferences 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-11 · 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, record review, and staff interviews, the facility failed to coordinate care and services for 1 (Resident #13) of 1 sampled resident's receiving dialysis by failing to ensure medications related to dialysis were administered as ordered by the physician. The findings included: Review of a facility policy titled; Dialysis Management dated 10/2022 indicates that the nurse will obtain orders for Medication as ordered to dialysis schedule. A review of an admission Record indicated the facility admitted Resident #13 on 2/19/24 with the following diagnosis: End stage renal disease and dependence on renal dialysis. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that the Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. MDS also indicated that the resident was currently receiving dialysis for end stage renal failure. Review of Resident #13's Care Plan initiated 2/28/24 indicated Resident #13 needed dialysis related to end stage renal disease 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 · D2024-07-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 appropriate care and services to prevent a decline in urinary continence for 1 Resident (#21) of 2 incontinent residents reviewed. The findings included: Review of the facility policy for bladder and bowel evaluation revised 1/2023: Residents are evaluated for continence on admission/readmission, quarterly, and with significant change in status. Residents who have been determined to be incontinent without a documented irreversible cause, presenting with a significant change in continence, will be further evaluated for potential bowel or bladder management. On admission, residents without a documented reversible cause for bowel or bladder incontinence will be assessed for the potential of bladder/bowel retraining program. Quarterly those residents with a significant change decline in bowel or bladder continence, that is not transient and self-limiting, will have a bowel and bladder evaluation completed, and will have bowel and bladder diary…

    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 · D2024-07-11 · tag F0755 — failed to provide safe pharmacy services — isolated
    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 have a process in place to minimize loss or diversion of controlled narcotic medications. The findings included: Review of the facility policy for Controlled Substances: Documentation/Destruction/Storage revised 6/5/21: Once removed from count, discontinued drugs are stored in a double-locked area which is secure and accessible to the director of nursing and administrator only. On 7/1/24 at 12:36 p.m., Licensed Practical Nurse (LPN) Staff F said she gives the unused controlled substances from the medication cart to the Director of Nursing (DON) for destruction. She said the DON locks them in her drawer. On 7/11/24 at 12:36 p.m., observed the DON open her desk drawer with her key to reveal multiple narcotic drug packs and controlled substance record sheet. On 7/11/24 at 12:36 p.m., the DON was interviewed in her office. She said the unused controlled substances are stored in her desk in the left-hand side drawer. She said does not know which narcotics are in her drawer and does not have a list for which she…

    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 · F2023-07-16 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, and record reviews, the facility failed to ensure the Dietary Manager possessed the necessary qualifications and to ensure frequently scheduled consultation by a qualified dietitian. The findings included: On 7/11/23 at 11:45 a.m., the Director of Food and Nutrition Services said she had completed a course work on June 28, 2019, at a university for Nutrition and Food service Professional training. She said the completed course allowed her to take the certification exam but has not done so yet. She stated the Registered Dietician (RD) worked offsite but came in once a month. The Director of Food and Nutrition Services provided a certificate of completion dated June 28, 2019 which noted she had, Satisfactorily completed the requirement for the Professional Development pre-certification course. Nutrition and foodservice [sic] Professional Training. On 7/12/23 at 4:13 p.m., the regional RD said he visits the facility monthly to monitor the food and nutrition services. He said the facility RD normally does the clinical part of the assessments, including…

    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
Show the remaining 15 citations
  • Potential for harm · F2023-07-16 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interview, record review, and observation, the facility failed to provide palatable food at appropriate temperatures for 3 (Residents #7, #17 and #385) of 4 residents interviewed for food palatability. Poor food quality may cause resident to eat less of their food or not at all, which can lead to weight loss and impaired nutrition. The findings included: On 7/10/23 at 9:55 a.m., Resident #385 stated the food is cold. She said, the vegetables don't have any seasoning, are over cooked, no fruit, no soda. The oatmeal is dried and hard, no sugar or milk in it and the eggs are cold. On 7/11/23 at 10:30 a.m. Resident #7's private duty Certified Nursing Assistant (CNA) was interviewed. She stated she worked with Resident #7 two days a week. She stated, The food is often cold or just lukewarm. The staff will warm it if someone is here to ask them. On 7/11/23 10:55 a.m., Resident #385 stated she just can't eat cold eggs, the food is cold no matter what they bring. On 7/11/23 at 12:15 p.m., food was observed being delivered from the main kitchen to the satellite…

    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 · F2023-07-16 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, and record review the facility failed to have documentation of a comprehensive facility-wide assessment, including an evaluation of the resident population and resources needed to provide the necessary care and services. The findings included: On 7/10/23 at 9:20 a.m., and on 7/14/23 at 12:00 p.m., a request was made to the administrator to provide documentation of a facility assessment. On 7/14/23 at 2:00 p.m., the Administrator provided an 18 page document titled, Facility's Quality Assessment and Assurance which he said was the facility assessment. The document a clinical systems scorecard summary, and a long term care essentials clinical assessment test which noted individuals scoring less than a 70 on assessments will be given the opportunity to retest at a later time and/or date. The document did not include an evaluation of the resident population, including diseases, conditions, physical, functional or cognitive status, acuity of the resident population, and any other pertinent information about the residents that may affect and plan for the services 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-07-16 · tag F0843 — widespread
    Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure they had an updated transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. The transfer agreement was to be used to ensure a safe and appropriate transfer of a resident between the facilities. The findings included: A review of the Facility Transfer Agreement (Revised on 01-2009) between the long-term care facility/nursing home and the hospital revealed it was signed on [DATE] with an end date of [DATE]. Further review of the Facility Transfer Agreement noted it was not renewed after the [DATE] end date. On [DATE] at 1:50 p.m., in an interview with the Administrator, he said the current transfer agreement between the nursing home and the hospital expired on [DATE]. He said he was unable to find documentation the facility had renewed the transfer agreement with the hospital or had attempted to secure a new transfer agreement with a hospital as required per federal regulation.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-16 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, and record review the facility failed to complete performance reviews for 3 (Certified Nursing Assistants Staff G, Staff E, and Staff F) of 3 Certified Nursing Assistants (CNAs) surveyed for performance review. The findings included: Review of the current staff list provided by the facility revealed CNA Staff G had a date of hire of 9/16/21, CNA Staff E had a date of hire of 5/6/21, and CNA Staff F had a date of hire of 5/20/21. On 7/14/23 at 12:00 p.m., 2:00 p.m., a request was made to the Administrator for documentation of the annual performance review for CNAs Staff G, E, and F. On 7/14/23 at 4:00 p.m., an additional request was made to the Administrator in training for documentation of the annual performance review for CNAs. Staff G, E, and F. As of the exit date of 7/16/23, the facility's administration did not provide documentation verifying CNAs. Staff G, E, and F had an annual performance review completed.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-16 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    5. On 7/12/23 a review of the Medication Regimen Review for Resident #13 revealed a consultant pharmacist's recommendation dated 6/13/23 that read, The resident is receiving both Escitalopram and Bupropion for depression. Could you please consider a gradual dose reduction of Bupropion with the hopeful possibility of eventually eliminating this drug? On 6/30/23 the APRN agreed with the recommendation. On 7/12/23, a review of Resident #13's medical record revealed the resident was still receiving Bupropion 75 mg once daily. On 7/12/23 at 10:18 a.m., the DON confirmed the APRN agreed to the dose reduction of the Bupropion recommended by the consultant pharmacist, but it had not been changed in the Resident #13's medical record. Based on record review, policy review, and staff interviews, the facility failed to ensure medication irregularities and/or concerns were addressed in a timely manner when the consultant pharmacist identified irregularities and/or medication concerns, for 3 (Residents #11, #13 and #25) of 5 resident's medication regimens which were reviewed. The findings…

    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 · E2023-07-16 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility failed to ensure no greater than 5% medication error rate. 38 opportunities with 5 errors were observed resulting in a 13.16% medication error rate. The findings included: On 7/14/23 at 8:15 a.m., Licensed Practical Nurse (LPN) Staff P was observed administering 13 different medications to Resident #16. Upon reconciliation of the observation with the physician's orders, it was revealed in addition to the 13 medications administered, an order to administer Lorazepam (medication used for anxiety) 0.5 milligram (mg) one tablet by mouth two times a day, hold for sedation. The morning Lorazepam was scheduled for 9:00 a.m. Staff P was not observed administering the Lorazepam to Resident #16 as ordered. The physician's orders also included Cyanocobalamin (Vitamin B12) 1000 micrograms (mcg) one tablet by mouth one time a day for supplement. Staff P was not observed administering the Cyanocobalamin to Resident #16. On 7/14/23 at 8:26 a.m., LPN Staff P documented in a progress note she held the Lorazepam since, Daughter…

    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 · E2023-07-16 · tag F0810 — pattern
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    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 2 (Residents #15, and #21) of 2 sampled residents of 25 residents requiring assistance with eating received the necessary assistive devices during dining. The findings included: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses including hemiplegia (Paralysis on one side of the body), and Parkinson's disease. Resident #15 had contractures (deformity) of both hands. Resident #15 received a pureed diet. On 7/11/23 at 12:30 p.m., Resident #15 was observed eating a pureed lunch in the dining room with a regular spoon. The resident had difficulty getting the food to his mouth, spilling the content of the spoon on the plate. On 7/12/23 at 11:48 p.m., the Director of Physical Therapy stated Resident #15 should have a weighted utensil when he was eating his meals. Review of the care plans for activities of daily living and nutrition showed no intervention to provide the resident with weighted utensils for meals. 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-16 · 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

    Based on record review, review of the facility's policies and procedure, and staff interviews the facility failed to submit an immediate report for an elopement, which could be considered neglect, to the State Survey Agency and adult protective services in accordance with State law for 1 (Resident #386) of 3 incidents reviewed. The findings included: Cross reference to F600 and F689 The facility's abuse policy, section resident rights, revised 10/23/22 noted, The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient . neglect . Neglect. Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental abuse . Reporting . Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident . Review of the facility's incidents investigations on 4/1/23 at approximately 4:30 p.m., revealed Resident #386, who 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-16 · 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 record review, resident and staff interviews, the facility failed to ensure resident care plan meeting/conference was conducted with the resident and/or their representative after completion of the comprehensive admission Minimum Data Set (MDS) assessment for 2 (Resident #29 and #25) of 5 sampled residents. This did not allow the resident and/or their representative to participate in decision-making related to their plan of care and ensure the resident's care plan had the required information. The findings included: 1. On 7/10/23 at 10:26 a.m., during an interview with Resident #29, he said he was not invited to his care plan meeting. Resident #29 said because he was not invited to his plan of care meeting, he did not know what the Interdisciplinary Team (IDT) had determined his plan of care would be while he is at the facility. On 7/12/23 a review of Resident #29's medical records revealed he was admitted to the facility on [DATE] with a diagnosis of pathological left femur fracture, and abnormalities…

    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 · D2023-07-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 implement individualized, care planned interventions to prevent the decline in range of motion for 2 (Resident #15, and #21) of 2 sampled residents with limited range of motion. The findings included: 1. Resident #15 was admitted to the facility on [DATE]. Diagnoses included as of 8/11/22 hemiplegia (Paralysis on one side of the body) related to a cerebral vascular accident (stroke), and Parkinson's disease as of 2/22/19. Observation on 7/11/23 at 12:15 p.m., showed Resident #15's fourth and fifth fingers of both hand were contracted, pointing downwards toward the palm of his hands. Resident #15 said he did not have any splints or other device to keep his hands open. Clinical Record review showed the admission Minimum data Set (MDS) assessment dated [DATE] noted Resident #15 was admitted from an acute care hospital. Resident #15's cognition was moderately impaired with a Brief Interview of Mental Status (BIMS) score of 11. The MDS noted…

    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 · D2023-07-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 observation, clinical record review, staff, resident, and family interview, the facility failed to provide nutritional interventions and physician's orders to prevent weight loss for 1 (Resident #7) of 1 resident identified at risk for compromised nutrition and weight loss. The findings included: Clinical record review revealed Resident #7 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] noted diagnoses of non-Alzheimer's dementia, hypertension, Parkinson's Disease, Dysphagia (swallowing difficulties), and cognitive communication deficit. The MDS noted the resident was receiving a mechanically altered diet (change in texture of food and/or liquids). The clinical record noted Resident #7 had an allergy to shellfish which was not listed on the meal ticket. The Care area assessment dated [DATE] indicated Resident #7's BMI (Body Mass Index) was too low (17) (Body Mass Index less than 18.5 indicates the resident is at nutritional risk), and the resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to ensure ongoing communication between the nursing facility and the dialysis center related to the phyiscal assessment of a dialysis resident before, during, and after each dialysis treatment for 1 (Resident #17) of 1 resident receiving dialysis. The findings included: The facility policy CD-3, Dialysis Management revised 10/2022 stated Residents receiving hemodialysis treatments [a procedure whree a dialysis macing and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood] will be assessed and monitored to ensure quality of life and well-being. The procedure included the following information. On admission the resident will be assessed to determine [hemodialysis] access type. The site will be observed for function and signs and symptoms of infection. The nurse will obtain orders for monitoring of site, and interventions as appropriate. Facility will establish open communication with the Residents…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-10 · 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, review of facility's policy and procedure and staff interview the facility failed to maintain safe food temperature during preparation of meal, and failed to discard expired food items to prevent their use beyond the manufacturer's specified safe use date. The findings included: The facility's policy for Meal Service and Snacks with a revision date of 1/2021 read, . The Dietary department shall be responsible for food preparation for all meals and snacks . On 11/8/21 at 12:30 p.m., observation of the food prep area showed one tray of egg salad sandwiches on a table in the food preparation area. Upon request the Certified Dietary Manager (CDM) measured the temperature of the egg salad sandwiches which measured at 54 degrees Fahrenheit (F). The CDM verified the cold food should be held at 41 degrees F or lower. He placed the sandwiches back in the refrigerator. On 11/8/21 at 12:40 p.m., observation of the satellite kitchen with the CDM revealed the following: An opened, undated bottle of honey mustard sauce with a large accumulation of black/greenish substance…

    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 · D2021-11-10 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to have documentation of a baseline care plan for 2 (Resident #26 and #80) of 2 residents reviewed for baseline care plans. The findings included: On 11/9/21, review of the clinical records revealed Resident #26 was admitted to the facility on [DATE]. The clinical record lacked documentation of a baseline care plan. On 11/9/21, review of the clinical record revealed Resident #80 was admitted to the facility on [DATE]. The clinical record lacked documentation of a baseline care plan. On 11/9/21 at 1:30 p.m., in an interview the Minimum Data Set (MDS) coordinator verified the lack of documentation a baseline care plan was developed for Resident #26 and #80 to reflect interventions to address their needs. The MDS coordinator said, No residents at this facility have a baseline care plan in their records.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interview the facility failed to provide assistance for grooming and nail care for 2 (Resident #15 and #18) of 2 dependent residents reviewed for activities of daily living. The findings included: 1. On 11/8/21 review of Resident #15's care plan noted the resident has limited physical mobility related to exacerbation of Parkinson's, dementia. The care plan revised on 4/2021 also noted the resident required assistance of one to two with all activities of daily living. On 11/8/21 at 3:23 p.m., Resident #15 was observed in a wheelchair. Resident was not able to answer questions. The Resident's fingernails were uneven and extended approximately half centimeter from the base with a large accumulation of brown substance underneath the nails. Resident #15 was observed scratching her arms and shoulders. The same observation was made on 11/9/21 at 2:20 p.m., and 11/10/21 at 9:00 a.m. 2. On 11/8/21 review of Resident #18's care plan dated 10/24/21 noted the resident had limited physical mobility related to weakness and poor sight. The 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ADVINIACARE — 11 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 1 of 52.0-1.0 vs chain
Health inspection 1 of 52.2-1.2 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 10 homes this chain runs (chain average 2.0★, 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 / managerTypeRoleSince
DAVID A BERKOWITZ REVOC TR DAVID BERKOWITZ TTEEOrganizationDIRECT OWNERSHIP INTERESTsince 04/23/2021
FREDERICK S FRANKEL TRUSTOrganizationDIRECT OWNERSHIP INTERESTsince 04/23/2021
YOSEF MEYSTEL DECLARATION OF TR OF YOSEF MEYSTEL TTEEOrganizationDIRECT OWNERSHIP INTERESTsince 04/23/2021
BERKOWITZ, BENJAMINIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
CROWE, JULIEANNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
TALAMONA, RAYMONDIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/23/2021
LABELLA, CATERINAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
SPECTOR, JENNIFERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
POINTE GROUP CARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/17/2025
GLEICHER, HERMANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
LADEHOFF, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
TUROFSKY, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
WILHELM, NAFTALIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2021
BERKOWITZ, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/19/2025
MEYSTEL, YOSEFIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/17/2025
CURIS SERVICES LLCOrganizationADP OF THE SNFsince 04/23/2021

CMS files one row per role, so the 31 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 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.

$4.9M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
$706K
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 21%Medicare 35%Other / private 44%

This home reported $706K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$426per resident / day
operating cost
$12,957per month
≈ monthly operating cost
$410per 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 105955. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-11, 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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