Sunset Lake Healthcare And Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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.

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.

50.5% 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 332 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 71.7% 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 159 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 109.8 residents a day — about 92% occupied, or roughly 10 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 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 3.49 hrs/resident/day on weekends vs 4.01 on weekdays — 13% thinner on weekends. RN hours go from 0.61 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

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

• Immediate jeopardy · L2024-12-06 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  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 record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure the safety of residents during emergency evacuation ahead of hurricane [NAME] landfall, a major category 3 hurricane with winds of 120 miles per hour. On 10/8/24 the facility evacuated 112 residents. Due to heavy traffic related to the large scale evacuation, 96 residents traveled approximately 197 miles for eight hours to two receiving facilities. The facility neglected to ensure residents on the buses/vans received necessary medications, food, or hydration, during the transfer to receiving facilities and failed ensure staff were available during transport. Resident #19, who was receiving rehabilitation services by the facility for multiple fractures, and wore a neck brace, suffered serious harm during the evacuation when she was improperly laid by staff across two seats on a coach bus. During the approximately seven…

  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 · Lcited before2024-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
  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 record review and interviews with residents, residents representative and staff, the facility failed to ensure appropriate transportation, availability of assistive devices, and adequate supervision of dependent residents during emergency evacuation related to hurricane [NAME] a major category 3 storm. This failure affected all 112 residents evacuated from the facility and resulted in the emergency transfer of 2 residents (#7 and #9) to the hospital and unaddressed excruciating pain for 1 resident (#19). Resident #19 had multiple fractures and wore a neck brace. Facility staff inappropriately laid the resident across two seats on a coach bus for a 197 miles trip that lasted approximately seven hours, causing excruciating pain and suffering. Resident #7 was wheelchair bound and required a full body mechanical lift for transfers. She was inappropriately transported approximately 197 miles for seven hours on a coach bus. She sustained an open fracture of the ankle when two staff members physically carried…

  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 · L2024-12-06 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility's administration failed to utilize its resources effectively to prevent the neglect of residents by failing to develop and implement an effective Emergency Plan emergency plan, including contingency planning for evacuation transportation and failing to adequately train and verify competency of staff to respond to natural disasters including emergency evacuation procedures in a safe and orderly manner. This failure resulted in avoidable serious harm of residents #7, #9 and #19 and created a likelihood of serious injury of 112 residents during emergency evacuation on 10/8/24 ahead of category 3 hurricane [NAME] landfall. Resident #19 had multiple fractures and suffered excruciating pain when staff inappropriately laid her across two seats for approximately 197 miles and seven hours during transport to the receiving facility. Resident #7 was evacuated in a coach bus instead of necessary transportation equipped with a lift. She suffered a fractured…

  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 · L2024-12-06 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to implement corrective actions for identified quality deficiencies related to staff training and competency to respond appropriately to natural disasters to prevent the neglect of residents during natural disasters and emergency evacuation of residents. On 10/8/24 the facility did not ensure the safety of 112 residents during emergency evacuation ahead of category 3 hurricane [NAME] landfall. The facility did not ensure transportation to meet the needs of wheelchair and stretcher bound residents and failed to staff each transport bus or van with nursing staff to ensure residents safety, provision of care and administration of necessary physician ordered medications. Resident #19 had multiple fractures and suffered excruciating pain when staff inappropriately laid her across two seats for approximately 197 miles and seven hours during transport to the receiving facility. Resident #7 was evacuated in a coach bus instead of necessary transportation…

  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
• Actual harm · Gcited before2023-03-09 · 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

  Based on record review, review of the policies and procedures, and staff and family interviews, the facility failed to implement appropriate interventions, including adequate supervision to prevent avoidable falls, including fall related major injuries for 1 (Resident #74) of 3 residents reviewed who sustained multiple falls at the facility. The failure to implement appropriate interventions to prevent falls and fall related injuries resulted in Resident #74 sustaining preventable falls, including falls with major injury requiring transfer to a higher level of care. The findings included: The facility policy Falls-Clinical Protocol (revised 3/18) documented The physician will help identify individuals with a history of fall and risk for falling. Staff will ask the resident and the caregiver about a history of falling. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-04-16 · 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, and staff interviews, the facility to follow proper sanitation and food handling practices in accordance with professional standards for food service safety. The findings included: On 4/13/25 at 9:35 a.m., during a kitchen observation, Dietary Staff B was observed removing a cut glove (glove to prevent injury during food prep) from his back pocket and putting it on his right hand to prepare raw vegetables for lunch. Dietary Staff B was not observed performing hand hygiene or sanitize the glove before using it. In an interview, Dietary Staff B was asked how long he has been using the glove. He stated, I've been using it as long as I've worked here, for a year. When asked how he makes sure the glove is clean before using it, he demonstrated by putting one pump of hand sanitizer on the palm of the glove while he was wearing it. On 4/13/25 at 12:00 p.m., during a kitchen observation, Dietary Aide Staff C was observed washing his hands in the 3-compartment sink for less than 10 seconds. On 4/13/25 at 12:11 p.m., during a kitchen observation, Dietary Staff B…

  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 before2025-04-16 · 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

  Based on observation, record review, review of facility's policies and procedures, resident, resident representative and staff interviews, the facility failed to provide care and services to meet the needs for Activities of Daily Living (ADL) for 2 (Residents #275 and #276) of 5 residents reviewed for assistance with ADL. The findings included: Review of the facility policy titled, Activities of Daily Living (ADLs), supporting, last revised on March 2018 revealed, Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including hygiene (bathing, dressing, grooming, and oral care). Review of the clinical record for Resident #276 revealed an admission date of 4/9/25. Diagnoses included cerebral infarction (stroke), hemiplegia (paralysis) on her left side, aphasia (language disorder affecting speech), and muscle weakness. Clinical record review revealed Resident #276 sustained a fall at the facility on 4/9/25, on the day of admission. Review of the admission Minimum Data Set (MDS) assessment with a target date of 4/12/25 revealed…

  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 · E2025-04-16 · 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, review of the clinical record, review of the facility policy and procedures and resident and staff interviews, 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's physical, mental, and psychosocial well-being for 2 (Residents #29 and #48) of 3 reviewed for involvement in the activity programs. The findings included: Review of the facility policy Activity Programs revised August 2006 revealed, Activity programs designed to meet the needs of each resident are available on a daily basis . Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 1. Review of the clinical record revealed Resident #29 had an admission date of 4/8/24. Diagnoses included major depressive disorder. The Annual Minimum Data Set (MDS) (standardized assessment tool that measures health status in 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
• Potential for harm · Ecited before2025-04-16 · 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, interview, and record review, the facility failed to ensure a safe environment and provide adequate supervision to prevent multiple falls for 1(Resident #65) of 3 residents reviewed for accident. The findings included: Review of the facility policy on Safety and Supervision of Residents revised July 2017, our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Page 1, Individualized, Resident Centered Approach to Safety: #3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision . Systems Approach to Safety, continued on page 2: #2 Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs . #3 The type and frequency of resident supervision may vary among…

  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 · E2025-04-16 · 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, review of facility policy and procedure and staff and resident interviews, the facility failed to ensure sufficient nursing staff to meet residents' needs for 4 (Residents #9, #17, #29, #37) of 34 sampled residents. The findings included: The facility policy Staffing documented Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans. 1. On 4/13/25 at 12:24 p.m., in an interview Resident #9 said it takes a while before someone comes to answer the call light. She said it depends on who is working, some staff are good, and some are not. They say they don't have the staff so what can you do? 2. On 4/13/25 at 9:53 a.m., in an interview Resident #17 said sometimes he waits an hour or more for someone to answer his call light. He said the staff tell him they are shorthanded and they don't have enough people to care for us. I was left on the bed pan for over an hour one day a week or so ago. I was on there for a long time and my legs and my…

  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 · E2025-04-16 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to ensure staff followed infection prevention interventions when entering the room of 1 (Resident #1) of 1 resident observed on enhanced barrier precautions and failed to change the dressing as ordered to prevent catheter related infections for 2 (Residents #69 and #173) of 2 residents reviewed with Peripherally Inserted Central Catheters. The findings included: Review of the Policy for Midline and PICC(peripherally inserted central catheter) line dressing changes Revised 4/2016 stated Change midline/PICC line catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of Resident #173's medical record revealed admission to the facility on 4/8/25. Diagnoses included osteomyelitis (bone infection) of the vertebra. Review of the Medication Administration Record (MAR) revealed an order for Daptomycin (antibiotic) 500 milligram (mg) Intravenous (IV)…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-16 · 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 — 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's policy and procedure, resident, resident representative and staff interviews, the facility failed to develop and communicate a resident centered baseline care plan to meet the needs of 1 (Residents #273) of 3 newly admitted residents reviewed. The findings included: Review of the facility's policy for Baseline Care Plan revised December 2016 revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . The resident and their representative will be provided a summary of the baseline care plan on the 21st day that includes but is not limited to the initial goals of the resident, a summary of the resident's medications, any services and treatments to be administered and any updated information based on the details of the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-16 · 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, clinical record review, staff and resident interview, the facility failed to provide the appropriate care and services to prevent a decline in range of motion for 1(Resident #55) of 3 residents reviewed with a limitation in range of motion (ROM). The findings included: Review of the undated facility Policy and Procedure titled, Splints and Braces, revealed, Residents of the facility who wear splint or braces shall be monitored periodically assessed by OT (Occupational Therapy) and or PT (Physical Therapy) department. Splints and braces are usually fabricated and provided by Occupational Therapists and or Physical Therapists to treat temporary conditions of muscle weakness, joint limitations, pain and swelling. On occasion the splints and braces may be required for long term use to prevent contracture or to stabilize joints. Review of the clinical record revealed Resident #55 was a [AGE] year-old female admitted on [DATE] with diagnoses including left hand contracture, hemiplegia (paralysis…

  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 · F2024-12-06 · 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, record review the facility failed to ensure the Facility Assessment was complete and involved input from facility staff and ensured documentation of how the facility informed staff of the current Comprehensive Emergency Management Plan (CEMP) The findings included: Review of the Facility Assessment provided by the facility last updated on 1/11/24 listed the Activities Director, The Director of Housekeeping, the Social Service Director and Resident #28 as contributors to the assessment. On 11/19/24 at 8:45 a.m., in an interview the Activities Director said she wasn't sure what the facility assessment was and did not participate in the development and did not provide any feedback on the development of the assessment. On 11/19/24 at 10:00 a.m., in an interview the Director of Housekeeping and the Assistant Director of Housekeeping said they were not familiar with the facility assessment, did not attend any meetings or provide any input about the facility assessment. On 11/19/24 at 10:07 a.m., in an interview the Admissions Director said, I am not familiar with 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 · E2024-12-06 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and interviews, the facility failed to ensure 3 ( Licensed Nurses N, HH, and I) of 5 sampled nurses reviewed received training and were competent in checking the function of the wander alert bands (alert staff when a resident leaves a designated safe area) to prevent cognitively impaired residents unsafe wandering and elopement. The findings included: Clinical record review for Resident #16 revealed an admission date of 7/13/22. Diagnoses included Encephalopathy, Anxiety Disorder, Adult Failure to Thrive and generalized weakness. The elopement risk evaluation dated 10/11/23 noted an elopement risk score of 16. The form noted a score of 15 or above indicated a high risk for elopement. Review of facility's incident investigations showed on 7/6/23 at approximately 7:30 p.m., Resident #16 was found outside of facility doors. A staff member quickly discovered her and returned her safely back to her room. The investigation noted Resident #16's cognition was moderately impaired with a Brief Interview for Mental Status score of 07. The resident 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.

  Nursing and Physician Services 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.

Fines & penalties

$319,770 in federal fines across 1 penalty.

• $319,770 — penalty dated 2024-12-06

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 GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

1 organizational owner 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.

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

Cost & finances

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

What families pay in FL